Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222999 Renewal 04/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The fire extinguisher located throughout the home was not inspected annually. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The CEO contacted the Philadelphia Pa Fire Protection Co. and had fire extinguisher services scheduled for 5/22/23. 05/22/2023 Implemented
6400.141(c)(14)Individual #3's annual physical dated 1/24/23 did not include information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. A staff meeting and medication training were both conducted on May 10th in which all staff was informed that when escorting participants to any appointments, staff are to make sure that all forms are completed in its entirety with no lines left blank to prevent missing information such as the information pertinent to #3s diagnosis not documented on his physical. 05/10/2023 Implemented
6400.144Individual #3's medication CERTIRIZINE TAB not in the individual's med box but signed by staff as administered all month including today 04/17/2023.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. Due to the amount of medication citations found on 4/17/23 during ODP¿s licensing the CEO mandated all SCALP staff to attend medication training scheduled on 5/10/23, to minimize unwanted medication errors by participating in a refreshers course to prevent encounters such as #3s medication not being inside the box where it belongs and documenting properly as required by state regulations. 05/10/2023 Implemented
6400.165(c)Individual #3's medication(s) LITHIUM CARB CAPS 300mg, HALOPERIDOL TAB 10mg, is not being administered as prescribed.A prescription medication shall be administered as prescribed.The CEO mandated all SCALP staff to attend medication training scheduled on 5/10/23, to minimize unwanted medication errors by participating in a refreshers course to prevent encounters such as #3s medication not being inside the box where it belongs and documenting properly as required by state regulations. 05/10/2023 Implemented
SIN-00204797 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)There was trash and debris that lined the back exit walkway at the kitchen exit and needs to be cleaned.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The trash and debris was cleared out immediately after the inspection was conducted on 4/20/2022. 04/20/2022 Implemented
6400.71There were no emergency numbers found at or near the telephone in the living room area.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. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center etc. was printed out and taped down near each landline telephone at the facility. 04/23/2021 Implemented
6400.72(a)There was no screen found in the window in an unoccupied bedroomWindows, including windows in doors, shall be securely screened when windows or doors are open. The CFO who¿s also owns a licensed construction company, had 1 of his contractors come conduct measurements and the missing screen was replaced on 4/23/22. 04/23/2022 Implemented
6400.76(a)The headboard in Individual #2's bedroom is not secure and needs to be secured to the bed frame. Furniture and equipment shall be nonhazardous, clean and sturdy. The CFO who¿s also owns a licensed construction company, had 1 of his contractors come out and secure the headboard to individual #2's bedframe, making it sturdy on 4/23/22. 04/23/2022 Implemented
6400.142(e)Individual #2 was ordered to have 4 teeth extracted during the dental visit on 3/5/2020. The exam form states that those 4 teeth were impacted and infected. There was another referral made during the dental visit on 3/15/2021. As of most recent dental visit on 4/16/2022, those same 4 teeth have not been extracted.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The program specialist contacted "Special Smiles" and had Individual #2 dental appointment scheduled for 6/29/22 for teeth extractions. 04/20/2022 Implemented
6400.144Individual #2's ISP states that he is currently being prescribed "Deep Sea Premium Saline .06% Spray" for Congestion, however this medication was not listed on the MAR, nor was it present during the time of inspection.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. The program specialist and/or house manager will participate in individuals ISP meeting and was instructed to cross reference all medications listed and being updated on the ISP to coincide and match all medications/mgs that¿s documented on the providers MARS log as well as prescribed medications. 05/01/2022 Implemented
6400.163(d)There were medication boxes left in unlocked kitchen cabinets for both Individuals who reside in this home.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.During staff meeting on 5/1/22 all House managers were given new medication lock boxes with 3-digit lock codes to secure all medications at each facility. 05/01/2022 Implemented
6400.165(b)During the medication review for Individual #2, Lithium carb cap 300 mg 8am blister pack has 11 pills left. Lithium card cap 300 mg 8pm blister pack has 9 pills left. There are no notes on the MAR or on blister packs to determine if this is an accurate count. Staff was not able to explain the excess/shortage of meds at the different times of day.A prescription order shall be kept current.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(c)During the medication review for Individual #2, Lithium carb cap 300 mg 8am blister pack has 11 pills left. Lithium card cap 300 mg 8pm blister pack has 9 pills left. There are no notes on the MAR or on blister packs to determine if this is an accurate count. Staff was not able to explain the excess/shortage of meds at the different times of day.A prescription medication shall be administered as prescribed.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(c)Regarding Individual #2's medication review: the Cetirizine 10mg (to be administered at 8am) was not recorded as administered on the MAR.A prescription medication shall be administered as prescribed.