Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231422 Renewal 10/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's financial record was not current and up to date. In February 2023 after receipt #4 was deducted from the total, the total should have been $88.13 and was documented as $88.06. Throughout the remainder of the petty cash logs, this was not rectified.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The Program Specialist rectified the financial log for Individual #1's petty cash and the missing 7 cents was placed in the petty cash. All residential staff will be re-trained by the program specialist by October 31, 2023, to enter receipts correctly onto the ledger. 10/30/2023 Implemented
6400.114(b)The smoking safety procedure indicates that smoking and tobacco materials must be always stored in a safe manner and remain inaccessible to the individuals. At the time of the inspection, there was an ashtray filled with cigarette butts on the back patio.Written smoking safety procedures shall be followed.The policy for fire safety regarding safe smoking procedures has been updated and now reads "Cigarette butts/smoking materials or waste from smoking are to be discarded in an approved location and container. Ash trays and receptacles for waste after smoking will be covered. Smoking and tobacco materials must be stored in a safe manner at all times and remain inaccessible to program participants." All staff were informed of new policy updates on 10/26/23. The policy is attached. 10/27/2023 Implemented
6400.141(c)(4)Individual #1's most recent annual physical completed on 3/27/23 did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The annual physical form was updated with yes/no check boxes for the physician to indicate if an individual's hearing is within normal limits. The updated form is attached. The Program Specialist will call the PCP by 11/9/23 to schedule an appointment to have the hearing evaluated. 10/27/2023 Implemented
6400.144Individual #1 is prescribed Ibuprofen and Mucinex as PRN's. At the time of the inspection, neither of these medications were available in the home. Individual #1 is prescribed Pedia-Lax to take on Day 3 if they have no bowel movements for two days. No bowel movements were documented for Individual #1 from 5/28/23 through 5/31/23. Individual #1 did not receive their Pedia-lax until 6/1/23.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Ibuprofen and Mucinex are on hand in the home for Individual #1 as of 10/20/2023. House managers will inventory all PRN medications monthly on their medical updates form (reviewed monthly by Program Specialist) to ensure the medications are available, and to order refills if needed. Form is attached. 10/27/2023 Implemented
6400.166(a)(2)Individual #1's medications on their MAR do not include the prescriber for each medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Individual #1's MARs have been updated to include a space for the prescriber to be added for each medication horizontally next to the medication order.PS will create new MARS for all individuals using the new form by 10/31/2023 10/31/2023 Implemented
6400.166(a)(7)Individual #1 is prescribed 10mg of Diazepam Gel to be administered as needed for seizures. The MAR lists that they are only prescribed 5 mg as needed. Individual is prescribed Ibuprofen 200mg two tablets as needed for pain/fever. A number of times that Individual #1 was administered the Ibuprofen, it was not documented that the Individual received two tablets.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Individual #1's diazepam MAR entry has been corrected. An updated copy of this is attached. PS will re-train all staff that administer medications on the proper documentation of a PRN medication on the back of the MAR. This training will take place at the upcoming staff meeting on 10/26/2023. 10/26/2023 Implemented
6400.166(a)(11)Individual #1's MAR's do not include the diagnosis/purpose for their following medications: Mupirocin, Nystatin, or Baby Lax.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1's MARS have been updated to include the purpose for each medication on a separate line of the MAR. PediLax and Nystatin both listed a purpose within the order, but it has been listed separately on the updated MAR. Mupirocin has been updated to include the purpose. The updated MARs are attached. 10/26/2023 Implemented
6400.167(a)(1)Individual #1 did not receive their Senna Tab 8.6 mg on 2/28/23. Individual #1 did not receive their noon dose of Baclofen 20mg on 5/31/23.Medication errors include the following: Failure to administer a medication.Individual #1 did receive their noon dose of Baclofen on 5/31/23 at day program, the MAR is attached. Residential staff failed to indicate that the dose was given at day program upon her return to the home after day program. All staff who administer medications will be re-trained by the program specialist by October 31, 2023 regarding proper documentation of a medication pass that was missed due to the absence of a person (while at day program or on leave). An incident has been filed for the 8am dose of Baclofen on 5/31/23 that was not signed for by staff. Incident # 9302797 10/26/2023 Implemented
