Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232216 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #1's annual physical examination, completed on 11/23/2022, did not include a review of the individual's medication regimen. This section stated "See attached"; however, no attachment was present.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. Serenity Care program director or other designee will ensure that all individuals' physical examination include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 10/13/2023 Implemented
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness. Individual #1's 90-day psychiatric medication reviews were completed on 9/3/2022 and again on 2/7/2023. The provider and physician's office confirmed via telephone that an appointment occurred via telehealth on 11/15/2022; however, no documentation of this appointment could be provided [Repeat violation 10/12/22, et. al. and 6/16/23].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.Serenity care staff will ensure that a prescription order shall be kept current, and prescription medication shall be administered as prescribed. Serenity care staff A prescription medication shall be used only by the individual for whom the prescription was prescribed. Serenity care staff will ensure that 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. 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. 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 documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. 10/13/2023 Implemented
SIN-00226848 Unannounced Monitoring 06/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The microwave in the kitchen contained splattered dried food particles on the inside of the appliance. The blinds in the second-floor full bathroom were covered with dirt and debris.Clean and sanitary conditions shall be maintained in the home. Serenity care staff will ensure that homes remain clean and in sanitary conditions. Serenity care staff will complete daily cleaning logs documenting the completion of daily mandatory cleaning shift responsibilities. Serenity care staff will deep clean homes weekly to ensure they are in regulatory compliance with Chapter 6400.64(a) . 07/15/2023 Implemented
6400.67(a)In the staff office, located on the second floor of the home, the ceiling had and area approximately one foot by six inches with peeling and bubbling paint and plaster and an area approximately three feet by two feet where the paint is stained brown from what appears to be previous water damage.Floors, walls, ceilings and other surfaces shall be in good repair. All peeling areas and bubbling paint within the home have been plastered and repainted. All areas with visible water damage have been checked to ensure no leaks and painted and replastered. 07/15/2023 Implemented
6400.67(b)In the living room, the wooden windowsill is broken and there are sharp protruding edges creating a potential hazard. Additionally, broken wood from the windowsill was laying on the floor below the window creating a hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The maintenance designee will ensure that all work orders are addressed within the priority of the issues, and all efforts towards fixing the maintenance order will be adequately and appropriately documented within the work order system. ( Including the use of outside vendors) Serenity care staff and maintenance designee will ensure that there are no potential hazards within the home and all safety measures are taken to ensure the area is secured until the work order is completed. Serenity care staff will monitor the activity in the area to ensure that any potential hazard does not harm the individual. 07/15/2023 Implemented
6400.72(a)The screen door located at the basement exit at the rear of the home had an approximately 1-inch gap at the bottom. This door is not providing a tight seal to prevent from infestation.Windows, including windows in doors, shall be securely screened when windows or doors are open. Serenity Care program director will conduct monthly checks to ensure that screens are still installed and submit work orders for the maintenance designee to fix any screens that need to be completely sealed. All staff of Serenity Care was trained and in-service on regulation 6400.72(a) and reported any screens not properly sealed immediately to the program director. 07/25/2023 Implemented
6400.74The exit located in the family room at the rear of the home leads to stairs that descend into the backyard. The nonskid adhesive on the second step from the bottom is not secured to the stair tread creating a potential slipping or tripping hazard.Interior stairs and outside steps shall have a nonskid surface. To ensure the safety of the individual and avoid any accidental falls, the maintenance designee will ensure that anti-skid surfaces are installed at the exit doors of the homes.. To ensure regulatory compliance and prevent violations of 55 PA code 6400.74. The maintenance designee will conduct monthly physical site inspections to ensure regulatory compliance. 07/15/2023 Implemented
6400.76(a)The blinds located on the windows in the dining room were observed with broken slats. A loveseat located in the small family room at the rear of the home was observed with broken down seat cushions and torn fabric on the seat cushions. Located in the vacant bedroom of the home was a dining room chair. This chair had a seat cushion covered with various stains. Furniture and equipment shall be nonhazardous, clean and sturdy. Serenity care staff will replace any broken or hazardous furniture with non-hazardous furniture. The Program Manager will ensure this site is well maintained according to 55 PA Code Chapter 640076(a) and that all furniture remains clean and sturdy. 07/15/2023 Implemented
