Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240483 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 has a documented hire date of 11/6/23. There was no Pennsylvania criminal history record check available for review.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. On 3/14/24 all Staff (management/direct care) were trained on the importance of ensuring that an 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 #1 had already had a background check on file on the online portal but was not printed off and in his employee book/file at the time of review, due to this his book was reviewed and all components and training updated to reflect criminal background check and most recent POC training. 04/03/2024 Implemented
6400.67(a)The screws holding the shower curtain rod were lose in the wall and exposed, the rod could be freely moved back and forth and was not in good repair. The top hinge on the right door of the upstairs bathroom vanity was lose causing the door to drop down when opened. Repeat Violation 2/6/23Floors, walls, ceilings and other surfaces shall be in good repair. On 3/14/24, A retraining of all staff (direct care and management) occurred which focused on the importance of ensuring that Floors, walls, ceilings and other surfaces shall be in good repair. The shower curtain rod curtain was repair/secured on 4/5/24. 04/05/2024 Implemented
6400.72(a)At the time of inspection there was no screen in the upstairs bathroom window. There was no other ventilation in the room. Repeat Violation 2/6/23Windows, including windows in doors, shall be securely screened when windows or doors are open. On 3/14/24, A retraining of all staff (direct care and management) occurred which focused on Windows, including windows in doors, shall be securely screened when windows or doors are open. The screen was updated on 4/5/24 and replace in the bathroom. 04/05/2024 Implemented
6400.143(a)Individual #2 has a behavioral support plan in place to address "treatment refusals" that addresses medication and appointment refusals. Lack of documentation for follow up visits and purchasing of glasses illustrates that Individual #2 has refused or missed appointments. Provider indicates that several appointments and medications were refused. There was no documentation of the refused appointments or attempts to train the individual about the need for health care. Unused medications in the home illustrate that Individual #2 has refused medications or the medications were no administered as prescribed. There was no documentation of the medication refusals or attempts to train the individual about the need for health care at the time of the refusals.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. On 3/14/24, A retraining of all staff (direct care and management) occurred which focused on cases 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. staff were trained on the new treatment refusal plan process on 4/4/24 04/05/2024 Implemented
6400.144Individual #2 had an ER follow-up on 11/17/23 where it was recommended that they follow-up again on 2/9/24. There was no documentation to illustrate that this was completed. Individual #2 received a script for new glasses on 10/12/23. They were not obtained. Individual refusal was noted as the cause, no refusals were noted. Individual #2 had their ears flushed on 11/6/23. It was noted that they should follow-up with their primary physician on 2/9/24. There was no documentation that this occurred. Individual #2 was given referrals for Nephrology on 8/8/23 and 11/17/23. It was indicated that the Nephrologist stated that she did not need to be seen. There was no documentation to support the statement. Individual #2 was seen for a UTI on 3/21/23. Follow-up with their primary physician was recommended in three months. There was no documentation to support that the follow up occurred. The March 2023 Medication Administration Record for Individual #2 contained entries for PRN medications Deep Sea nasal spray, Icy Hot back pads, NYAMYC powder and Robitussin. The named medications were not in the home and available for use.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. on 3/14/24 all staff were retrained on the importance of ensuring that all individuals are completing 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. Per the new portal access for client, it was confirmed that the pcp visit occurred on 2/9/24 as a follow up the ER and her ears being flushed. An appointment was made to attend Lindsey eye to pick out her new glasses on 4/9/24. Nephrology appointment was made for 4/16/24. Per the online portal access Indvidual #2 had pcp follow up on 6/20/23 as a follow up for the march 2023 UTI. On 3/8/24 a med review was completed by the director of operations and the prn meds were replaced onsite and current med list updated by the doctor. 04/06/2024 Implemented