SIN-00215412 Renewal 11/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(2)The agency assumes responsibility for managing large funds and bills for Individual #1. The individual's record has checks written out to them for large sums of cash ($100-$300) at least monthly. The home reports that the individual is given the cash directly or takes the check to the bank to cash. Documentation of when and how much cash is given directly to the individual is not documented. At the time of the 12/1/22 inspection, a check for cash was written out on 11/11/22 and there was no record if it had been given to Individual #1 yet. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. Individual #1 will now sign a petty cash request form when they ask for money. Attached is the most recent request signed by individual #1 for money on $200.00 on 12/5/2022 12/05/2022 Implemented
6400.63(a)The water temperature in the only bathroom sink used by both Individual #1 and #2, reached 122.4 degrees Fahrenheit creating a safety hazard.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The water temperature has been turned down in the home and no longer exceeds 120F. 12/05/2022 Implemented
6400.106The furnace was inspected and serviced on 5/18/21 and not again until 11/21/22.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The furnace has been cleaned and will be scheduled to be cleaned again before 11/21/2023 11/21/2022 Implemented
6400.143(a)Individual #1 refused a gynecological and pelvic exam on 11/10/21 and 6/9/22. The last completed PAP smear for Individual #1 was on 3/11/21 and not again since then. The agency explained that if Individual #1 has an appointment with their primary care physician, and the physician is unavailable, but another physician can complete the appointment, Individual #1 will refuse the appointment. Individual #1 was to see their primary care physician on 5/11/22, but the physician was out. Individual #1 did not go to that appointment and another one was scheduled for a later date. Individual #1 refused their annual eye examination on 1/20/22. The individual often refused to wear their glasses. Individual #1 refused to leave the home on 3/7/22 and 6/3/22 to attend their dentist appointments. And refuses medication administration at the correct time most days. The continued attempts to train the individual about the need for health care was not documented in the individual's record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The program specialist has created a refusal plan to further document refusal and will list the education offered for each refusal. 12/05/2022 Implemented
6400.216(a)Individuals #1 and #2 daily financial records with identifying information on, and money were unlocked in the closet in the kitchen An individual's records shall be kept locked when unattended. Daily financial records were placed in the locked office at time of discovery during inspection. 12/01/2022 Implemented
6400.32(n)Individual #1 was upset during a discussion with staff on 2/12/22. Staff #2 recorded that Individual #1 grabbed the telephone, then staff took the telephone from Individual #1 and hung it back on the wall.An individual has the right to unrestricted and private access to telecommunications.At no time was individual #1 restricted from using the phone. Management looked into the documentation and investigated what happened. Staff simply "took" the phone and hung it up once individual #1 had moved on to other things. 12/02/2022 Implemented
6400.165(g)Individual #1's 3/3/22, 5/5/22, 9/15/22 review of their psychotropic medications with their psychiatrist did not include the current, milligram dosage ordered for Venlafaxine, Divalproex, Quetiapine, and Trazodone or the reason for prescribing each medication. Their 11/14/22 review didn't include a review of their Trazodone medication or the reason for prescribing all their psychotropic medications. Their 9/15/22 and 11/14/22 reviews reason for prescribing the medications was noted as "chronic illness." At the time of the 11/30/22 inspection, the program specialist was not aware that on 11/14/22 the individual's psychiatrist did not indicate the individual should be taking Trazadone. The program specialist reported Individual #1 is still administering their Trazodone currently. The home doesn't have record from any physician that Trazodone was reviewed as a current medication, or documentation that the medication was discontinued. The home did not describe or relay any of Individual #1's behaviors described in 6400.165(f) of this report, to the individual's prescribing psychiatrist at any point in 2022.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.A new form has been created listing each medication, the does , the reason for prescribing, and the need to continue. This form will be signed by the Dr. quarterly. Behaviors are currently reported to the Penn State Psychological Clinic, to Individual #1 therapist which are then relayed to the psychiatrist who also works as part of Individual #1 team at the Penn State Psychological Clinic on a weekly basis. 12/06/2022 Implemented
