Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227836 Unannounced Monitoring 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The floor and shower of the bathroom in the basement is completely covered with dark stains that appear mold-like and render the bathroom unusable. This needs to be addressed/repaired. There is also unknown material in the toilet. Staff indicated these issues are from water damage in the basement.Clean and sanitary conditions shall be maintained in the home. The LIFEGROUP will ensure clean and sanity conditions will be maintained in the home. Maintenance has been called in to clean up the mold like substances on the floor and shower. The toilet was cleaned. 08/11/2023 Implemented
6400.64(b)There were multiple ants observed in the drawer of the 2nd floor kitchen (the kitchen used to prepare meals and store food for individual #1).There may not be evidence of infestation of insects or rodents in the home. The LIFEGROUP will ensure that there is no evidence of insect or rodent infestation in the home. An exterminator contracted to sole the ant problem. 08/04/2023 Implemented
6400.65No working fan in 1st floor bathroom. There was no working fan in basement bathroom. There was no working fan in 3rd floor bathroom. No other ventilation source exists for these rooms.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The LIFEGROUP will ensure all areas that require ventilation will be ventilated by at least one operable window or mechanical ventilation. A contractor has been employed to assess the areas and address the ventilation issue. 08/11/2023 Implemented
6400.67(b)There was a large accumulation of lint in the dryer lint trap. Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFEGROUP will ensure the residential site is free from Hazards. The lint was immediately was removed from the lint trap. 08/04/2023 Implemented
6400.73(a)There is no handrail secured to the wall for the top half of the interior basement stairs. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The LIFEGROUP will ensure ramps, interior stairways and outside steps exceeding 2 steps will have a well secured handrail. The LIFEGROUP has contacted a contractor to install a handrail in the designated area. 08/16/2023 Implemented
6400.81(k)(6)The bedroom for individual #1 did not have a mirror.In bedrooms, each individual shall have the following: A mirror. The LIFEGROUP will ensure each bedroom has a mirror. The PM put a mirror in the bedroom. 08/11/2023 Implemented
6400.82(f)There were no paper towels or soap in the first-floor bathroom. There was no toilet tissue available, nor was there paper towels available for use in the second-floor bathroom (the floor where individual #1's bedroom and kitchen area are located). There were no paper towels or soap available in the third- floor bathroom. There was no soap, toilet tissue or paper towels available in the basement bathroom.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. The LIFEGROUP will ensure all site bathrooms are supplied with paper towels, toilet paper and soap. The PM supplied all bathrooms at this site with toilet paper, paper towel and soap. 07/18/2023 Implemented
6400.144Medication prescribed for individual #1, Atorvastatin (generic Lipitor) 20mg, 8pm daily dosage, was not administered at on 7/8/23 and remains in the blister pack with no explanation on the medication administration record. [REPEATED VIOLATION 4/5/23]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. The staff was identified, and the PM performed a counseling with the identified staff. 07/21/2023 Implemented
6400.214(b)There was no copy of the behavior support plan for individual #1 available for review at the home. Staff interviewed were not knowledgeable about the plan. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The LIFEGROUP will ensure the current behavior support plan for individual#1 is in the residential home. 08/11/2023 Implemented
6400.166(b)On 7/8/23, staff initials on the MAR indicate that individual #1's prescribed medication Atorvastatin (Lipitor) 20mg 8pm dosage was administered, however this dosage is still in the blister pack. There is an "x" indicating that another prescribed medication Aripiprazole 10mg 8pm dosage was not administered, however this dosage was not present in the blister pack. There was no information on the medication administration record which explains this discrepancy. [REPEATED VIOLATION 4/5/23]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Medication error was entered in EIM. The med errors were addressed with staff on duty. 07/18/2023 Implemented
6400.167(c)Individual #1 prescribed medication Atorvastatin (Lipitor) 20mg 8pm dosage was not administered at 8:00pm on 7/8/23 and was not reported via an incident report in HCSIS.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).The LIFEGROUP will ensure that all medication errors will be identified and entered into HCSIS in a timely manner. The medication error was entered into HCSIS on 7/18/23. 07/18/2023 Implemented