6400.163(h)At the time of inspection there were discontinued and expired medications in the locked daily medication box. The locked medication box contained the following: Fluticasone, pharmacy label filled date of 3/21/23-not the current bottle in use. Fluticasone, pharmacy label filled dated of 4/28/23-not the current bottle in use. Albuterol pharmacy label discard after date of 2/9/24-not the current bottle in use. Albuterol pharmacy label discard after date of 9/26/23-not the current bottle in use. Docusate sodium pharmacy fill date of 12/20/22 and pharmacy discard after date of 12/20/23.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.on 3/14/24 all staff were trained on the importance of ensuring that Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. on 3/08/24 a mar review and medication and medication box audit was completed by the director of operations and all items that were expired were removed form the box. the doctor's office was contacted and reviewed current medication and expired medication with the office. a fax was sent over with all current meds for Indvidual. 04/05/2024 Implemented
6400.165(g)Records indicate that three month medication reviews were completed on 7/13/23 and not again until 1/12/24. This exceeds the three month requirement.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.on 3/14/24 all staff were trained on the importance of ensuring that 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. Per the new online portal access that was updated as of 4/8/24 the provider was able to get information on past psyche appointments which include -10/9/23 psych appointments 12/8/23 and 1/12/24, 2/27/24 and next psyche appointment April 30, 2024 04/08/2024 Implemented
6400.166(b)Notations on the blister pack of Hydroxyz HCL with a pharmacy label fill date of 12/4/23 was marked with dates and initials to indicate that the medication had been administered on 3/1 by Staff #1, 3/2 by Staff #1 and on 3/4 by Staff #4 with the pills in the marked blisters not present. There were no dates or times of the medication administration and no initials of the person administering the medication on the corresponding March 2024 Medication Administration Record for Individual #2 as required.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.on 3/14/24 staff were retrained on the importance of documenting the information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. a mar and med review were completed by the director of operations on 3/8/24 04/05/2024 Implemented
6400.169(c)(2)Individual #2 has an epi pen due to an allergy to bee stings. There was no documentation that Staff #1 was properly training in its use.A staff person may administer an epinephrine injection by means of an auto-injection device in response to anaphylaxis or another serious allergic reaction following successful completion of both: Training within the past 24 months relating to the use of an auto-injection epinephrine injection device provided by a professional who is licensed, certified or registered by the Department of State in the health care field.On 3/8/24 staff were trained on the importance of ensuring that proper training is on place for epi pen administration since a staff person may administer an epinephrine injection by means of an auto-injection device in response to anaphylaxis or another serious allergic reaction following successful completion of both: Training within the past 24 months relating to the use of an auto-injection epinephrine injection device provided by a professional who is licensed, certified or registered by the Department of State in the health care field. 04/08/2024 Implemented
6400.181(b)In the assessment for Individual #2 dated 2/15/24 it is noted that "has a 1:1 team member staffing/support 24 hours per day" and "has 2 hours of alone time in the home with staff not present on Saturday's only." At the time of inspection Staff #3 indicated that the alone time on Saturdays has not been used in quite a while due to Individual #2 locking staff out of the home during the two hours of alone time and noted that the removal of the two hours of alone time was needed. Staff #3 stated that it was discussed with the Service Coordinator for Individual #2. No specific dates were provided. The Individual Support Plan (ISP) for Individual #2 with a plan last updated date of 6/22/23 noted supervision levels to be "has a 1:1 team member staffing/support 24 hours per day" and "has 2 hours of alone time in the home with staff not present on Saturday's only." The assessment for Individual #2 was not updated to reflect their current level of supervision as required.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.On 3/14/24 staff were trained on the importance of ensuring that if the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. The supports coordinator was contacted, and supervision level discussed and per the team the individual no longer utilizes alone time on Saturday and her plan will be updated to reflect this and the plan updated as of 4/8/24 to reflect her new supervision for Saturday and in general. 04/08/2024 Implemented
SIN-00217269 Renewal 02/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of inspection the upstairs bathroom of the home had several large cobwebs and gathered dust above the window and to the left of the window near the ceiling. The miniblinds in the upstairs bathroom were covered with a layer of what appeared to be dust. The baseboard in the downstairs bathroom was soiled and covered with a layer of dust. The exhaust fan cover in the downstairs bathroom was covered in a layer of what appeared to be dust. Clean and sanitary conditions shall be maintained.Clean and sanitary conditions shall be maintained in the home. on 2/28/2023 a deep cleaning of the bathroom was completed, and cobwebs removed, miniblinds cleaned, the baseboard cleaned the exhaust fan cleaned. on 2/17/2023 all staff were trained on the importance of Clean and sanitary conditions shall be maintained in the home. 02/28/2023 Implemented