SIN-00199943 Renewal 02/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)The annual fire safety training for Individual #1 is late; training conducted on 7/01/20 and not again until 9/3/21. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. 113a Fire safety training will be completed annually. During the current inspection year the annual training date was changed to align with the rest of the company to simplify tracking, and a miscalculation occurred. This will not be an issue moving forward, and fire safety training for staff and individuals will be held annually and on-time moving forward. 02/14/2022 Implemented
SIN-00182955 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)As of the 2/8/21 inspection, there has not been a sleeping fire drill conducted since 7/19/20.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Supervisor is responsible for scheduling and monitoring all fire drills. This will ensure that no less the 6 months has passed since the last fire drill and they will alert the house manger to conduct a fire drill. Attached is the Overnight Fire Drill Completed Feb 13, 2021 for Market Street. 02/13/2021 Implemented
6400.34(a)The Department issued updated rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 2/9/21 annual inspection, individual #1 was never informed of the individual rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.It is the Program Specialists (PS) responsibility to ensure that all induvial are informed of their rights and the process to report a rights violation. The PS will review yearly, or sooner if regulations change before the year with the individuals. A signed copy will be kept in their permanent files, and a copy given to each individual. Attached is the updated Rights form that was reviewed and signed with the individual. 02/11/2021 Implemented
SIN-00168014 Renewal 02/13/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Rights- Bedroom doors locked- Individual #1's, bedroom door does not contain a locking mechanism for privacy.An individual has the right to lock the individual's bedroom door.Individual #1 is unable to use any form of key, key card, pin system etc. She is also a health and safety risk of biting, chewing and or ingesting anything given to her. The program specialist has spoken with the entire team, including Individual #1, and it will be added to her ISP that she will not have a lock on her bedroom door. 02/18/2020 Implemented
6400.166(a)(12)Medication time-7/7/19 the medication Ibuprofen 200mg tab was initialed as administered to Individual #1, but there is no time of the administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.The house supervisor has retrained all staff on the proper documentation of medication records. To ensure this error does not happen again, the house manager will be reviewing all documentation weekly, and the residential CEO will be reviewing all documentation ever two weeks. 02/20/2020 Implemented
SIN-00149970 Renewal 02/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Water temp was 122 degrees F. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted on 2/8/19. Due to a furnace being serviced earlier in the month the water temperature was reading at 122 degrees at time of inspection. The temperature has been adjusted to below the 120 degrees. It is the house manager and PS responsibility to ensure the temperature remains below 120 degrees. On 2/19/19 the water was tested again and was reading at 116.2 degrees. The PS has created a safety committee to meet monthly and the safety check list is to be completed weekly, starting on 02/25/19. The results of the monthly meetings will then be shared with the CEO to ensure all problems have been addressed and taken care of. Attached is a picture of the current temperature reading and also a copy of the check list. 02/08/2019 Implemented
6400.73(a)Metal Hand railing to front entrance not fully secured. Moved approximately 5 inches when leaned on. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 02/22/19, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. During this meeting the PS and CEO trained all staff on the importance of reporting any safety concerns regarding the home. The metal hand railing was missing a screw and has been replaced and also reinforced to ensure safety. The PS has created a safety committee to meet monthly and the safety check list is to be completed weekly, starting on 02/25/19. The results of the monthly meetings will then be shared with the CEO to ensure all problems have been addressed and taken care of. Attached is a picture of the repaired railing and also a copy of the check list. 02/22/2019 Implemented
