Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237976 Unannounced Monitoring 01/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 1/23/24 a temperature water test was completed at Individual #1's home. The water temperature exceeded the 120f in the following areas of the home- Kitchen sink- 129.5F, full bathroom sink- 126.1F, & half bath sink -125.4F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. On 1/23/24 a temperature water test was completed at the Individual #1's home. The water temperature exceeded the 120f in the following areas of the home- Kitchen sink- 129.5F, full bathroom sink- 126.1F, & half bath sink -125.4F. On 1/23/24 - The water temp regulator was reduced by 11am by the program specialist in order to decrease the temperature to a regulatory compliant number. The temperature(s) later on that day was read and it was below 120 degrees and complaint - full bathroom sink (119F), kitchen sink (119.5F), half bath sink (118F). On 1/23/24 - The staff were retrained on the importance of ensuring that Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. 02/02/2024 Implemented
6400.67(a)On 1/23/24, an inspection was completed at Individual #1's home. During the walk-through of the full bathroom- there was a large area of white peeling paint around and behind the toilet exposing the green tile and an area of the painted tile on the wall near the paper towel holder that is on the counter that is also peeling. The painted arch way leading into the kitchen has the metal dry wall corner bead exposed. The wall outside the full bathroom has an area where it was repaired with dry wall. This area needs to be painted.Floors, walls, ceilings and other surfaces shall be in good repair. During the inspection the floor walls and ceilings were not in good repair in the bathroom and hallway and kitchen hallway area. Due to the repairs needing to be completed, the provider hired on 1/25/24 a handyman to complete the necessary repair in the bathroom, hallway and area leading into the kitchen of the home. On 1/23/24- Staff were retrained on the importance of ensuring that floors, walls, ceilings and other surfaces shall be in good repair and how to report it if there is a maintenance concern. 02/02/2024 Implemented
6400.67(b)On 1/23/24 an inspection was completed of Individual #1's home. The dryer contained a large amount of lint that had not been removed. The dryer was not in use at the time of the inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.On 1/23/24 an inspection was completed of Individual #1's home. The dryer contained a large amount of lint that had not been removed. The dryer was not in use at the time of the inspection. On 1/23/24 the dryer lint was removed by the program specialist and cleaned. On 1/23/24 the dryer lint was cleaned, and staff retrained on the importance of ensuring that floor walls and ceilings were in good repair. 01/23/2024 Implemented
6400.80(a)During the inspection on 1/23/24 the entire driveway had approx. 3 inches of snow & ice on it. The exit steps leading from the basement outside was covered in ice and snow. Individual #1's meeting place in case of a fire is at the end of the driveway. Individual #1 is afraid of falling. Outside walkways shall be free from ice, snow, obstructions and other hazards. During the inspection on 1/23/24 the entire driveway had approx. 3 inches of snow & ice on it. The exit steps leading from the basement outside was covered in ice and snow. Individual #1's meeting place in case of a fire is at the end of the driveway. Individual #1 is afraid of falling. This snow was shoveled by a staff person while on site but due to the potential hazard the provider contracted/hired an outside handyman on 1/23/24 so that an assigned person is responsible to complete the task if a snowstorm does occur. The handyman completed the job on 1/23/24 and cleared all of the snow. 1/23/24 -staff were retrained on the importance of keeping walkways free of hazards and if a hazard does occur, they were trained on how to report it to correct the issue ASAP. 02/01/2024 Implemented
6400.166(a)(13)When reviewing Individual #1's medication record, Staff #1 initialed administering medication on 1/20-21/24. Staff' #1 did not include their name on the back of the medical record.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.During the inspection - When reviewing Individual #1's medication record, Staff #1 initialed administering medication on 1/20-21/24. Staff' #1 did not include their name on the back of the medical record. Staff #1 was retrained on 1/23/24 on the importance of ensuring that the medication record should include their name on the back. 01/30/2024 Implemented
SIN-00225892 Renewal 06/20/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The upstairs bathroom is not equipped with a window or active ventilation device.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On 7/6/3 staff were retrained on the importance of ensuring that Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Per their availability - Contractor was contacted and is scheduled to visit the home the week of 7/31/23 to assess and fix the issue. Management staff including the lead staff and the director were retrained on providing oversight to the home regarding upkeep and repairs. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance. 07/31/2023 Implemented
6400.67(a)The magnetic screen door on the front entrance was entirely ripped off the door frame from the top and left side, leaving it hanging off the door to the right upon arrival to the home on 6/21/23. Prior to walking into the home, staff ripped the rest of the screen door off the frame.Floors, walls, ceilings and other surfaces shall be in good repair. On 7/6/23 staff were retrained on the importance of having floors, walls, and ceilings in good repair. As of 7/24/23 the old screen was removed and a new one ordered on 7/25/23.Management staff including the lead staff and the director were retrained on providing oversight to the home regarding upkeep and repairs. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance. 07/25/2023 Implemented
