Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230777 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The home's furnace was inspected and cleaned on 1/12/22, and then again on 2/2/23. This exceeds the annual requirement.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. Not Forgotten scheduled all furnace at all sites be inspected and clean twice a year (April and October) be a licensed HVAC company-Admiral Heating and Cooling. 09/21/2023 Implemented
SIN-00194707 Renewal 10/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There is not a source of light at the outside doorway leading from the laundry room in the basement to the patio in the rear of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Immediate Action: The light on the back porch was repaired the same day of inspection. Three photos of the completed worked was sent to licensing the same day. 11/29/2021 Implemented
6400.141(c)(14)Individual #1's most recent physical examination, completed 9/7/2021, did not include medical information pertinent to diagnosis and treatment in case of an emergency. Separate documentation with medical information was provided to the Department; however, compliance could not be measured since the physician had not dated or signed the document.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Immediate Action: To ensure the previous medical information pertinent to diagnosis, had been reviewed. NFHCS has resubmitted the original addendum form for review and signature for Individual #1 . In addition, NFHCS has conducted an audit of all of our Residential Individuals original addendum. And has sent them to their MD, who completed the physical for acknowledgement and signatures. 11/29/2021 Implemented
SIN-00139291 Unannounced Monitoring 07/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 11:48AM, the hot water temperature measured 125.6°F in the shower in the bathroom in the hallway on the first floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. Person Responsible-House manager Action-(1) Not Forgotten adjusted hot water temperatures in bathtubs and showers may not exceed 120°F. (3) Not Forgotten will monitor weekly the temperatures with a weekly tracking sheet.Protocol-Residential staff will perform a weekly check to make sure of water temperatures in bathtubs and showers may not exceed 120°.House Manager will perform monthly inspection of all physical facility and will record finding on a checklist. If problems exist, HM will notify her direct supervision of any problems and will immediately fixed the problem.Monthly inspection was completed. [Immediately, all staff persons responsible for monitoring hot water temperatures shall be educated by a designated management staff person on the accurate measuring, documentation and procedures for adjusting hot water temperature. Documentation of the trainings shall be kept. Immediately and at least daily for 1 week after a temperature adjustment and continuing at least weekly, a designated trained staff person shall measure hot water temperature at all bathtubs and showers to ensure the hot water temperatures in bathtubs and showers may not exceed 120°F. Immediately, after water temperature adjustments and at least weekly for month and then continuing at least monthly, the program specialist shall interview the individuals living in all the community homes home to ensure the water temperature is at a comfortable temperature. (DPOC by AES,HSLS on 8/30/18)] 08/25/2018 Implemented
6400.161(b)There was a bottle of maximum strength stomach relief that was unlocked and accessible in the trifold cabinet in the bathroom in the hallway on the first floor of the home. There was tube of hydrocortisone cream with a label that stated ''If swallowed contact poison control right away'' that was unlocked and accessible in the first aid kit. Individual #1 is not assessed to safely use or avoid toxic materials including medications and poisons.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. Person Responsible-House Manager Action-Not Forgotten performed an internal investigation. it was determined that no staff were responsible in bringing the maximum strength stomach relief in the home. The mother of a client, who was notified by Not Forgotten prior, she was not to bring any form of medication in the house unless approved by the Nurse. Not Forgotten notified parent about the matter reiterated the protocol to her in notifying the nurse in the future. Staff was retrained to follow the 55 PA Code Chapter 6400.112(d) that Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual¿s assessment that each individual in the home can safely use or avoid toxic materials.The bottle was immediately removed.Protocol- Staff will be retrained by 8/25/2018 and mother was notified 7/27/2018 to follow Not Forgotten protocol. [Immediately, the CEO or designee shall develop and implement policies and procedures to ensure prescription and potentially toxic nonprescription medications are kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials and that individuals are administered medications as prescribed including over the counter medication's. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person working in community homes of the policies and procedures. Documentation of the trainings shall be kept.(DPOC by AES,HSLS on 8/30/18)] 08/25/2018 Implemented
SIN-00126921 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70The home did not have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Persons Responsible-Program Specialist & Program Coordinator Action-An operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons was added to the house.Protocol- Program Specialist and Program Coordinator will create checklist to make sure have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons according to regulations are covered. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection to make Not Forgotten is in compliance and will report issues and concerns to the quality management team. Next inspection will be 3/9/2018. [Immediately, prior to opening new homes and at least quarterly for 1 year, the CEO and a designated management staff person shall complete an onsite checks of all community homes to ensure compliance with all physical site regulations as per 6400. 61-86. Documentation of the onsite audits shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
6400.77(a)The home did not have a first aid kit. A home shall have a first aid kit. Persons Responsible-Nurse Coordinator Action-the first aid kit was installed Protocol-Nurse Coordinator is creating an inventory checklist and will train Residential Staff to follow daily. If an item is missing, the RS will notify NC. The NC will investigate what happen and will the protocol of her findings. The items will be replaced immediately in the first kit to make sure the health and safety of the individual is being met.All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of trainings and documentation of inventory checklist to make sure Not Forgotten is in compliance and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. [Immediately, prior to opening new homes and at least quarterly for 1 year, the CEO and a designated management staff person shall complete an onsite checks of all community homes to ensure compliance with all physical site regulations as per 6400. 61-86. Documentation of the onsite audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall educate all staff persons working in community homes of the required items in first aid kits and the agency's replacement and replenishment procedures to ensure all required items are in first aid kits at all times. Documentation of trainings shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
6400.111(a)There was not a fire extinguisher in the basement of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Person Responsible-Maintenance Facilitator Action-At least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic was added to each floor. Protocol-Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing fire extinguisher. MF will follow protocol of immediately replacing, adding fire extinguisher (s). [Immediately, prior to opening new homes and at least quarterly for 1 year, the CEO and a designated management staff person shall complete an onsite checks of all community homes to ensure compliance with all fire safety regulations as per 6400.101-114. Documentation of the onsite audits shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
SIN-00161562 Renewal 08/06/2019 Compliant - Finalized
SIN-00154987 Unannounced Monitoring 04/26/2019 Compliant - Finalized