Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240175 Renewal 02/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers posted by the telephone in the living room of the home. This was corrected at the time of inspection by staff obtaining a copy of the emergency numbers that appear by the other telephones and posting them by the living room phone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The emergency number was corrected during the time of inspection. 02/15/2024 Implemented
6400.72(b)The screen in the window located to the left of the fireplace in the living room is torn and requires repair. Screens, windows and doors shall be in good repair. The screen has been replaced as of 03/20/24. A picture will be sent in an email. 02/17/2024 Implemented
6400.104Fire department notice does not provide specific information (i.e. floor plan) of the individuals' bedrooms.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. COO revised and re-sent letters to local fire departments. Revised letters will be sent via email attachment with other supporting documentation. 02/16/2024 Implemented
6400.110(e)The second-floor smoke alarm was inoperable and did not sound when the interconnected alarms were set off. There are currently unoccupied bedrooms on this floor. This home has three stories (basement, first floor, second floor). [REPEAT VIOLATION]If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Electrician came out and rewired the house, all smoke detectors are now working conjointly. 03/20/2024 Implemented
6400.110(g)Staff working in the home indicated that the second-floor inoperable smoke alarm was a previously known issue, someone came to the home to look into the repair but never returned and the issue was not resolved. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. We had an electrician come out in the last inspection and repair the smoke detector and the smoke detectors were repair. When having other work done it may have made the smoke detectors inoperative. The House Manager will notify all staff of any repair issue and make sure that it resolved with 48 hours of notification. 02/16/2024 Implemented
6400.111(f)The tags on all three fire extinguishers in the home (basement, first floor kitchen, and second floor) have the last date of inspection as November 2022. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire protection came out and inspected all fire extinguisher within the home on 02/16/24. All fire extinguishers have been examined and tagged with the 2024 date. 02/16/2024 Implemented
6400.144Individual 2 has several prescribed medications on the MAR which have not been present in the home since their admission. There were also other medications which were not available in the home for administration for the first two days of February. One medication was present in the home but listed as not administered for three days during the month of February without accompanying description reason. Specific medications and dates listed below: Not available since admission: · Genoya Tab, 1 tab per day for compromised immune system. · Selenium Solution lotion 2.5% apply once per day for seborrhea, red itchy flaky scalp. · Divalproex Tab 500mg DR 1 tab twice daily for mood instability. Not available February 1 & February 2: · Biktarvy 50-20-25mg tab, 1 tab daily for human immunodeficiency virus disease · Ketoconazole cream 2%-apply once every day for seborrhea · Risperidone tab 3mg-1 tab daily for schizophrenia · Solifenacin tab 10mg-1 tab daily for urine incontinence · Timolol Mal Sol 0.5%-instill one drop into affected eye once daily for glaucoma · Acetaezolamid Cap 500mg ER-1 capsule twice daily for glaucoma · Latanoprost Sol 0.005%-instill one drop into affected eye in the evening for glaucoma · Dorzal/Timol Sol instill one drop into right eye twice daily Medication present but not administered February 5, February 6 and February 7, 2024: · Timolol Mal Sol 0.5%-Instill 1 drop into affected eye once daily for glaucoma.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. Individual 2 came from a group home, and the medication list that was provided to us. We sent this list was sent to our pharmacy and the MAR was created. Our pharmacy reached out to the PCP on several occasions with no response back. The House Manager had to go to the office of the PCP provider to get a list of medication that are current and what medication was discontinued. This information has been sent to our Pharmacy to update the MAR for next month. 02/23/2024 Implemented
6400.216(a)Boxes of individual records were found to be in an unlocked area of the basement. An individual's records shall be kept locked when unattended. Progam Specialist relocated confidential records to a locked room in the basement. 02/16/2024 Implemented
6400.167(b)For individual 2, there were no corresponding reasons listed on the back of the MAR stating why the medications were not able to be administered.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Retrain staff on how to document on the MAR when medication is unavailable at the time. 02/26/2024 Implemented
6400.167(c)For individual 2, there is no documentation of medication errors due to the individual not receiving prescribed medications and there are no corresponding incident reports relating to these medication errors.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Incident number (9383543) has been created for the medication errors. 03/04/2024 Implemented
