Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230316 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #2's ISP indicates poisons must be kept locked. Poisons were found unlocked under the kitchen sink: Febreze, antibacterial hand soap, and Lysol spray. Bleach and other cleaning products were found unlocked on a shelf in the laundry room.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials were removed from a kitchen cabinet and stored in a locked laundry room. Staff was retrained on their responsivities in regards to keep poisonous materials in a laundry room and keep door locked at all times (see attachment#1) 09/07/2023 Implemented
6400.65There is no ventilation in the bathroom. The skylight cannot be opened and there is no mechanical ventilation.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 09/15/2023, roofing professional untangle a chain that opens skylight to provide proper ventilation and ensure operability. (see attachment#2) 09/15/2023 Implemented
6400.141(c)(7)Individual #2's quarterly Brightway medication appointment summaries listed dep shots. There was no exam for pap or breast examination.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. Individual had GYN appointment was scheduled prior to inspection, Individual visited GYN on 09/12/23. Proper documentation was received and filed. (see attachment #3). 09/12/2023 Implemented
SIN-00211874 Renewal 09/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 had a date of hire that was 8/1/22, however the PA criminal Background was completed on 8/23/22An 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. CFO retrained HR staff on 09/12/2022 on Chapter 6400 background compliance verification requirements 09/12/2022 Implemented
6400.21(b)Staff #2 had an FBI Check completed through OCYF which is not accepted under the 6400 regulations.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. CFO retrained HR staff on 09/12/2022 on Chapter 6400 background compliance verification requirements. Staff #2 PA Background check was done on 09/09/2022 (see attachment 7) 09/09/2022 Implemented
6400.64(a)The laundry room contained substantial lint around the dryer and vents in laundry area. In the bathroom there was a buildup of debris in the skylight/vent area including a dead bird.Clean and sanitary conditions shall be maintained in the home. Bathroom and Laundry rooms were cleaned by staff on 09/08/2022 (see attachment #3) to remedy the violation. 09/08/2022 Implemented
6400.67(a)The flooring in the laundry room is peeling up just at the edge of where one would step up to get in.Floors, walls, ceilings and other surfaces shall be in good repair. Floor Repairs were made on 9/20/2022 (see attachment #2) by the Assistant Residential Director to remedy the violation. 09/20/2022 Implemented
6400.72(a)The screen was missing in font window/kitchen area. It had the frame of where a screen once was but was ripped out.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screen Repairs were made on 9/20/2022 (see attachment #1) by the Assistant Residential Director to remedy the violation. 09/20/2022 Implemented
6400.82(f)No Trashcan present in bathroomEach 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. New trashcan was added to a bathroom 9/20/22 (see attachment #4) by the Assistant Residential Director to remedy the violation. 09/20/2022 Implemented
6400.151(a)Last physical provided for staff #3 was August 8, 2019. Staff physicals need to be completed every two years. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #3 physical was completed on 8/15/2022 (see attachment #10) 08/15/2022 Implemented
6400.24Controlled substance in the home was not being counted/double locked as required under the Controlled Substance Act of 1970The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Second lockable container and count sheet were added to a med box on 09/08/2022 by the Assistant Residential Director to remedy the violation. 09/08/2022 Implemented
6400.207(4)(I)Individual #1 is prescribed Prescribed PRN Lorazepam 0.5 for behavioral purposes which is outlined in the prohibited procedures section of the RCGA chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.Program specialist reached out to the individual #1 Psych Doctor prior to inspection and prescribed medication was changed from PRN to BID on 9/7/2022 09/07/2022 Implemented
SIN-00172759 Unannounced Monitoring 03/11/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The Back bedroom had broken blinds, which are in need of replacing. Furniture and equipment shall be nonhazardous, clean and sturdy. To remedy the broken blinds in the back bedroom, the CFO has replaced the blinds with new blinds on 3/15/2020 (see Ex 6) All blinds in all sites have been inspected by the House manager for compliance. Moving forward the plan to prevent future occurrences , the house managers will conduct a weekly inspection of sites using a check off list . This ongoing monitoring will be double checked by the Director on a Monthly bases by an onsite inspection using a check off list that will be stored at the main office. (see Ext 3) 03/15/2020 Implemented
6400.82(f)The Bathroom did not contain soap, toilet paper or individual towels.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 house manager has corrected the violation of no soap, toilet paper and paper towels by placing all items in the bathroom on 3/12/2020 (see ex.5). Although the site was vacant at the time of the unannounced inspection , to prevent future occurrences of the violation The house manager will inspection the site using a check off list weekly to ensure these items are present in all vacant sites . This ongoing monitoring will be followed up and double checked by the Director on a monthly bases using a check off list. (see Ex 3) All check off lists will be stored at the main office for future review. 03/12/2020 Implemented
SIN-00165152 Unannounced Monitoring 10/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The trash can outside of the home did not have lids.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.To fix the immediate problem of the outside trash cans not having a lid, the CFO was responsible to purchase a trash can with an attached lid from a local hardware store.(see Photo) The correction task of trash outside of the homes shall be kept in closed receptacles that prevent the penetration of insects and rodents was completed and new cans purchase on 11/08//2019. The plan to prevent future occurrence is to assign the duty of inspecting the homes to the house manager to ensure that all cans have lids . Moving forward ongoing monitoring by the House manager shall include inspecting that all outside receptacles are closed and document on a weekly bases that an inspection occurred and that cans are in compliance. Documentation shall be forwarded to the office. The Executive Director will review the documentation on a weekly bases and follow-up with an on site inspection to confirm the documentation. 11/08/2019 Implemented
SIN-00192316 Renewal 09/02/2021 Compliant - Finalized
SIN-00176222 Renewal 09/02/2020 Compliant - Finalized