6400.67(a)At time of inspection the living room carpet, carpet on the stairs and carpet in the bedroom of Individual #4 all had several stains across their surface. The surface of the flooring in the dining room was peeling in several areas. One larger area to the left of the dining room table had peeled back exposing and wearing away the composite material of the flooring. The linoleum in the kitchen near the back door had a hole approximately five inches by six inches that exposed the flooring underneath. The faucet on the downstairs bathroom sink was loose and easily moved back and forth. The handle on the toilet in the downstairs bathroom was loose. A portion of the plaster wall at the top of the stairs covering approximately two feet by two feet was cracked in several places and loose from the lathe beneath. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. On 2/17/2023 all staff were retrained on the importance of ensuring that Floors, walls, ceilings and other surfaces shall be in good repair. The bedroom carpet was spot cleaned and carpet cleaning is scheduled to be completed by 3/6/2023, per the carpet cleaning company availability. on 2/21/2023 -the living room carpet and steps were professionally cleaned DC carpet company On 2/23/2023 the flooring in the dining area was replaced with new vinyl flooring. on 3/1/2023- the dining room table had protective covering purchased and added to the table. On 3/3/2023 the contractor will be addressing and repairing the hole in the linoleum in the kitchen near the back door. The faucet on 2/28/2023 the bathroom sink was tightened by the contractor and no longer moves and is no longer loose. On 2/28/2023 the handle on the toilet in the downstairs bathroom was repaired by the contractor. The wall was repaired on 2/25 by the contractor - the wall was replastered completely at the top of the stairs and is no longer loose. 03/06/2023 Implemented
6400.67(b)At time of inspection the edges of the throw rug over the living room carpet were curled up near the front door and the dining room entrance. Both sections created a tripping hazard. Surfaces shall be free of hazards. Floors, walls, ceilings and other surfaces shall be free of hazards.the throw rug was cleaned on 2/23/2023 and removed from the front area. another rug that is bigger was purchased at ross and it does not pose any tri hazards and is secure. on 2/17/2023 all staff were trained on the importance of floors, walls, ceilings and other surfaces shall be free of hazards. 02/23/2023 Implemented
6400.72(a)The upstairs bathroom window was open approximately two inches at the time of inspection. There was no screen in the window. Windows shall be securely screened.Windows, including windows in doors, shall be securely screened when windows or doors are open. the screen was replaced on 2/28/2023 but the coordinator up review realized That he had a small hole in it and will be getting another to replace it by 3/3/3023 and he/she ensured that the window was closed back all the way. on 2/17/2023-All staff were trained on the importance of having a Windows, including windows in doors, shall be securely screened when windows or doors are open. 03/03/2023 Implemented
6400.80(b)At the time of inspection the small deck located off the kitchen had soft spots on the surface and were in poor condition. The awning over the stairs on the back deck had a long piece of wood that had rotted creating a large hole approximately twelve inches in length. The cigarette butt container on the back porch was completely full of cigarettes butts making in impossible to safely dispose of them in the container. There were approximately 20 cigarette butts thrown on the ground in the area surrounding the trash cans. This area also contained mulch and other dried wood debris beneath the discarded cigarette butts. The outside of the home shall be in good repair and free from unsafe conditions. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.on 2/25/2023 the deck was repaired, and the screw tightened on the deck flooring the awning was replaced/repaired on 2/25/2023. 2/10/2023 - the cigarette but container emptied, and sign posted by the kitchen exit to remind staff to empty the cigarette butts appropriately and the debris outside was removed as well. Staff retraining was done on 2/17/2023 which addressed the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. 02/25/2023 Implemented
6400.32(r)(4)At time of inspection a pin key lock was on the bedroom door of Individual #4. Pin key locks do not allow for easy and immediate access. (Repeat Violation)The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.the lock was replaced on 2/22/23 and updated and key given to individual, and the other key was left in the home for staff access. on 2/17/23 all staff were retrained on the importance of having the locking mechanism which shall allow easy and immediate access by the individual and staff persons in the event of an emergency. 02/22/2023 Implemented