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(c)Regarding Individual #2's medication review: the Haloperidol 10mg tab (to be administered 8am and 8pm). The 8 PM blister pack suggests 21 pills were administered, when it should be only 20 administered (as of the morning of 4/21/22). It could not be determined when this medication was administered as a result.A prescription medication shall be administered as prescribed.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(c)Regarding Individual #2's medication review: the Clonidine 0.1mg is the be administered 3 times a day (8am,5pm,8pm). The 8am dosage was not signed out for on MAR on 4/21/22. it could not be determined if the medication was administered as it was not recorded on the MAR.A prescription medication shall be administered as prescribed.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(e)Regarding Individual #2's medication review: the Guaifenesin 600mg tab is listed on the blister pack as to be administered at 8am & 8pm. However, the MAR lists this medication as a PRN-1 by mouth 2x's a day for mucus as needed. There were 2 blister packs for each time of day of this medication, none was used.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(e)Regarding Individual #2's medication review: the Naproxen 250mg is listed on the blister packs as to be administered twice a day at 8am & 8pm. However, the MAR lists the Naproxen 250mg tab as needed for pain (PRN) If the prescriber changed the order the mar and blister packs must be updated to reflect the change. The staff wrote (PRN) on the existing medications that list the meds to be given twice a day.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. 05/01/2022 Implemented
6400.165(g)There was a 5-month lag time between Individual #2's most recent psych med reviews. The Individual was seen on 10/13/21, then not again until 3/30/22.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.The medical liaison scheduled individual #2's psych med review for 6/09/22. 06/09/2022 Implemented
6400.166(b)Regarding Individual #2's medication review: the Cetirizine 10mg (to be administered at 8am) was not recorded as administered on the MAR.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. 05/01/2022 Implemented
6400.166(b)Regarding Individual #2's medication review: the Clonidine 0.1mg is the be administered 3 times a day (8am,5pm,8pm). The 8am dosage was not signed out for on MAR on 4/21/22. it could not be determined if the medication was administered as it was not recorded on the MAR.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. 05/01/2022 Implemented
6400.166(d)Regarding Individual #2's medication review: the Clonidine 0.1mg is the be administered 3 times a day (8am,5pm,8pm). The 8am dosage was not signed out for on MAR on 4/21/22. it could not be determined if the medication was administered as it was not recorded on the MAR.The directions of the prescriber shall be followed.All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. 05/01/2022 Implemented
6400.166(d)Regarding Individual #2's medication review: the Cetirizine 10mg (to be administered at 8am) was not recorded as administered on the MAR.The directions of the prescriber shall be followed.All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. 05/01/2022 Implemented
6400.166(d)Regarding Individual #2's medication review: the Haloperidol 10mg tab (to be administered 8am and 8pm). The 8 PM blister pack suggests 21 pills were administered, when it should be only 20 administered (as of the morning of 4/21/22). It could not be determined when this medication was administered as a result.The directions of the prescriber shall be followed.All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. 05/01/2022 Implemented
6400.166(d)Regarding Individual #2's medication review: the Naproxen 250mg is listed on the blister packs as to be administered twice a day at 8am & 8pm. However, the MAR lists the Naproxen 250mg tab as needed for pain (PRN) If the prescriber changed the order the mar and blister packs must be updated to reflect the change. The staff wrote (PRN) on the existing medications that list the meds to be given twice a day.The directions of the prescriber shall be followed.All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. 05/01/2022 Implemented
SIN-00163645 Renewal 07/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water in the home was found to be 130° Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. An in-service staff meeting was conducted on 8/4/19 to address the issues and concerns of violations found during inspection. The house managers were instructed to do weekly water temperature checks and was instructed to contact anyone from the administration staff if any temperature was above 120* The administration staff will have the water corrected within 24hrs. 08/04/2019 Implemented
6400.112(f)On the Fire Drill Form dated 6/15/18 and 7/16/18 the form was incomplete and failed to log the exit routes used, the Time it took, and if the fire drills were conducted during awake or sleep times.Alternate exit routes shall be used during fire drills. An in-service staff meeting was conducted on 8/4/19 to address the issues and concerns of violations found during inspection. Staff was informed and retrained on Fire Drill procedures and documentation expectations. 08/04/2019 Implemented
6400.141(c)(10)Individual #1's annual physical exam dated 10/02/2018 did not indicate if the individual was free of communicable diseases.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Participant #1 had an annual physical exam completed on 10/4/19 that includes communicable disease section completed 10/04/2019 Implemented
6400.141(c)(11)Individual #1's annual physical exam dated 10/02/2018 did not indicate assessment of health maintenance.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Participant #1 had an annual physical exam completed on 10/4/19 that includes assessment of health maintenance needs, medication regimen and need for blood work at recommended intervals. 10/04/2019 Implemented