SIN-00220482 Renewal 03/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(c)For staff 1, the provided criminal background check (from 2019) was completed more than two years prior to the indicated DOH (9/20/22); the more recently completed background check was completed four months after the indicated DOHThe Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire. Staff #1 was originally hired in 2019. Staff #1 left in Feb 2022 and returned in Sept 2022. Criminal history clearance reprocessed on 2/15/23. 02/15/2023 Implemented
6400.110(e)The home is three levels and the smoke detectors are not interconnected. The smoke detector on the third floor is inter-connected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Homes have hardwired, interconnected smoke detectors and separate carbon monoxide detectors. Video demonstrating interconnected smoke detectors being activated is attached. 02/15/2023 Implemented
SIN-00200462 Renewal 02/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct support staff #5, hired 10/6/21 did not have a PA state criminal check completed. Direct support staff #4, hired 12/7/21 did not have a PA state criminal check completed. Direct support staff #6, hired 11/30/21 did not have a PA state criminal check completed. [REPEATED NON-COMPLIANCE 1/26/21]An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Staff¿s state police clearance was not in file at the time of inspection. Clearance was emailed to licensing for review (attachment: LB_clearance). 03/15/2022 Implemented
6400.43(c)It cannot be determined if staff #1 meets the education and work experience requirements to be CEO as their job history nor their degree verification were provided at the time of inspection. Only their unofficial transcript was provided which does not show if a degree was awarded or not. A chief executive officer shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years work experience in administration or the human services field. The CEO's qualifications of their education and experience were not provided at the time of inspection. A copy of the CEO's degree (attachment: CEO_degree) and resume (attachment: CEO_resume) , were added to CEO's file and have been emailed to licensing for review. 02/24/2022 Implemented
6400.62(c)There was an unlabeled cleaner under the sink in the first floor bathroom. [REPEATED NON-COMPLIANCE 1/26/21]Poisonous materials shall be stored in their original, labeled containers. An unlabeled spray bottle with an undetermined liquid was under the first floor bathroom sink. Since spray bottle had no label and type of liquid was unknown, it was assumed to be a poisonous material, and the bottle was immediately removed and disposed of. 03/31/2022 Implemented
6400.62(d)There was all-purpose cleaner and a Pop-Tart located together under the sink in the second floor bathroom.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.An all-purpose cleaner and a pop-tart were located together under the second floor bathroom sink, posing a potential danger from poisonous substances and food being kept together. Both were removed immediately, and cleaner was put away in storage cabinet and pop-tart was disposed of. 03/31/2022 Implemented
6400.77(b)The first aid kit was missing antiseptic, tweezers, tape, scissors and a thermometer. [REPEATED NON-COMPLIANCE 1/26/21] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. First aid kit was not complete in its contents at the time of inspection. First aid kit was restocked with required items - antiseptic, bandages, gauze pads, thermometer, tweezers, tape, and scissors. Syrup of Ipecac is not needed in the homes as we do not serve any individuals under age 5 or who might ingest poisonous substances. Photo of complete first aid kit emailed to licensing (attachment Davis_first_aid_kit) 03/31/2022 Implemented
6400.112(c)A written record is to be kept for all fire drills; the form used by the agency for Davis Ave. did not mention the exit route used on 6/03/21, 05/05/21, 02/08/21 or 1/1/21.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. For the fire drills for Jan, Feb, May and June 2021, the exit route was not indicated. This form was revised in February 2021 to include the exit route. All blank fire drill forms have been removed from circulation and a new form, revised 2/2022, has been put into use moving forward (attachment NEW_FIRE_DRILL_FORM_0222) starting with March 2022 Fire Drill. 03/31/2022 Implemented
6400.112(c)The fire drill conducted on 6/3/21was not completed, no summery or problems encountered or if alarm was workingA written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. For June 2021 Fire Drill, reporting form was not entirely completed. Summary, problems encountered, and whether smoke alarm was activated & operating fields were left blank. A new fire drill reporting form was created 2/2022 and COO will retrain House Manager and Direct Support Staff on Fire Drill protocols to be implemented with March 2022 fire drills. COO will train House Manager on completing the new fire drill reporting form. 03/31/2022 Implemented
6400.52(a)(2)It cannot be determined if direct support staff # 3 and 4 completed 24 hours of annual trainings for the year of 2021 completed, as verification was not provided at the time of inspection.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct supervisors of direct service workers.Staff #3 and #4 annual trainings were not present at the time of inspection. Staff¿s orientation, fire safety, medication administration to be emailed to licensing for review for review. (attachment: DSP_training) 03/31/2022 Implemented