SIN-00200554 Renewal 03/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit in the home did not contain tweezers. 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. The first aid kit was updated and staff (direct care /lead staff retrained on the importance of having the firstaid kit stocked with all necessary supplies 05/30/2022 Implemented
6400.101The door leading out of the basement was blocked on the outside with a chair sitting on top of it.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The chair was removed and relocated and staff trained on the importance of keeping all exits free of obstructions 05/30/2022 Implemented
6400.114(b)The home's smoking policy states that the designated smoking area is at the bottom of the back steps where the receptacle is located. Individual #6 is a regular smoker and will not comply with the home's smoking policy and sits on the back porch of the home to smoke. The location where the individual smokes creates a blocked egress as the individual's chair sits on top of the exit from the basement and the individual is not disposing of cigarettes butts appropriately, disposing of them in an open coffee can.Written smoking safety procedures shall be followed.more than one smoking designated area was identified neither of which blocks the exit .and smoking receptable updated. the individual was able to be in compliance once the health and safety risk were explained 05/30/2022 Implemented
6400.15(b)The self-assessment of the home was completed on 9/2/21. This assessment was not completed on the appropriate licensing inspection instrument.(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.program coordinator and lead staff were trained on the correct self-assessment that needed to be completed. 05/30/2022 Implemented
6400.32(r)Individual #6 has a lock on the individuals bedroom door. The lock that is currently on the door is a pin hole lock. There is no key accessible to the individual or the staff for this lock, preventing the individual from locking the door when the individual is not in the room. Individual #6 expressed that the individual would like a lock with a key on the door.An individual has the right to lock the individual's bedroom door.individual's bedroom door was updated to so that she is able to lock her room door. staff were retrained on the importance of an individual's right to lock their bedroom door 05/30/2022 Implemented
SIN-00183557 Renewal 03/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The fan housing in the main bathroom was covered with a thick layer of dust.Clean and sanitary conditions shall be maintained in the home. The bathroom fan was cleaned on 4/2/2021. staff was trained on cleaning expectations 04/23/2021 Implemented
6400.67(b)Peeling paint was noted on the ceiling in the staff office, both to the left and to the right of the ceiling fan. Floors, walls, ceilings and other surfaces shall be free of hazards.A handyman was hired to complete the work by 4/28/2021. Staff trained on the importance of keeping the floors, walls and ceiling clear of hazards. 04/28/2021 Implemented
6400.106Written documentation of furnace inspection was provided. The furnace was inspected but not cleaned on 3/19/21. Notation on the 3/19/21 bill submitted are "Inspected oil furnace. Blower belt(4L330) is in poor condition. System needs to be cleaned as the nozzle assembly is very dirty. Replaced air filter as it was very dirty and wrong size. System does appear to be operating properly at this time. But would definitely need the blower belt changed and the unit cleaned/serviced." Cleaning was not completed.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 cleaned and fixed at the upland site .staff trained on the importance of cleaning a furnace yearly 04/23/2021 Implemented
6400.112(c)The May 2020 fire drill was not fully dated. The date was recorded as "5/ /20". The day was not included. The 7/15/20 fire drill did not have a time that the drill was conducted entered. The space for time of drill was completed with "Mohamed Sheriff." The 12/18/20 fire drill did not have a time that the drill was conducted entered. The space for time of drill was blank.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. The firedrills for the dates specified documents were updated l and the staff trained on the importance of ensuring there is a written documentation of all firedrills completed. 04/23/2021 Implemented
6400.141(b)A physical for Individual #1 was completed on 10/09/20, it was not was not signed and dated as required.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Individual #1 has an appointment to complete all missing items on her physical , so that it can be date/signed. 04/29/2021 Implemented
6400.141(c)(3)A physical for Individual #1 was completed on 10/09/20 but did not contain documentation of Tetanus (Td) being administered every 10 years as required.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Individual #1 has an appointment to complete all missing items on her physical , so that it can be date/signed and an update of her tetanus shot added to the physical 04/23/2021 Implemented