6400.81(k)(2)The mattress and box spring in individual #1's bedroom were soiled and had several areas of brown discoloration.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Serenity care staff will replace all soiled mattresses with new ones and ensure all mattress covers are washed weekly to ensure that the bed is protected and maintained in compliance with 55 PA Code Chapter- 6400.81(k)(2). 07/15/2023 Implemented
6400.83(c)In individual #1's bedroom multiple plates, bowls, and utensils that were used and some still containing food were located inside the chest of drawers, on the nightstand, and on the bedroom floor.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.Serenity care staff will ensure that all dishes are properly washed and disinfected, and stored in the proper storage areas in the designated area in the kitchen. Serenity care staff will do room checks to ensure that individuals' rooms are free of soiled or dirty dishes. 07/15/2023 Implemented
6400.105In the basement of the home, the lint trap on the dryer was observed with a thick layer of lint creating a potential fire hazard.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Serenity care staff will check dryers after each use to ensure no excess lint buildup. The Program Director or other leadership designee will complete weekly on-site inspections to ensure dryers are free of fire hazards. 07/15/2023 Implemented
6400.163(d)Sodium Fluoride 5000 ppm prescription toothpaste was being stored unlocked in the second-floor full bathroom.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Serenity Care will ensure that all prescription medication, including toothpaste, will be locked and stored in the designated area. Serenity care staff will ensure the MAR is correctly documented daily. 07/15/2023 Implemented
6400.165(b)Individual #1 is currently using Sodium Fluoride 5000ppm prescription toothpaste. No current order for this medication is on file.A prescription order shall be kept current.Serenity Care will ensure that all prescription medication, including toothpaste, has the correct corresponding MAR for the prescription medication in the designated MAR book and or Electronic MAR system. Serenity care staff will ensure that the MAR is appropriately documented with daily use. 07/15/2023 Implemented
6400.166(a)(13)The June 2023 medication administration record did not include the name and initials of the person(s) administering the medications to individual #1 on 6/3/2023 at 8:00PM, 6/4/2023 at 8:00AM, 6/10/2023 at 8:00PM, 6/11/2023 at 8:00AM, and 6/13/2023 at 8:00AM.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Serenity Care will ensure that A medication record shall be kept for each individual for whom a prescription medication is administered. Serenity Care will ensure that if an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. 07/15/2023 Implemented
SIN-00226291 Unannounced Monitoring 06/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)In the drawers of Individual #1's dresser, there was multiple dirty bowls, plates, and silverware, there was a bowl of molded baked beans, half-eaten chicken wings, and other molded foods that were unable to be identified due to their state of decomposition. On top of Individual #1's dresser there was a plate of half-eaten chicken wings, multiple containers of condiments, and open bottles of hot sauce. On Individual #1's bedroom floor, there were crumbs of food located throughout the room and a spilled bag of Cheetos was located in between the dresser and the be. In individual #1's bedroom, there was trash located under the entirety of bed to include empty beverage containers, food containers, and food wrappers. In individual #1's bedroom, there was a bag located behind the dresser that included a banana peel that was black. In individual #1's bedroom, the bed had a pile of dirty sheets and blankets laying in the center of the mattress there were no sheets on the mattress, the mattress and box spring were both very dirty with several large areas of brown stains. The odor in individual #1's bedroom was very pungent, making it difficult to breathe. The toilet in the bathroom adjacent to individual #1's bedroom was covered with urine and feces, and there was urine on the floor around the toilet. The bathtub in the bathroom adjacent to Individual #1's bedroom was covered with dirt, hair, and soap scum on the entire surface.Clean and sanitary conditions shall be maintained in the home. Immediately, the agency will clean the entirety of the home to ensure it meets the minimum standards as set forth in the 6400 regulations. 07/07/2023 Implemented
6400.82(f)The bathroom located adjacent to Individual #1's bedroom did not contain toilet paper, individual clean paper or cloth towels, or a trash receptacle.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Immediately, the CEO or designee shall ensure all bathrooms in all homes shall meet the standards set forth in 6400.82f. 07/07/2023 Implemented
6400.84(a)Clean bed linens, washcloths, towels, and clothing could not be located for individual #1. Dirty laundry was scattered throughout the home to include individual #1's bedroom, the second-floor bathroom, and in the basement near the washer and dryer.Bed linens, towels, washcloths and individual clothing shall be laundered at least weekly. Immediately, the CEO or designee shall ensure all individuals in all home have bedlinens, towels, washcloths, and individual clothing. 07/07/2023 Implemented
