Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224037 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bottom drawer in bathroom was waterlogged and falling apart.Floors, walls, ceilings and other surfaces shall be in good repair. This is a health and safety hazard and was completed by our facilities team immediately after inspection. Photo attached. 05/01/2023 Implemented
6400.72(b)A window in the bedroom of individual 3 does not stay up and falls back down when opened. Screens, windows and doors shall be in good repair. The window was repaired by our facilities team immediately after inspection to ensure that all windows are in good repair. 05/01/2023 Implemented
6400.111(f)Fire Extinguisher in the attached garage was last inspected September of 2020. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. a work order was placed upon inspection to update the fire extinguisher to ensure the health and safety of the residents at Arch Rd. 05/01/2023 Implemented
6400.141(a)Individual 3 does not have a current physical on file. Their last physical is dated 1/24/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Having an annual physical completed is essential to ensure the health of the individual¿s we support. The individual in question has a history of refusing appointments, however there was no documentation to support that, and in addition to that, more attempts should have been made to ensure this was completed. The completed and corrected physical is attached. 06/07/2023 Implemented
6400.144Two medications for individual 3 were not present on site. Those medications are as follows: AYR Saline Nasal Gel -- 3 sprays in each nostril twice daily as needed for dryness Sildenafil Tab 25mg -- Take 1 tablet by mouth daily one hour before sexual activity.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. All prescribed medications must be on site at all times. Should a med not be needed further, it is essential that the provider have that medication discontinued by the prescribing physician. These 2 meds are still prescribed and so when it was noted at the time of inspection that they were not on site AYR Saline Nasal Gel and Sildenafil Tab 25mg were ordered from the pharmacy and are back in the site should the individual require these. 05/01/2023 Implemented
6400.165(g)Individual 3 has not had psychotropic medication reviews every 90 days. A period greater than 90 days elapsed between reviews dated 5/17/22 and 2/14/23.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Its essential to have psychotropic medication checked every 90 days. In the event a doctor¿s office is delayed, or an appointment is cancelled, it¿s important that we have this cancellation clearly documented and that we have the medications reviewed promptly. Please see attached documents that ensure we are following this guidance. 05/01/2023 Implemented
SIN-00203988 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Staff member #1 did not have a declaration of residency on file for her hiring in 2022, so an FBI background check would have been needed. Staff member #2 does not have a current background check or proof of residency on file.If a prospective employee 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.This staff person is going through re-credentialing. While she had all NJ and Delaware qualifications, we did not have her PA run, this is actively being worked on, documents attached, 05/04/2022 Implemented
6400.64(a)Individual#1's Bedroom had a strong odor consistent with urine near the bed and clothing hamper. The hall bathroom tub was stained with dirt and scum residue. Hydrogen peroxide was left open on individual #2's dresser and multiple containers of petroleum jelly were left unopened stacked in the individuals bedroom.Clean and sanitary conditions shall be maintained in the home. deep clean was done and a contract is being established with a cleaning service as daily cleaning is not sufficing to keep the rooms and home in perfect condition. Also a crate was purchased for the individual to store his products in so that open jar are not exposed. 05/04/2022 Implemented
6400.104There was no documentation showing that the notifications to the fire department were sent at the beginning of the current occupancy of the homeThe 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. This was in place, however the notifications were not dated, so it was unclear as to when they were sent out to the fire departments. The letters were revised and sent out immediately after licensing to include the current date. 05/04/2022 Implemented
6400.112(e)The fire drills for 28 Arch Road location did not have an overnight fire drill in the six months prior to the 10/16/21 fire drill which was the sleep drillA fire drill shall be held during sleeping hours at least every 6 months. A sleep fire drill was held in addition the management team was retrained on 5/13/22 the importance of regular overnight drills as well as changing the setting area and egress so that residents are prepared for any emergency and can safely evacuate. 05/13/2022 Implemented
6400.46(b)Staff #1 did not receive Fire Safety Training from a Fire Safety Expert annually as required under this Chapter.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).This was an error- the staff did have fire safety, training file attached 05/04/2022 Implemented
SIN-00187192 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions were not maintained throughout the home. A dark brown/grey material consistent with grease or grime was observed in large spots around the top of the range on the oven, as well as its interior, where it was seen on the door and around the bottom of the oven. Two large spots were also observed on the linoleum under the toilet in the bathroom as well, ranging in color from dark brown to a red/pink, consistent with dirt or grime.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions were not maintained throughout the home. A dark brown/grey material consistent with grease or grime was observed in large spots around the top of the range on the oven. The stove had been cleaned prior to the inspection and it is believed the glare off the stove gave it a smeared appearance. The stove ultimately is in good repair and in good condition. 04/23/2021 Implemented