6400.103Emergency Evacuation procedures do not include individual responsibilitiesThere shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. On 02/19/19 the Administrative Assistant (AA) and PS updated the Emergency Evacuation Procedures (EEP) to clearly describe the individual¿s responsibilities, means of transportation and emergency shelter in the event of an emergency. The EEP was then reviewed by the CEO and reviewed with staff agency wide on 2/22/19. The AA and PS will continue to work together to ensure that all policies and procedures contain the required information. The CEO and CFO will review all polices on a quarterly basis, beginning on 04/01/19. On 02/22/19, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. On 02/22/19, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Attached is the updated EEP. 02/19/2019 Implemented
6400.144Individual # 1's Dental plan of brushing teeth did not occur on 11/24/18 (before bed)Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Induvial #1¿s TAR was not signed off on 11/24/18 that her teeth were brushed before bed. The PS did review the daily documentation, and it was noted that she indeed did have her teeth brushed. Staff were retrained on 2/19/19 on her dental hygiene plan and documentation to ensure it is not missed. It is the PS responsibility to check all daily documentation weekly to ensure nothing is left blank and all documentation is filled out correctly. This was started on 2/19/19. On 02/22/19, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #1 daily documentation for 11/24/18 is attached to show the individual¿s teeth were brushed. 02/19/2019 Implemented
6400.181(e)(7)Individual # current assessment does not indicate her ability to move away quickly from heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. On 02/19/19 the Program Specialist (PS) reviewed individuals #1 assessment, using the record review check list. The assessment was updated to include her ability to move quickly away from a heat source, which was missing in the assessment. The updated assessment was presented to the individual¿s team members on 02/19/19. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present using the check list for accuracy. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 02/18/19 and it was correct for all content. The PS and the Administrative Assistant (AA) will start to review all assessments, utilizing the record check list, starting on 03/01/191 to be concluded by 04/01/19. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 04/01/19 to ensure all documentation is correct, the CEO will also use the record check list during reviews. On 02/22/19, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #1 assessment is attached to show the individual¿s ability to move quickly away from a heat source. 02/19/2019 Implemented
6400.186(c)(2)Individual # 1's 12/06/18 ISP review did not include dental plan utilization. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. On 02/08/19 the Program Specialist (PS) reviewed individual #1s assessment. The assessment was updated to include her Dental Plan Utilization. The updated assessment was resent to her and her team on 02/19/19. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 2/18/19 using the record review check list. The PS and the Administrative Assistant (AA) will start to review all assessments, starting on 03/01/19 to be concluded by 04/01/19 using the check list. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 04/01/19 to ensure all documentation is correct also using the record review check list. On 02/22/19, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #1¿s assessment is attached to show her updated Dental Plan Utilization, also attached is the record check list. 02/19/2019 Implemented
6400.213(11)Individual # 2's 09/18/18 ISP indicates that "...has a hearing loss and communicates with sign language, by reading lips and by writing". Assessment dated 07/18/18 states that she is "verbal and speaks and understands english. She is hard of hearing, but she is a proficient lip reader. Individual # 1's preferred method of communication with others is primarily verbal." ISP indicates that Nancy has forgotten on occasion or has taken her medications at inappropriate times. Assessment indicates she self administer's medications. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. On 02/08/19 the Program Specialist (PS) reviewed individual #2's ISP for content with the individual¿s SC. Corrections have been requested by the PS to the SC to update the ISP to ensure content matches throughout the ISP. The PS and Administrative Assistant (AA) will review ISP¿s quarterly, using the record review checklist to ensure no changes need addressed. This will start on 3/1/18 to ensure all documentation is correct. A staff meeting was held on 2/22/19, the results of the inspection was reviewed with all staff. A copy of the email sent to individual #2¿s SC is attached, as is the record check list. 02/21/2019 Implemented
SIN-00126605 Initial review 12/29/2017 Compliant - Finalized