6400.141(c)(10)A physical for Individual #1 was completed on 10/09/20. There was no statement that the individual is free from communicable disease and specific precautions that must be taken to prevent spread of disease were not listed.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. Individual #1 has an appointment to complete all missing items on her physical , so that it can be date/signed and an update of her tetanus shot added to the physical and free of communicable diseases check off . currently has a negative TB 04/29/2021 Implemented
6400.141(c)(11)A physical dated 10/9/20 for Individual #1 did not contain an assessment of the individual's health maintenance needs.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. Individual #1 has an appointment to complete all missing items on her physical , so that it can be date/signed and an update of her tetanus shot added to the physical and free of communicable diseases check off and documentation of the individual health needs 04/29/2021 Implemented
6400.141(c)(12)A physical for Individual #1 was completed on 10/09/20 but did not list the physical limitations of the individual as required.The physical examination shall include: Physical limitations of the individual. Individual #1 has an appointment to complete all missing items on her physical including physical limitations. 04/29/2021 Implemented
6400.141(c)(13)A physical dated 10/9/20 for Individual #1 did not list allergies or contraindicated medications.The physical examination shall include: Allergies or contraindicated medications.Individual #1 has an appointment to complete all missing items on her physical including current allergies or contraindicated medications. 04/29/2021 Implemented
6400.141(c)(15)A physical for Individual #1 was completed on 10/09/20 but did not review special instructions on the individual's diet. * REPEAT VIOLATIONThe physical examination shall include:Special instructions for the individual's diet. Individual #1 has an appointment with PCP to complete all missing items on her physical including diet 04/29/2021 Implemented
6400.34(a)Individual #1 consumer rights document submitted was dated "12/18/21." The review did not include all rights as outlined in § 6400.32. Rights of the individual. (b) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion. (c) An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. (d) An individual shall be treated with dignity and respect. (e) An individual has the right to make choices and accept risks. (f) An individual has the right to refuse to participate in activities and services. (g) An individual has the right to control the individual's own schedule and activities. (i) An individual has the right of access to and security of the individual's possessions. (j) An individual has the right to voice concerns about the services the individual receives. (n) An individual has the right to unrestricted and private access to telecommunications. (p) An individual has the right to choose persons with whom to share a bedroom. (q) An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices). (r) An individual has the right to lock the individual's bedroom door. (1) Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. (2) Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access. (3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. (4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. (5) Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. (s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. (1) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. (2) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. (3) Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. (t) An individual has the right to access food at any time. (u) An individual has the right to make health care decisions.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.the updated Rights were reviewed with individual #1 and signed 04/23/2021 Implemented
6400.52(c)(1)Training records submitted for Staff #1 did not contain training on the application of community integration, individual choice and supporting individuals to develop and maintain relationships. Training on person-centered practices was last completed on 1/29/20. Training is required on an annual basis.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff # 1 was retrained on the missing annual review areas identified. 04/23/2021 Implemented
6400.165(c)On the March 2021 Individual #1 medication administration record (MAR) there is an entry for "Vitamin D2 1.25mg (50,000 UNIT) (generic for DRISDOL)/EA Take 1 capsule by mouth every week." Administration time is noted to be 9am. MAR is initialed as being given on the 1st, 9th, 16th and 23rd. The one-week time frame was exceeded between the 1st and the 9th. The medication was not given at 9am on 3/30/21 also exceeding the one-week time frame. On the March 2021 Individual #1 MAR there is an entry for "Fluconazole Tab 150mg USP 150mg Take 1 tab immediately as a one-time dose and repeat in 72 hours if symptoms persist." According to initials on the MAR the one time does was administered on 3/19/21. The medication was again administered on the 20th, 21st, 22nd and 23rd according to initials on the MAR. Additionally, the medication was initialed as being administered on the 24th, 25th, 26th, 27th and 28th with those initials being crossed out. There were no notations on the back of the MAR to indicate the need for the additional doses. The medications were not administered as prescribed.A prescription medication shall be administered as prescribed.Staff had an training on the importance of giving meds as prescribed 04/23/2021 Implemented