6400.103During the 6/21/23 inspection, the agency produced an Emergency Evacuation Policy for the agency. This policy did not include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation. The home produced an Emergency Evacuation and Temporary Placement plan. This plan did not include the individual's responsibilities or applicable staff responsibilities. This plan states staff on shift are to contact a program coordinator for directions and the process of evacuation, can contact an on-call point person, and is to take further direction for delivery of medications, supplies, and notification of family members by the program coordinator or program specialist. The agency, Case Sense Living LLC., did not provide the Department with any staff member that holds the title of a program coordinator for the direct support staff to know who to contact for further instructions. Both plans were missing components of the requirements defined in 55 Pa. Code § 6400.103.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. On 7/06/23 Staff person were updated on the updated emergency evacuation and temporary Placement protocol. The emergency evacuation and temporary Placement protocol were updated to reflect the missing components and they now include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation. The Emergency Evacuation and Temporary Placement plan now includes the individual's responsibilities or applicable staff responsibilities. This plan has been updated who the staff and family members should contact in an emergency. Both plans updated to reflect all components of the requirements defined in 55 Pa. Code § 6400.103. 07/13/2023 Implemented
6400.104The fire department notification letter dated January 2023 indicated that the one Individual that resides in this home requires verbal prompting to exit during fire drill. The fire letter does not indicate which bedroom is the individuals. There are two bedrooms in this home.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. On 7/6/23 -Staff were retrained on the importance of the home notifying the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. On 7/25/23 - A new fire letter was written and Sent to the fire department which is updated to reflect individuals' room - fire letters for other individuals were reviewed for accuracy and updated and resent if necessary - scheduled date for fire letter review is 8/4/23. 08/04/2023 Implemented
6400.110(a)The upstairs of the home was not equipped with a fire extinguisher with the appropriate 2A-10BC rating. The only fire extinguisher upstairs was labeled as a 1A-10BC rating. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. A new fire extinguisher was purchased and inspected as of 7/25/23 by Kistler fire protection. On 7/6/23 staff were retrained on the importance of ensuring that the home has a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Management staff including the lead staff and the director were retrained on providing oversight to the home regarding appropriate fire safety device kept to standard in the home. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance. 07/28/2023 Not Implemented
6400.111(f)The date of the inspection by a fire safety expert of the upstairs fire extinguisher, was not located on the tag on the fire extinguisher or the extinguisher itself. 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 fire extinguisher tag was updated to reflect inspection date and reattached. On 7/6/23 staff were trained on the importance of ensuring that 55 PA Code Chapter 6400.110(a). Management staff including the lead staff and the director were retrained on providing oversight to the home regarding appropriate fire safety device and tags/inspection kept current in the home. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance fire extinguishers. 07/28/2023 Not Implemented
6400.112(h)The electronic and paper fire drill records from July 2022 to June 2023 do not document if individuals went to the meeting place during the monthly fire drills. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.On 7/06/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the monthly meeting place. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full. 07/28/2023 Not Implemented
6400.112(i)The electronic and paper fire drill records from July 2022 to June 2023 do not document or report if a smoke detector was activated to simulate the monthly fire drills. A fire alarm or smoke detector shall be set off during each fire drill.On 7/6/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the activation of the smoke detector. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full including utilizing the smoke detector during drills and documenting which was used. 08/04/2023 Implemented
6400.145(1)During the 6/21/23 inspection, the agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the hospital or source of heath care the individuals in the home are to utilize in an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. On 7/06/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency. as of 7/25/23 -the emergency plan was updated to reflect all components. 07/25/2023 Implemented
6400.145(3)During the 6/21/23 inspection, the agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the emergency staffing plan the home is to utilize in an emergency.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.On 7/06/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency and the staffing plan . 07/06/2023 Implemented
SIN-00207428 Renewal 06/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The 5/17/22 Self-Assessment has an identified violation, but not an acceptable, attached, plan of correction.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The plan to address noncompliance regarding the agency self- assessment started with the retraining on self-assessment form and areas of the Director and Program specialist of the Lancaster area. The Director of operations reviewed the self-assessment form and all sections of it, how to accurately document and how to address areas of non-compliance as well as sample plan of corrections with the Director of the Lancaster region and program specialist. 07/19/2022 Implemented
6400.61(a)Individual #1's assessment and ISP state that poisons are to be locked. During the physical site walkthrough on 6/22/22 the following poisonous substances were found unlocked under the kitchen sink- Lysol foaming bathroom cleaner spray, Hot shot ant, roach & spider killer spray, glade spray.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. 7/7/22 the Director of Lancaster was retrained on individual #1 poison safety level, which specifies that all poisons should be locked. On 7/12/22 - The Director of Lancaster completed retraining of direct care staff on poison safety protocol for individual # 1 -which includes that all poisons should be locked in the home. 07/14/2022 Implemented
6400.141(c)(1)Individual #1's annual physical 11/15/21- Medical history section was missing PDD ( pervasive developmental disorder), ADHD Mitral value d/o, reflux, anxiety, ( ISP) ( diagnosis on psychiatric forms)The physical examination shall include: A review of previous medical history. The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the medical history filled out and all other sections as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. 07/12/2022 Implemented
