Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242236 Renewal 04/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)The current assessment for individual 1 is dated 10/06/23 and the assessment done prior to that is dated 08/05/22 which is more than one year apart. 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. Every other assessment was reviewed to ensure compliance on 4/10/2024 by the Program Specialist and the Program Director. 04/10/2024 Implemented
SIN-00222456 Renewal 04/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)The shower located in Ind. number 3 bathroom did not contain a slip mat. Bathtubs and showers shall have a nonslip surface or mat. The nonslip mat was put in the bathtub on 4/4/23 and the picture is attached. 04/04/2023 Implemented
6400.112(c)There is no time listed on the drill held on 11/2/22.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. All the fire Drills were reviewed to ensure everything is updated. The review was completed on 4/20/2023 04/20/2023 Implemented
6400.141(c)(3)Individual number 3 last Tdap immunization was in 2010. This should be done every ten years.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. The DTAP Immunizations for individual #3 was completed on April 12 2023 at 10am. 04/12/2023 Implemented
6400.169(a)Med practicum for staff number 1 not completed properly. There need to be four observations. There needs to be two observations of medication administration and MAR review.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Per our discussion with the Lead inspector, there were violation from the documents reviewed. The training was completed per regulation. See the attached document. 04/04/2023 Implemented
SIN-00203289 Renewal 04/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)The PA criminal background check for Staff #1 is dated 12/22/21, which is more than one month after their date of hire, which is 11/17/21.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. All staffing records were reviewed, and we will make sure that all incoming staff have their Pennsylvania Criminal Records checked within the 5 working days after the person¿s date of hire. 04/07/2022 Implemented
6400.21(b)The FBI background check for Staff #2 is dated 10/12/21, which is more than one month after their date of hire, which is 9/10/21.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. Every prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for Federal Bureau of Investigation criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check; within 5 working days after the person¿s date of hire. 04/07/2022 Implemented
6400.52(a)(1)There is no verification that Staff #3 has completed 24 hours of training during the most recent full training year (10/20-9/21)The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.All Direct care staff shall their annual 24 hours training every year. Training hours will be tracked with a newly developed tracker in Excel. 04/07/2022 Implemented