6400.166(a)(2)The name of the prescriber was not listed for any of the medications on the March 2021 medication administration record for Individual #1.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.MARS were updated for April to reflect prescriber. 04/23/2021 Implemented
6400.166(a)(11)The March 2021 medication administration record for Individual #1 did not contain the diagnosis or purpose for the medication for Fluconazole, Probiotic Colon Support, Advair and Mutivites Gummy Vitamins.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.MAR's were updated for April to reflect al diagnosis for each medication 04/23/2021 Implemented
SIN-00167270 Renewal 12/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(b)There was a side porch of the kitchen that did not have a railing and the drop to the ground was greater than 18 inches.Each porch that has over an 18-inch drop shall have a well-secured railing.Contractor was hired to fix and add the missing porch rail on the back porch estimated tie to be finished will be 2/14/2020. In order to prevent this oversight from occurring again staff will be retrained on how to complete a biweekly home checklist , so that he/she can recognize possible danger or household items that need fixing and report immediately ( 1/22/2020). 02/14/2020 Implemented
SIN-00147532 Renewal 12/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #2's receipt ledger from October 24th, 2018 states "went out to eat" and the receipt attached is from the post office from something being mailed. Individual #2 is very high functioning and historically signs all of her receipts over $15 and this one wasn't signed. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Upland staff were retrained on the client funds process which includes the handling of client receipts including those over $15 as well as the process of documentation of the client funds receipts. 02/21/2019 Implemented
6400.73(a)There was no railing leading up from the basement, which the individual regularly accesses for laundry. There were 9 steps leading up to ground level through bilco doors. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 2/19/19 -Railings were installed on both sides of the steps leading out through the ground level of the bilco door at the Upland site. 02/19/2019 Implemented
6400.106There is no furnace inspection for 2018. The furnace was last inspected in August of 2017.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. Upland furnace inspection was completed on 2/21/19 , which included a complete cleaning and tune up of the oil fired heating system at the upland site and it passed inspection. 02/21/2019 Implemented
6400.112(d)On May 26th, 2018, during a sleep drill, the evacuation time was documented as 5 minutes and 26 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Upland staff were retrained on the process of completing a fire drill including the max evacuation time ( 2 and 1/2 minutes) for completing fire drills and follow up reporting process. Staff trained included the lead staff (1) , direct care staff (3), and program coordinator(1) 02/21/2019 Implemented
6400.141(c)(10)The section on Individual #2's physical form pertaining to communicable diseases was left blank.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. Individual #2 Annual Physical was updated by the doctor to reflect that she is free from communicable disease. 02/21/2019 Implemented
6400.151(c)(3)There is no documentation that Staff #1 is free from communicable diseases. There isn't even a place on her physical form where that question is asked. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #1 got a new physical completed on 2/21/19., which indicates that she is free from communicable diseases. 02/21/2019 Implemented
SIN-00126182 Renewal 02/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 was hired on 6/14/2017. A Criminal History Check wasn't submitted until 7/7/2017.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. The Program Specialist and Residential Coordinator were retrained on 2/14/18 by the Director of 6400 Programs on the need for the criminal history check to be completed within 5 days of hire (Document #1). The most recent staff who have been hired for this home have had the criminal history check completed within the time frame. 02/14/2018 Implemented
6400.46(a)Staff #1 was hired on 6/14/2017. He didn't have orientation until 7/27/2017.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. The Program Specialist and Residential Coordinator were retrained that new staff must have orientation to the home, the agency and the individuals prior to working with them on 2/14/18 by the Director of 6400 Programs (Document #1). The most recent staff who have been hired for this home have had orientation prior to working with the individuals. 02/14/2018 Implemented