6400.182(a)The behavior plan provided for individual #1 utilizes different pronouns to refer to this individual throughout the plan. This is noted in the reports from the behavior specialist that were available at the home as well. This behavior plan is not individualized and shows that portions of the plan were cut and pasted from another individuals plan.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.The LIFEGROUP will ensure that the entire BSP will reflect the named individual throughout the plan. The Program Specialist will meet with the team and the individual to review revisions and corrections . 08/18/2023 Implemented
6400.182(c)The individual plan for individual #1 states that the behavior plan is restrictive. However, the written behavior plan provided does not contain a restrictive component. This information needs to be updated to reflect accurate information.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The SC will be notified of the error in the plan by the Program Specialist. The plan will be updated by the SC 08/31/2023 Implemented
SIN-00222347 Unannounced Monitoring 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Pungent odor coming from Individual 1's bedroom on the second floor. This odor was extremely strong even with facial masks worn by inspector.Clean and sanitary conditions shall be maintained in the home. The Life Group will ensure that clean and sanitary conditions will be maintained in the home. The soiled mattress was removed from the home and discarded. a new mattress was brought and a waterproof mattress pad was purchased to use on the bed. The room was thoroughly cleaned and room deodorizer was purchased to use in the room. 04/10/2023 Implemented
6400.64(a)There is an unidentifiable brown stain on second floor couch.Clean and sanitary conditions shall be maintained in the home. The LIFE Group will ensure clean and sanitary conditions will be maintained in the home. On the day of inspection, the couch slipcover was washed to eliminate the stain. 04/05/2023 Implemented
6400.67(a)The floor planks on second floor hallway are tearing and coming up from the surface.Floors, walls, ceilings and other surfaces shall be in good repair. The Life Group will ensure that the floors, walls, ceilings and other surfaces are in good repair. The floor planks were repaired by the contractor to ensure the planks are even and sturdy. 04/14/2023 Implemented
6400.67(b)The shower knob on third floor bathroom fell off when attempted to turn water on/ Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFE Group will ensure that all surfaces will be free of hazard. The plumber repaired the shower knob to ensure it does not fall off when the water is turned on or off. 04/21/2023 Implemented
6400.72(a)There is no screen in second floor hall window.Windows, including windows in doors, shall be securely screened when windows or doors are open. The LIFE Group will ensure all windows will be securely screened. A screen was purchased for the 2nd floor window and inserted in the 2nd floor window. 04/06/2023 Implemented
6400.77(b)There were no scissors in first aid kit at the time of inspection. 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 LIFE Group will ensure that all First Aide kits contain all items per the 6400 regulations. The original pair of scissors was replaced with a new pair of scissors to make the First Aide kit complete. 04/05/2023 Implemented
6400.81(k)(2)Individual 2's bed was covered with clothes and other materials, making it impossible to lay comfortably in bed.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. The LIFE Group will ensure all bedrooms have a clean, comfortable and solid foundation. The consumer prefers to have his personal items on the bed at all times. .The Program Specialist and the Program Manager will work with the consumer to get him to understand that by removing items from his bed, he will have a more comfortable surface to sleep on. 04/08/2023 Implemented
6400.81(k)(3)There are no bed linens on Individual 2's bed.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.The Life Group will ensure that each bed has bedding, pillows, linens and blankets that are appropriate for the season. On the day of inspection the individual had soiled the bed the night before and the the staff took off the bedding to let it air out. The soiled mattress was replaced and bedding as per 6400 regulations was put on the bed. 04/10/2023 Implemented
6400.82(e)The bathroom in basement does not have a nonslip mat. Bathtubs and showers shall have a nonslip surface or mat. The Life Group will ensure that bathtubs and showers have a non-slip surface or mat. Although the basement bathroom is not used by consumer or staff, a bathmat was purchased and put in place to remain in compliance with the 6400 regulations. 04/10/2023 Implemented