6400.141(c)(12)Individuals #1's annual physical 11/15/21 does not contain physical limitations. This section is missing from the form.The physical examination shall include: Physical limitations of the individual. The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the physical limitations section filled out and all other section, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. 07/12/1922 Implemented
6400.141(c)(13)Individuals #1's annual physical 11/15/21 does not contain a section for allergies or contraindicated medications. This section is missing from the form.The physical examination shall include: Allergies or contraindicated medications.The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the allergies section filled out and all other sections, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. 07/12/2022 Implemented
6400.141(c)(14)Individuals #1's annual physical 11/15/21 does not contain Medical information pertinent to diagnosis and treatment in case of an emergency. This section is missing from the form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the medical information pertinent to diagnosis section filled out and all other sections, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. 07/12/2022 Implemented
6400.141(c)(15)Individuals #1's annual physical 11/15/21 does not contain instructions for the Individuals diet. This section is missing from the form.The physical examination shall include:Special instructions for the individual's diet. The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the diet section filled out and all other sections, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. 07/12/2022 Implemented
6400.181(e)(7)Individual #1's annual assessment 11/25/21 does not have if the Individual can move away quickly from heat sources. It has that Individual #1 would require prompts and will stay away from things that are hot.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Director of Lancaster and program specialist were retrained on what components are required in an annual assessment with additional attention on heat sources and how quickly and individuals can move aways from them. On 7/12/22, The director of Lancaster (fire safety trainer) had a discussion with individual #1 regarding fire safety awareness, including assessing how quickly y she could move away from a heat source. during the assessment, the individual #1 was able to move away quickly from a hypothetical heat source and an email was sent on 7/18/22 to her Supports Coordinator to let her know of the ISP update regarding her safety awareness as it pertains to moving away from a heat source quickly. individual #1 assessment was also updated on 7/19/22 to reflect the results of the training/observation on 7/12/22 07/19/2022 Implemented
6400.166(a)(2)The medication records from July 2021 through June 2022 for Individual #1 did not include the name of the prescriber of the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The most recent medication administration record (MAR) for July has been updated to reflect prescriber of medications. The director of Operations trained the director of Lancaster on 7/7/22 on the importance of having MARS that are in compliance and reflecting the name of all prescribers of medication listed for the individual. 07/14/2022 Implemented
6400.166(a)(11)The medication records from July 2021 through June 2022 for Individual #1 did not include the diagnosis or the purpose of the medication prescribed.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.The most recent medication administration record (MAR) for July has been updated to reflect prescriber of medications. The director of Operations trained the director of Lancaster on 7/7/22 on the importance of having MARS that are in compliance and reflecting the diagnosis and or purpose of medication listed for the individual. 07/14/2022 Implemented
6400.167(a)(1)The following medication errors were found during the annual inspection on the medication record for Individual #1: July 3, 8,9 Multivitamin cap 8am signed as administered, but the rest of the month was not initialed as administered Aug 3 & 17, 2021 Vienva-28 take 1 tab daily -- these days was not initialed as administered Dec 24,25 &26, 2021-Busprirone HCL 10mg 1tab 3x's day 8pm -these days were not initialed Dec 6, 2021- Daily Vite 1 tab daily 8am- was not initialed as administrated. April 1 thru 17th, 2022- Atomoxetive HCL 25mg 8am this was a duplicate on the MAR's =staff initialed as medication being administered. This would mean they administered this medication 2 times. April 1 thru 12th, 2022- Cetarize HCL 10mg 8am- staff initialed this medication as being administered, the was duplicated on the MAR's. This showed that staff administered this medication twice.Medication errors include the following: Failure to administer a medication.On 7/12/22, direct care Staff had a medication administration refresher completed by a med trainer which addressed aspect of medication administration, documentation, documentation when on client is on a home visit, as well as recognizing med errors and next steps. On 7/7/22, Director of Lancaster was training on how to do compliance checks of the MAR and next steps regarding med errors. the med errors were also submitted via EIM. 07/31/2022 Implemented
SIN-00191560 Renewal 07/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The Emergency Evacuation Procedures do not include individual responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Emergency Evacuation procedure was updated by the Assistant Director to include the client responsibilities as it pertains to the emergency evacuation procedures. The program coordinator was trained by the director of operations on the updated Emergency Evacuation procedures and policy compliance checks . 09/01/2021 Implemented
6400.110(c)The are no smoke detectors in the common area of the first floor.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. Within 24hrs, a new additional smoke detector was purchased and installed for the hallway area outside of the bedroom at New Hampshire site and fire drill conducted to make sure the newly purchased smoke detector was in working order. 07/29/2021 Implemented
6400.166(a)(11)Individual #1 July 2021 Medication Administration Record does not contain the reason or diagnosis for each prescribed medication.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.The coordinator contacted individual#1 PCP doctors office to get information on all prescribed diagnosis and updated the pharmacy as well-info was updated on the diagnosis on 7/30/2021. The upcoming MA for individual #1 was updated to reflect diagnosis for all prescribed meds. Training with the Program coordinator was conducted by the director of Operations to ensure further compliance of all upcoming MAR as it pertains to compliance/diagnosis. 09/01/2021 Implemented
SIN-00174203 Initial review 08/03/2020 Compliant - Finalized