6400.46(e)Staff #1 was hired on 6/14/2017. He didn't receive training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation until 7/27/2017.Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. The Program Specialist and Residential Coordinator were retrained on 2/14/18 by the Director of 6400 Programs on the need for new staff to have training on the areas of intellectual disabilities, principles of normalization, rights and program planning and implementation prior to working with the individuals (Document #1). The most recent staff who have been hired for this home have had the training completed prior to working with the individual. 02/21/2018 Implemented
6400.46(f)Staff #1 was hired on 6/14/2017. He didn't receive fire safety training until 7/27/2017.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The Program Specialist and Residential Coordinator were retrained on 2/14/18 by the Director of 6400 Programs on the need for new staff to have fire safety training prior to working with the individuals (Document #1). The most recent staff who have been hired for this home have had the training completed prior to working with the individuals. 02/14/2018 Implemented
6400.46(h)Staff #1 was hired on 6/14/2017. He didn't receive training in 1st Aid techniques until 7/10/2017.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. The Program Specialist and Residential Coordinator were retrained on 2/14/18 by the Director of 6400 Programs on the need for new staff to have training on First Aid Techniques prior to working with the individuals (Document #1). The most recent staff who have been hired for this home have had the training completed prior to working with the individuals. . 02/14/2018 Implemented
6400.141(c)(7)Individual #1 was admitted on 6/1/2017. As of the date of this inspection, she has not had a breast exam performed.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. A breast exam was scheduled for Individual #1 for 2/20/18 but her PCP cancelled this appointment and rescheduled it for March 22, 2018 since she already had a check up appointment scheduled on this date and she sees no need to see her any sooner. The PCP also is the physician to complete Individual #1's gyn exams and would be the one to complete the breast exam. Individual #1 is having her mammogram completed on 2/21/18. Program Specialist and Residential Coordinator retrained on the assurance that this exam is completed yearly with the gynecological examination (Document #1). 03/22/2018 Implemented
6400.141(c)(10)This section was not filled in on Individual #1's physical exam completed 12/19/2017.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. The Program Specialist and Residential Coordinator were retrained on the need for the communicable disease section of the individuals physical to be completed thoroughly (See Document #1). The communicable disease section was completed by the physician (Document #2) 02/20/2018 Implemented
6400.151(c)(2)Staff #1 was hired on 6/14/2017. He didn't have a TB test until 7/12/2017. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The Program Specialist and Residential Coordinator were retrained on the need to have the TB test completed for new staff prior to hire on 2/14/18 by the Director of 6400 Programs (Document #1). The most recent staff who have been hired for this home have had the test completed prior to hire. 02/14/2018 Implemented
SIN-00104771 Initial review 12/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The half bathroom on the main floor in this residence has neither an operable window nor a mechanical vent.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. We will replace prior vent with a mechanical vent. Sabrina Rodriguez will assure that vent is always working properly. 12/27/2016 Implemented
6400.70At the time of this Initial Inspection, there was no landline phone at this residence. There was only 1 pre-paid cell phone.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. We will call company to install a landline to the residence. Sabrina Rodriguez will assure that landline is always available in residence. (Landline internet based phone installed. a cell phone will be on premises at all times as a back up. 1/12/17 CH) 12/27/2016 Implemented
6400.72(a)The attic in this residence was converted into a bedroom. At the time of inspection, the 2 windows were not screened.Windows, including windows in doors, shall be securely screened when windows or doors are open. We will install new window screens to both windows in the attic bedroom. Sabrina Rodriguez will insure that all screens are maintained in the windows. 12/27/2016 Implemented
6400.82(d)There was a cut out hole approximately 8 inches wide and 8 inches high in the bottom of the door leading to the half bathroom on the main level. This does not provide for privacy in the bathroom. In this bathroom, there are steps that go down into the basement. There is no door for privacy separating the bathroom from the steps.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger.We will replace door that has the cut hole in it and install new door for privacy leading to stairwell to basement. Sabrina Rodriguez will insure that for future references all doors are in good condition and privacy is adhered to. 12/27/2016 Implemented