6400.144The following medications were not present during the medication review for Individual #2: Ensure (to be taken daily), Total block SPF 65.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. The LIFE Group will ensure that prescribed medication and supplements be provided as ordered. The Director contacted the Pharmacy and doctor to get a supplement that was more readily available than the one originally ordered or discontinued. The sunblock was changed to SPF 50. A new MAR was sent to reflect the change. 04/06/2023 Implemented
6400.216(a)Individual program books with confidential information were stored in an unlocked hall closet on the second floor. An individual's records shall be kept locked when unattended. The Life Group will ensure that all individuals records be kept locked when unattended. The Service notes book was relocated to the site office. A sign is posted for all staff to remind them to lock up the books after use. This office is kept locked when not in sure. 04/05/2023 Implemented
6400.163(a)Loose unidentified medications were stored inside clear non latex gloves.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The Life Group will ensure that all medications be kept in their original containers. The medication found on the day of the inspection was medication that the individual refused. The medication was properly discarded. 05/12/2023 Implemented
6400.163(h)Old medications were stored in a closet in one medication bin and not disposed properly.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The Life Group will ensure that discontinued or expired medication will be destroyed in a safe manner according to Federal and State Statues and regulations. On the day of the inspection the old medication was taken to Walgreens and put in the receptacle for discarded medications by the Director. 04/05/2023 Implemented
6400.165(b)Regarding the medication review for Individual #2: The MAR states to take two tablets of Therems Multivitamin at 8 AM, however, the blister pack states to take one tablet at 8 AM.A prescription order shall be kept current.The Life Group will ensure that all Prescription orders are kept current. On the day of the inspection the Pharmacy was called for clarity of the order and a new MAR and blister pack was sent to the home to reflect the correct order of Therems Multivitamin take 1 tablet at 8am. 04/24/2023 Implemented
6400.165(b)Regarding Medication review for Individual #2: The MAR states to take two Topiramate 200 mg at bedtime, however the blister back states to take one at bedtime.A prescription order shall be kept current.The Life Group will ensure that a prescription order will be kept current. on the day of the inspection the Director called the pharmacy and the ordering physician to get clarification of the order. The Pharmacy sent an amended MAR to match the Pharmacy label. 04/05/2023 Implemented
6400.166(b)Regarding the medication review for Individual #2: Ziprasidone 80 MG was not signed off as administered on 4/1/23 at 8 PM, 4/2/23 at 8 PM, 4/3/23 at 8 AM, 4/4/23 at 8 AM, and 4/5/23 at 8 AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Life Group will ensure that all medication administration signatures are completed at the time of administration. The Program Manager reviewed the documentation errors with the staff involved to resolve the error. 04/06/2023 Implemented
SIN-00212346 Unannounced Monitoring 09/23/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(4)On July 24, 2022, The LIFE Group's ("LIFE") Chief Executive Officer submitted a "Self-Inspection and Declaration Tool" to the Department for 318 Parker St., Unit A, Chester, PA 19013 for purposes of adding the location to LIFE's existing license. On August 4, 2022, the Chief Executive Officer submitted a second "Self-Inspection and Declaration Tool" for 318 Parker St., Unit B, Chester, PA 19013, also for purposes of adding the location to LIFE's existing license. During the Department's September 23, 2022, inspection, it was discovered that Units A and B were not separate and distinct locations, but rather structured and operated as a single, 3-floor Community Home as follows: · There was only one entrance door to access the home. · There was a single stairway to access all floors in the home. · There was only one washer and only one dryer in the home. · LIFE staff were moving from floor to floor to perform their duties. · All individuals' medications were stored together on the third floor. · There was only one first aid kit for the entire home. Additionally, the Department identified violations of the following regulations (specific details about the violations are provided elsewhere in this inspection summary): 55 Pa.Code: · § 6400.64(a) (relating to Sanitation) · § 6400.67(a),(b) (relating to Surfaces) · § 6400.71 (relating to Emergency telephone numbers) · § 6400.80(b) (relating to Exterior conditions) · § 6400.81(k)(5) (relating to Individual bedrooms) · § 6400.111(f) (relating to Fire extinguishers) The Chief Executive Officer documented