6400.52(a)(3)It cannot be determined if staff #2 whom serves as the agency's program specialist completed 24 hours of annual trainings for the year of 2021 completed, as verification was not provided at the time of inspection. [REPEATED NON-COMPLIANCE 1/26/21]The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.Program Specialist¿s documentation of yearly 24 hours of training was not available at the time of inspection. Documentation was obtained from Program Specialist, placed in his file to be emailed to licensing for review (attachment: PS_training) 03/31/2022 Implemented
SIN-00183408 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)No overnight fire drills were performed at the program on Davis Ave for a 1 year period, from January 2020 -- January 2021A fire drill shall be held during sleeping hours at least every 6 months. To ensure fire drills are completed, including overnight/sleeping hour drills at least every six months, the house manager will create fire drill schedule and carry it out in each home. The house manager will complete the fire drill documentation and submit it for review to the Program Specialist monthly. Implemented
6400.112(f)Exit routes were not documented on the fire drill documentation for all fire drill forms provided.Alternate exit routes shall be used during fire drills. To ensure that fire drill documentation is accurate and complete, the house manager will create a fire drill schedule and carry out the fire drills, alternating and documenting exit routes for each home. Fire drill documentation will be submitted monthly to the Program Specialist for review. 04/01/2021 Implemented
6400.141(a)Most recent physical provided for INDIVIDUAL #1 is dated 9/12/19. This is greater than 4 months past the 12 month requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Most recent physical for individual #1 was dated 9/12/2019. Individual was not able to have a physical during 2020 due to COVID-19. His physical was scheduled as soon as his practitioner began seeing patients in person again. Physical dated 2/19/2021 was emailed for review. 02/19/2021 Implemented
6400.141(c)(14)Medical information pertinent to diagnosis and treatment incase of an emergency not filled out on the physical dated 7/22/20 for individual #2The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical for individual #2 dated 7/22/2020 did not contain medical information related to her diagnosis and treatment in case of emergency. We have contacted her psychiatrist and primary care physician to provide this information in writing as her diagnoses are primarly psychiatric. Once sent to us, we will forward for review. 10/04/2021 Implemented
6400.142(a)No dental exam provided for individual #1 at time of inspection.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. No dental exam provided for individual #1 at time of inspection. Individual #1 was not able to see the dentist during 2020 due to COVID-19. Individual #1 had a dental exam on 3/22/21. Documentation was emailed for review. 03/22/2021 Implemented
6400.181(a)No assessment was provided for individual #2 Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. No assessment was provided for individual #2. Assessment was completed on 04/03/2020 and emailed for review. 02/01/2021 Implemented
6400.181(e)(10)Assessment for individual #1 dated 6/3/20 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. Assessment for individual #1 did not include a lifetime medical history. Individual #1's lifetime medical history was emailed for review. 02/01/2021 Implemented
6400.217Documentation of release of information for individual #1 not provided at time of inspection. Documentation of release of information for individual #2 not provided at time of inspection.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Documentation of release of information for individual #1 and 2 was not provided at time of inspection. Individual #2's release of information was emailed for review 02/01/2021 Implemented
6400.31(b)No evidence of individual rights training provided to individual #1 No evidence of individual rights training provided to individual #2The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights.Individual rights training documentation was not provided for individuals #1 and #2. Individuals #1 and 2's rights training was emailed for review. 02/01/2021 Implemented
6400.163(a)There was a bottle of Risperidone prescribed to Individual #1 that indicated on the label that its strength was 1mg. The staff person #1 stated that it was .5 mg and went on to say that the wrong dosage was in the bottle. The Medication Administration Record called for .5, but both label and record did not match.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.A bottle of risperidone prescribed to individual #1 indicated on the label that its strength was 1mg. The staff person #1 stated that it was .5 mg and went on to say that the wrong dosage was in the bottle. The MAR called for .5mg but both label and record did not match. Individual #1 was prescribed 1.5 mg of risperidone in the morning. Because his insurance did not cover the 0.5 mg, the pharmacy sent his dosage in two separate blister packs, and it was listed on the MAR as two separate medications: 1mg and .5 mg. That morning, he was administered 1mg from the blister pack, and the last dose of .5mg from the second blister pack before new meds were delivered that afternoon, which was why there was no .5 mg blister pack for AM medication in his box. No medication was being administered from the bottle of risperidone, and it was removed from his medication box. We consulted with EIM regarding the situation, and they determined no medication error occurred. 02/01/2021 Implemented