6400.141(c)(14)Individual #1's annual physical exam dated 10/02/2018 did not indicate information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Participant #1 had an annual physical exam completed on 10/4/19 that includes medical information pertinent to diagnosis and treatment in case of emergencies. 10/04/2019 Implemented
6400.181(e)(14)For Individual #1, the assessment dated 11/20/2018 did not indicate the ability to swim or knowledge of hot water.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Participant #1's initial assessment has been completed with an addendum (on 7/23/19) expressing his knowledge of water safety and his ability to swim as stated in his ISP from that date of time. His progress and current knowledge will be updated on 11/20/19 and will have his knowledge of water safety and ability to swim on it as well. 07/23/2019 Implemented
6400.165(f)Individual #1 takes psychotropic medications and there were no psychotropic medication reviews in the record.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Participant #1 psychiatrist was unavailable to complete reviews and rescheduling wasn't done. The program specialist contacted COMHAR on July 29th 2019 and scheduled an appointment with a new Psychiatrist by the name of Dr. Bird who have conducted a 90 day psychotropic medication review on 10/22/19. and all further reviews will meet the required expectation. As a back up plan is the psychiatrist is unavailable to conduct a review participant #1 will meet with his PCP to complete assessment. 10/22/2019 Implemented
SIN-00131770 Renewal 04/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Hot water temperature was 136.4 degrees Fahrenheit. This was corrected prior to leaving the property and the temperature later registered at 109.4 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The Hot water temperature was adjusted during the inspection when it read at 136.4. The temperature currently reads at 119.3 Fahrenheit as of 6/1/18. 06/01/2018 Implemented
6400.77(b)There was no thermometer in the first aid kit. 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. There was a thermometer placed in the first aid kit on 4/27/18 immediately following the inspection. All first aid kits will possess all required content to meet expectations. 04/27/2018 Implemented
6400.80(b)Exit in the kitchen has debris in the walkway. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The debris has been cleaned up in the walkway exit of the kitchen. Pictures has been taken and weekend staff has been informed to follow a check off list that ensures that the physical plant and around the facility is clean of any debris to safely exit for fire drills and pathways. A checklist will be presented as evidence. 05/05/2018 Implemented
6400.141(a)No updated physical available on date of admission 8/30/17.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. a physical was conducted for individual # 1 on 7/27/17 before his admission date and a copy of the physical form will be submitted as evidence. 04/27/2018 Implemented
6400.142(a)No dental exam available.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. A Dental exam was conducted on 5/2/18. 05/02/2018 Implemented
6400.164(a)Medication Proventil(PRN)-(2 puffs by mouth every 6 hours as needed for wheezing), was in the medication box, however, it was not listed on the Medication log.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. On the medication log the listed medication was documented as Albuterol (which is the same as Proventil). A training was held for our program staff on 5/5/18, where they were reminded to document all prescribed medications as it is stated on the actual prescription word for word to meet regulation requirements. 05/05/2018 Implemented
6400.181(e)(12)No recommendations included in the assessment.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The initial assessment will be completed within the 1st 60 days of their move-in-date and annually thereafter, completed with recommendations for specific areas of training, programming and services. The assessment will be revised on 6/1/18. 06/01/2018 Implemented
6400.183(4)No protocol schedule outlining time without direct supervision.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. An ISP Meeting was conducted on 6/19/18 to address and implement a protocol outlining time without direct supervision. An ISP review form will be forwarded as evident of ISP revision. 06/19/2018 Implemented
6400.183(5)No protocol in ISP to address SEEP.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. An ISP Meeting was conducted on 6/19/18 to address and implement a SEEP Plan. During this meeting the SC, Program Specialist and Behavioral Specialist agreed to consult and gather information to create a plan and have it completed by 7/16/18 (Monday). 07/16/2018 Implemented
6400.184(a)No review meeting held to develop and update goals/outcomes. The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 6400.186 (relating to ISP review and revision). Review meetings/monitorings are held monthly and the SC's give the program a goal sheet after each meeting. However the SCALP Program LLC will now utilize the sheets given from the SC to develop and document, goals and outcomes discussed to be placed in the individuals chart for meeting review expectations. This will be conducted on 6/14/18 which is the next scheduled team meeting. 06/14/2018 Implemented
6400.186(a)No ISP quarterly review and signatures.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The Next quarterly review and signatures are scheduled to be completed on 6/13/18. 06/13/2018 Implemented
6400.186(c)(1)No ISP monthlies available.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. The ISP monthly was completed on 5/2/18 and 6/1/18 (to bring us up to date). 05/02/2018 Implemented
SIN-00186377 Renewal 04/20/2021 Compliant - Finalized