6400.171In the refrigerator there was a Styrofoam container that included leftover food from an unknown date, this container was not fully covered. There was also a brown paper bag that was rolled up that contained what appeared to be French fries.Food shall be protected from contamination while being stored, prepared, transported and served. Immediately, the CEO or designee shall check all food in all homes to ensure it is protected from contamination. 07/07/2023 Implemented
6400.163(a)The following medications were found at the bottom of Individual #1's dresser: Fluoxetine HCL 20 MG, Divalproex Sodium 500 MG, Lithium Carbonate 450 MG, Lodipine Besylate 10 MG, Quetiapine Fumarate 200 MG, and Losartan Potassium 50 MG. These medications were loose in the bottom of the dresser and were not being stored in their original labeled containers. Individual #1 is not able to self-administer medications.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Immediately, the CEO or designee shall ensure all medications for all individuals who are not able to self-administer medications have been locked. 07/07/2023 Implemented
6400.163(d)Licensing observed 27 individual pillow packs some of which contained all of individual #1's daily medications scattered throughout the individual's bedroom, the upstairs hallway, and the bathroom. Licensing observed 6 individual pillow packs containing all of individual #1's daily medications on the top of the kitchen cabinets.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Immediately, the CEO or designee shall ensure that all medications for all individuals who are unable to self-administer are kept locked. 07/07/2023 Implemented
SIN-00213103 Renewal 10/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)On 10/13/22 at 10:35 AM, the home did not have a financial ledger to account for Individual #1's cash on hand allowance that had been distributed onto a pre-paid Visa gift card with a remaining balance of $.93. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Serenity Care will create a separate Financial Ledger for each client that will be kept at the clients home, updated and monitored on a daily basis. The Financial Ledger will include the amount distributed to clients, and the subtraction of monetary transactions. 11/01/2022 Implemented
6400.72(a)The only operable window in the home's half bathroom was found without a screen at 10:24 AM on 10/13/22.Windows, including windows in doors, shall be securely screened when windows or doors are open. The maintenance technician will be responsible for checking all windows and door screens during the monthly maintenance inspections. 12/01/2022 Implemented
6400.101On 10/13/22 at 10:19 AM, the door in den area, located off the kitchen, was observed with a sliding latch door lock creating a blocked egress. On 10/13/22 at 11:05 AM, the only exit door leading from the basement to the outside was observed with two sliding latch door locks creating a blocked egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. All deadbolt locks with the keys that can only lock from the inside will be removed and replaced with one sided deadbolt locks where a key is only needed for entry not exit. 12/01/2022 Implemented
6400.141(a)Individual #1 had physical examinations completed 9/2/20 and then again 9/2/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Serenity Care will assure that all Physical Examination appointments are scheduled 12 months apart and monitored by the Program Manager. 11/01/2022 Implemented
6400.141(c)(4)Individual #1 had Hearing Screenings 2/5/21 and then again 2/28/22. Individual #1 had Vision Screenings 1/9/21 and then again 2/28/22.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The Program Management will schedule confirm and document all participant medical appointments completed according to 6400 regulations. 11/01/2022 Implemented
6400.141(c)(6)Individual #1's most recent Tuberculin skin testing by Mantoux method with negative results was completed 10/15/18.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. Program Manager will schedule, confirm and document all participant medical appointments annually, monthly and semi annually. 11/01/2022 Implemented
6400.141(c)(12)Individual #1's 9/2/22 physical examination did not include physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual. Serenity Care Program Management will confirm and include individual's physical limitations on the Physical Examination Forms prior to the participants appointment and ensures the physician reviews signs and dates form at the end of the appointment. 11/01/2022 Implemented
6400.141(c)(13)Individual #1's 9/2/22 physical examination did not include contraindicated medications. This section was left blank.The physical examination shall include: Allergies or contraindicated medications.Program Manager will schedule, confirm and document all participant medical appointments annually, monthly and semi annually. The Program Management will confirm and attach a medication list and diagnosis prior to the participants appointment and ensures the physician reviews signs and dates form at the end of the appointment. 11/01/2022 Implemented
6400.141(c)(15)Individual #1's 9/2/22 physical examination did not include special instructions for the individual's diet. This section was left blank.The physical examination shall include:Special instructions for the individual's diet. The Program Management will schedule confirm and document all participant medical appointments. The Program Management will confirm and attach a medication list, diagnosis, special diet instructions or changes prior to the participants appointment and ensures the physician reviews, updates any changes, signs and dates form at the end of the appointment. completed according to 6400 regulations. 11/01/2022 Implemented