6400.163(d)There were several packets of over the counter medications included in the first aid kit including Diphenhydramine and Aspirin.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Over-the-counter medications were included in the first aid kit. First aid kits were re-checked and OTC medications (aspirin and diphenhydramine) were removed and disposed of. Photos of first aid kids were emailed for review. 01/28/2021 Implemented
6400.167(a)(3)Due to the discrepancy of the MAR and the label on the Risperidone 1mg bottle, it was determined that the wrong dosage of the medication was being administered to Individual #1.Medication errors include the following: Administration of the wrong dose of medication.Due to the discrepancy between the MAR and the label on the 1mg risperidone bottle, it was determined that the wrong dosage of medication was being administered to individual #1. Individual #1 was prescribed 1.5 mg of risperidone in the morning. Because his insurance did not cover the 0.5 mg, the pharmacy sends his dosages in two separate blister packs, and it is listed on the MAR as two separate medications: 1mg and .5 mg. That morning, he was administered 1mg from the blister pack, and the last dose of .5mg from the second blister pack before new meds were delivered that afternoon, which was why there was no .5 mg blister pack for AM medication in his box. No medication was being administered from the 1mg bottle of risperidone, and it was removed from his medication box. We consulted with EIM regarding the situation, and they determined no medication error occurred. 02/01/2021 Implemented
6400.181(f)No documentation provided that shows the assessment dated 6/3/20 for individual #1 was sent to the team at least 30 days prior to meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.No documentation provided that shows the assessment dated 6/3/20 for individual #1 was sent to the team at least 30 days prior to meeting. An email with assessment was sent to the team on 4/21/21. The meeting had to be rescheduled several times and eventually occurred on 5/17/21. Copy of email sent to team was emailed for review. 04/21/2021 Implemented
6400.183(b)No record of attendees provided for individual #1 ISP meeting No record of attendees provided for individual #2 ISP meetingAt least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.A record of attendees at Individuals #1 and #2 ISP meetings was not provided. To ensure a record of the minimum number of attendees are present at an individual's ISP meeting, under normal circumstances, a sign-in sheet is completed by all attendees at the meeting. Since 3/2020, all ISP meetings have been held virtually due to the pandemic, and no physical sign-in sheet with signatures was created. SCs have emailed sign-in sheets with record of attendees, but no signatures. Once ISP meetings are held in-person again, sign-in sheets will contain signatures. Copies of ISP sign-in sheets will be emailed for review 01/31/2021 Implemented
6400.213(7)ISP Documentation not provided at the time of inspection for individual #1Each individual's record must include the following information: Individual plan documents as required by this chapter.ISP documentation was not provided at time of inspection for individual #1. ISP invite letter and sign-in sheet emailed for review. Please note virtual annual ISP meeting took place 4/21/21, after inspection. 03/15/2021 Implemented
SIN-00154808 Renewal 04/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The sofa on the second floor was torn on the left arm.Floors, walls, ceilings and other surfaces shall be in good repair. Upholstery repair kit has been ordered and sofa arm will be repaired. Estimated arrival date is 5/30/19. Documentation of repair will be sent once completed. Moving forward, house managers will check furniture monthly to ensure that all furniture is in good condition. 05/30/2019 Implemented
6400.112(h)All of the Fire Drills did not include a meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A section for the meeting place at each house was added to the fire drill record (examples supplied via email.) 04/26/2019 Implemented
6400.141(a)Individual # 1 had NO INTIAL PHYSICAL EXAM PRIOR TO ADMISSION PHSYCIAL COMPLETED 1/14/2019An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Prior physical exam documentation copies were requested from healthcare practitioner. Moving forward, individuals' annual physical documentation will be kept in individuals' records, and the program specialist will conduct periodic reviews to ensure files are complete and current. 05/31/2019 Implemented
6400.141(c)(6)Individual #1 Record did not include a Tuberculin skin test.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. TB test documentation was requested from healthcare practitioner. Moving forward, individuals' TB test results will be kept in individuals' records, and the program specialist will conduct periodic reviews to ensure files are complete and current. 05/31/2019 Implemented
6400.213(1)(i)Individual #1 Record did not indicate primary language of communicationEach individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Individual's primary language of communication was added to their face sheet (supplied via email). Moving forward, face sheets will be completed and annually updated by Program Specialist. COO will double check face sheets are complete and accurate. 04/26/2019 Implemented
6400.213(1)(i)Individual # 1's Religious affiliation was not found in the record.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Individual's religious affiliation was added to the face sheet (supplied via email). All other face sheets were checked to ensure this field was complete. Moving forward, face sheets will be completed and annually updated by Program Specialist. COO will double check face sheets are complete and accurate. 04/26/2019 Implemented