Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221465 Renewal 03/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)For individual 1, the prompt "information pertinent to diagnosis in the event of an emergency" is blank on the physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Director shall ensure that all areas of the Annual Physical are completed properly and in it's entirety. Staff shall ensure that all areas of the Annual Physical are competed prior to leaving the physicians office. Physical was returned to the physician for correction and the missing information was entered as; "call 911". 03/30/2023 Implemented
SIN-00202978 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There was no ventilation(mechanical or window) in the bathrooms.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 4/11/2022, the mechanical ventilation systems were serviced and cleaned thoroughly. It is now operating properly. Please refer to attachments 1 and 2 04/11/2022 Implemented
6400.82(f)There was no trash receptacle in Individual #1's bathroom in his bedroom. It was replaced during the inspection.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 trash receptacle was replaced during the inspection, as it was removed by staff during cleaning. 04/11/2022 Implemented
6400.111(c)There was no fire extinguisher in the kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). A Fire extinguisher was purchased and placed in the kitchen under the sink. Please refer to attachment 3 04/11/2022 Implemented
6400.141(c)(12)On the Annual Physical Exam for Individual #1 dated 3/21/22 the physical limitations portion was omitted.The physical examination shall include: Physical limitations of the individual. The physical has been returned to the physician for correction. Please refer to attachment 4 04/11/2022 Implemented
6400.141(c)(14)Information pertinent to diagnosis in case of emergency was left blank on the Annual Physical Exam for Individual #1 dated 3/21/22.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical has been returned to the physician for correction. Please refer to attachment 4 04/11/2022 Implemented
6400.181(c)The assessment dated 6/23/21 for Individual #1 did not indicate what the assessment was based on such as instruments, interviews, progress notes and observations used.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The Basis of assessment has been completed and signed by the program specialist and participant. Please refer to attachment 10. 04/11/2022 Implemented
SIN-00186381 Renewal 03/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct care staff 1-4 had criminal history checks completed more than 5 working days after their date of hire. Staff 1 was hired on 10/6/20 and had their criminal history check completed on 10/15/20. Staff 2 was hired on 8/13/20 and had their criminal history check completed on 9/15/20. Staff 3 was hired on 10/14/20 and had their criminal history check completed on 2/10/21. Staff 4 was hired on 8/14/20 and had their criminal history check completed on 9/15/20.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. We have created an HR Checklist document to ensure that the Criminal History Checks are done in accordance with the regulations. The Checklist will require a double verification. The first verification will be performed by the CEO ¿ Antonio Romero III. The second verification shall be performed by the CFO ¿ Antonio Romero Jr. Both executives shall sign the document verifying that checks have been performed and we are in compliance. We have checked all current staff and have found no further violations. 05/27/2021 Implemented
6400.141(c)(14)Individual #1 physical dated 6/18/20, does not contain information pertinent to diagnosis and treatment in case of emergency. This section on the above mentioned physical was left blank by the physician.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 was immediately scheduled for his annual physical with his primary doctor. The quickest appointment was for 6/10/2021. Previous physical was performed by his previous provider, Devereaux. We have created an Intake document for Individuals entering our residential program. This document will require a double verification process where the CEO- Antonio Romero III will check the document for compliance, then the CFO- Antonio Romero Jr. will double check the document for compliance. This process will help us verify that all pertinent information is on the Physical and that we are in compliance. We conducted a check of the existing Individuals and no further violations were discovered. All physicals are current and scheduled for next visit. 05/27/2021 Implemented
6400.142(a)Individual #1 has not had an annual dental exam. The last dental exam was completed on 2/14/20.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #1 was scheduled for a Dental Exam with Special Smiles. Special Smiles requires clearance from Individuals Primary Care Physician to place under anesthesia. Individual was taken to Primary Care Physician on 4/16/21. Individual did not comply with the Echocardiogram and therefore did not receive the clearance. Primary Doctor referred Individual to Cardiologist. Individual taken to Cardiologist on 4/20/21. Individual did not permit the nurse to perform the echocardiogram. Cardiologist has requested that a sonogram be performed. The sonogram is scheduled for 6/1/2021. If the Individual complies and the test is completed with positive results. The cardiologist will give the clearance for Special Smiles to sedate Individual #1 and perform the required dental exam. Should Individual #1 not comply and refuse the sonogram, we shall work with the Behavior Specialist and Support Team to devise a refusal plan for Individual #1. All other individuals supported have been scheduled for Dental exams, as they have all recently entered the residential program. We have also created an Intake document for Individuals entering our residential program. This document will require a double verification process where the CEO- Antonio Romero III will check the document for compliance, then the CFO- Antonio Romero Jr. will double check the document for compliance. This process will help us verify that individuals entering the residential program have had a Dental exam in accordance with the regulations. 05/27/2021 Implemented
6400.151(a)Direct care staff 4 did not have a physical examination completed within 12 months prior to employment. Staff 4 was hired on 8/14/20 and had their initial physical completed on 10/27/20. Direct care staff 5 hired 2/28/21, did not have a completed physical on file. 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. To correct the violation, the staff member who was missing their physical was required to obtain a physical immediately. The staff member complied but no longer works for the company. We have created an HR Checklist document to ensure that Staff Physicals are done in accordance with the regulations. The Checklist will require a double verification. The first verification will be performed by the CEO ¿ Antonio Romero III. The second verification shall be performed by the CFO ¿ Antonio Romero Jr. Both executives shall sign the document verifying that Staff Physicals are completed properly and we are in compliance. We have checked all current staff and have found no further violations. 05/27/2021 Implemented