6400.181(a)Individual #1 had annual assessments completed 8/10/21 and then again 9/16/22. [Repeat violation 11/30/21 et.al] 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. Serenity Care Program Specialist will complete the individual Annual Assessments dated and signed according to the individual's admission date to the residential home. The Program Specialist will provide the assessment to the team members at least 30 calendar days prior to an individual plan meeting. The Program Specialist will assure all assessments will be completed according the the 55 PA Code Chapter 6400.181 (a) regulations. 11/01/2022 Implemented
6400.34(a)Individual #1 was informed and explained individual rights and the process to report a rights violation 8/11/21 and then again 9/21/22.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.All annual Individual Rights will be signed and dated by the client, based off the client's admission date (month/ day) to Serenity Care and the current year. 11/01/2022 Implemented
6400.165(g)Individual #1 is prescribed psychiatric medications to treat mental illnesses. Individual #1 had medication reviews 2/1/22, 4/26/22, and 8/12/22. The psychiatric medication review conducted 2/1/22 does not include reason for prescribing the medications. [Repeat violation 11/30/21 et.al]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.Program Manager will schedule, confirm and document all participant medical appointments annually, monthly and semi annually. The Program Management will confirm and attach a medication list and diagnosis prior to the participants appointment and ensures the physician reviews signs and dates form at the end of the appointment. 11/01/2022 Implemented
SIN-00196798 Renewal 11/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 12/1/21, at 11:53 AM, the water temperature at the bathtub in the second floor bathroom to the right at the top of the stairs measured 128.8 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was immediately adjusted by maintenance not to exceed 120F 12/17/2021 Implemented
SIN-00182314 Renewal 01/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned on 4/12/2019 and then again on 11/9/2020.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 was last inspected and cleaned on 09/12/2019 (correction to 04/12/2019) noted in the violation; then again on 11/9/2020. The agency has a contract with the undisclosed professional furnace cleaning company to complete a cleaning annually which is scheduled in collaboration with the agency's maintenance supervisor as well as the furnace company scheduler. The appointment is then provided to the office manager who maintains a calendar schedule of all maintenance appointments. Due to the impact of COVID-19 at the time of scheduling for the September 2020 cleaning, the agency was advised that the company was unable to schedule any maintenance service calls that were not emergent. 01/29/2021 Implemented
6400.15(b)The agency did not use the Department's licensing inspection instrument when completing a self-assessment on 8/24/2020. The document did not include all of the elements of the 55 Pa. Code Chapter 6400 regulations including but not limited to the following sections: general requirements, individual rights, staffing, fire safety, individual health, individual records and restrictive procedures.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.On 1/29/2021; the office manager obtained the most up to date and current licensing inspection instrument available at: https://www.dhs.pa.gov/Services/Disabilities-Aging/Documents/Developmental%20Programs%20Licensing/Chapter%206400%20Score%20Sheet%20(s_002510).pdf. It. The CEO, Maintenance Supervisor, Office Manager, and Residential House Leads were trained in accordance to the form. information from the agency created inspection tools were transferred to the Department's licensing inspection instrument The Department licensing form will be distributed 30 days prior to its deadline to residential leads to be completed within 7 days returned to office manager. Office Manager will transfer documentation to Maintenance supervisor to be returned within 7 days to Office Manager. The form will be reviewed and approved by CEO and returned to Office Manager for submission at least 3 business days prior to deadline. The form will be maintained by Office Manager pending Department on-site inspection [Documentation of the aforementioned review and approval by the CEO shall be kept. (DPOC by AES,HSLS on 3/9/21)] 01/29/2021 Implemented
SIN-00164681 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The storm door on the outside of the wooden door in the basement of the home did not have screens in the upper and lower sections. Screens, windows and doors shall be in good repair. A screen has been installed to the storm door on the outside of the wooden door in the basement of the home. A review of screens, windows, and doors for the property has been added to the maintenance review list for monthly inspection. [Immediately and upon hire, all staff persons shall be educated on their responsibilities of the procedures to report, repair and maintain the physical site of all community homes. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned monthly maintenance check list to ensure competition and the all community homes are maintained as required. Documentation of trainings and audits shall be kept. (DPOC by AES,HSLS on 11/1/19)] 10/25/2019 Implemented