6400.68(a)The house's hot water was tested in the bathroom's shower, where the temperature was observed to reach only 82 degrees. The water must not exceed 120 degrees, but must be more than lukewarm as well.A home shall have hot and cold running water under pressure. We understand the importance of water being at the proper temperature for our individuals. We believe the individuals getting showers prior to the temperature being taken, and a load of laundry being completed may have contributed to the decreased temperature. Water temp was checked later in the day after the inspection and the temp was 102 degrees. To ensure that our temperatures continue to be in a safe and comfortable range, we will test water periodically before showers to ensure the water temperature is warm enough. In addition, both gentlemen are able to express their wants and needs and have been asked to alert management should they note that their shower water feels too cool. 04/24/2021 Implemented
6400.110(a)No smoke detector was observed in the attic at time of inspection. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. A smoke detector was placed in the attic immediately after inspection to ensure compliance with state regulations and the safety of our individuals. It is essential for the health and safety of all residents and employees in the home that a smoke alarm be present on all floors. In the event of a fire, we want to ensure all occupants in the home in all areas of the home are fully alerted in order to evacuate safely and timely. 04/23/2021 Implemented
6400.144Not all of the medications listed on individual 1's medication administration record (MAR) were maintained in the home. The clotrimazole 1% cream listed on his MAR was not present at time of inspection.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. This medication was prescribed by Dr. Keith Williams and was discontinued. Notation was not made on the MAR in a timely fashion. This was missed during the monthly medication audit and should have been discontinued on the MAR. It is essential that the provider ensure MAR¿s are accurate for appropriate and safe medication administration. 04/26/2021 Implemented
6400.166(b)Individual 1's March 2021 medication administration record (MAR) was reviewed. The staff who administered his medication did not consistently initial the MAR at time of administration. The following medications were found to have missing initials on the following dates/times: 1. Aspirin Low CHW 81 mg. -- 3/12, 3/26, 3/28, all at 8AM. 2. Clotrimazole Cream 1% - 3/12 at 8AM, 3/26 at 8AM, 3/28 at 8AM and 8PM. 3. Imipram HCL 50MG -- 3/26 and 3/28, both at 8PM. 4. Januvia 100mg - 3/12, 3/26, 3/28, all at 8AM. 5. Lisinopril 30mg - 3/12, 3/26, 3/28, all at 8AM. 6. Metformin 50mg - 3/12 at 8AM, 3/26 at 8AM, 3/28 at 8AM and 8PM. 7. Montelukast 10mg -- 3/28 at 8PM 8. Myrbetriq 50mg - 3/12, 3/26, 3/28, all at 8AM. 9. Omeprazole 20mg - 3/12 at 8AM, 3/26 at 8AM, 3/28 at 8AM and 8PM. 10. Quetiapine 100mg -- 3/25 at 8PM and 3/28 at 4PM and 8PM. 11. Ayr saline nasal gel -- 3/2, 3/3, 3/4, and 3/28, all at 8PM. 12. Triamcinolon cream 0.1% - 3/3 and 3/4 at 8PM, 3/26 at 8AM, and 3/28 at 8AM, 4PM, and 8PM. 13. Rybelsus 3mg -- 3/24, 3/25, 3/26, and 3/28 at 8AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.This staff has been assigned a medication review training as a follow up for the documentation error. The MAR was pulled and reviewed, and no further documentation error had occurred. The medication was properly administered, and the blister pack was dated appropriately however the MAR wasn't clearly signed. 04/23/2021 Implemented
SIN-00161361 Renewal 08/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The home had one trashcan and it was overflowing with trash. There was excessive trash next to the trash can and not kept in a closed receptacle.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The trashcan shall not overflow with trash. Trash is to be kept in receptacles that prevent the penetration of insects and rodents. An additional trashcan with an attached lid was purchased for the home. The trash pick-up day is on Thursday's, and the trash will be put out for collection and removed from the premises at least once per week. A memorandum was written and posted detailing how the trashcans outside the home shall be kept. The side patio area and the trashcans will be checked weekly in order to maintain sanitation. An update was A picture of the side patio and trashcans has been submitted. 09/11/2019 Implemented
6400.181(d)Individual #1's annual assessment dated 1/24/19 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment. In order to address the non-compliance, the program specialist made an addendum to the assessment. The assessment addendum was dated for 8/15/19 after the non-compliance was cited and attached to the end of the 1/24/19 assessment. In the future, the program specialist will sign and date the assessment upon it being completed and printed. The assessment be review for the program specialist's signature and date during quarterly audits. A copy of the assessment addendum is included for review. 08/15/2019 Implemented
SIN-00114615 Renewal 05/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(g)The bathroom did not contain a towel or paper towels. An individual washcloth, bath towel and toothbrush shall be provided for each individual.A washcloth, toothbrush and bath towel should be provided for each individual. During inspection time there were no towels or paper towels in the bathroom. This was an error on the provider that has been addressed. There are typically paper towels in the bathroom; however one of our individuals removed the paper towels. The provider will replace with a dispenser attached to the wall so this cannot be removed. The gentlemen in the home continue to keep their bath towels, toothbrush and washcloth in their respective bedrooms. 05/17/2017 Implemented
6400.104There was no documentation notifying the local fire department of indivduals who are need assistance evacuating.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. There was a notification to the fire department; however the notification did not include the exact location of the bedrooms in the event of an actual fire. Both individuals in this home are fully ambulatory and able to evacuate independently, however the notification has been updated to include more information about the residents in the home and the location of their respective bedrooms. Please see attachment for updated notification. 08/17/2017 Implemented
SIN-00043222 Initial review 09/27/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)ONE INDIVIDUAL DID NOT HAVE AN ANNUAL PHYSICAL PROSTATE EXAM.(9) A prostate examination for men 40 years of age or older. Mr. Briner had his Prostate Exam on 10/23/12 10/23/2012 Implemented
SIN-00138783 Renewal 06/18/2018 Compliant - Finalized