on the Self-Inspection and Declaration Tools for both Unit A and Unit B that LIFE was in compliance with all of the above regulations. The Self-Inspection and Declaration Tool reads "By signing below, I swear that the above information is true and correct, that the agency is responsible for compliance with all applicable statues and regulations, including but not limited to Article X of the Public Welfare Code, 62 P.S. § 1001 et seq. and 55 Pa. Code § 20.1 et seq., and that knowingly providing inaccurate information may lead to enforcement action up to and including revocation of the agency's license to operate." Both tools were signed by the Chief Executive Officer. The Chief Executive Officer knowingly providing inaccurate information to the Department about the number of homes to be operated and the compliance status of each unit for purposes of adding the "homes" to LIFE's existing license.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. DIRECTED PLAN OF CORRECTION: The CEO or designee will close the home in CLS listed as "318 Parker Street Unit B" immediately upon receipt of this Directed Plan of Correction. The CEO or designee will submit an "increase in capacity" self-inspection form to increase licensed capacity from 2 to 4 at "Unit A" to the Department immediately upon receipt of this DPOC. Immediately upon receipt of this DPOC, "Unit A" will operate as 1 community home with a maximum licensed capacity of 4. Immediately upon receipt of this DPOC, CEO will ensure staffing coverage is such that supervision needs of the individuals residing in the home are met. Within 48 hours, CEO will submit a staffing schedule to the SE regional office for the month of November 2022. 11/08/2022 Not Implemented
6400.64(a)Outdoor trash and trash cans were located in the living room space and the can holding the trash was overflowing. The kitchen had a trash bag tied and not in the can or discarded.Clean and sanitary conditions shall be maintained in the home. Due to construction in the backyard staff put the trash cans in the home. The trash cans were immediately removed while the inspector was on site. 09/23/2022 Implemented
6400.67(b)There were various light switches without protective plates. The locations missing protective platers were the entrance of the home, in the individual #1's bedroom and the switch at the top of the stairs leading to the basement. Floors, walls, ceilings and other surfaces shall be free of hazards.Protective light covering were replaced while the inspector was on site. 09/23/2022 Implemented
6400.71There were no emergency telephone numbers located nearby the telephones on all three levels.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The list for emergency numbers has been placed nearby all phones on all 3 levels in plain sight for all staff and consumers to utilize as needed. 10/06/2022 Implemented
6400.80(b)The exit in the rear of the home was not able to be accessed due to pending construction work. There was no precaution in place to caution the hazard if the rear exit was used. Signage was placed on door after discovery. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.DIRECTED PLAN OF CORRECTION: While the construction in the back was being completed a sign to not use that door as an exit was put up for everyone's safety while the inspectors were onsite. 11/08/2022 Implemented
6400.81(k)(5)Individual #1s bedroom did not contain a closet or wardrobe.In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. DIRECTED PLAN OF CORRECTION: A wardrobe for the bedroom was purchased and assembled for the individual to use. 11/08/2022 Implemented
6400.111(f)The fire extinguisher in the basement was dated 2021 with no annual inspection tag. The extinguisher was replaced with a new extinguisher during monitoring. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. DIRECTED PLANOF CORRECTION: The Life Group purchased a new fire extinguisher while licensing inspectors were onsite. 11/08/2022 Implemented
6400.165(c)Individual #1's prescribed Calcium/ Vit D3 600-400 medication to be taken twice daily at 8am and 8pm was logged as given on 9/23/2022 but not administered per the pill count on the blister pack. The medication was located in the as needed (PRN) medication boxA prescription medication shall be administered as prescribed.DIRECTED PLAN OF CORRECTION: An EIM report was submitted in HCSIS. The Life Group will train the staff on ensuring proper medication administration. 11/15/2022 Implemented
6400.166(b)Individual #1's Ozempic 1mg injections to begiven once weekly at 8am on Thursdays was not logged immediately after administration on 9/22/2022, the log was left blank on the aforementioned date.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.DIRECTED PLAN OF CORRECTION: The staff was identified and completed the documentation on the medication record. The Life Group retrained this staff on documenting after administration of medication. 11/08/2022 Implemented