41 Reports
Inspection Report — Aug 6, 2026
Date: Aug 6, 2026
Visit Reason
The inspection was a provisional, interim licensing inspection conducted as a partial, unannounced visit to the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Current Residents in Hospice: 10
Residents Served: 46
Residents Age 60 or Older: 46
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Inspection Report — Jun 23, 2026
Follow-Up
Date: Jun 23, 2026
Visit Reason
The inspection was a full, unannounced licensing inspection conducted on June 23, 2026, to verify compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes and to confirm the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to staff qualifications, medication storage and administration, emergency preparedness, and documentation. All deficiencies had corrective plans accepted and were implemented by August 3, 2026, with ongoing monitoring and training plans in place.
Citations (9)
54a - Direct care staff lacked required qualifications as one staff member did not have a U.S. high school diploma, GED, or active Pennsylvania nurse aide registry status.
82c - Poisonous materials were found unsecured in the resident laundry room, which was not locked and accessible to residents.
96a - The first aid kit in the medication room was missing adhesive bandages.
132d - During a fire drill, a resident requiring assistance was not evacuated to a fire-safe area as instructed.
183b - Prescription and topical medications were found unlocked and accessible in a resident's bathroom.
183e - Unopened Lispro insulin pens were stored improperly outside refrigeration contrary to manufacturer instructions.
185a - Resident's PRN medications were not available in the home at the time of inspection.
187d - Resident was administered double the prescribed dose of D-Mannose with Cranberry twice daily for over three weeks.
224a - A preadmission screening form was not completed within 30 days prior to admission for a resident.
Report Facts
Residents Served: 47
Staffing Hours: 49
Staffing Hours: 123
Staffing Hours: 92
Residents with Mobility Need: 27
Hospice Residents: 1
Inspection Report — Jan 7, 2026
Follow-Up
Date: Jan 7, 2026
Visit Reason
The visit was a partial, unannounced follow-up inspection to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The facility was found to have implemented corrective actions for multiple deficiencies including staff annual training, equipment safety, lighting, food labeling, hearing impairment accommodations, first aid kit contents, medication administration training, and resident assessments. Continued compliance and monitoring plans were established.
Citations (11)
65f. Staff persons lacked annual training in medication self-administration, resident needs, dementia care, infection control, personal care, and safe management techniques for training year 2025.
65g. Staff members did not receive annual training in fire safety, emergency preparedness, residents' rights, protective services, falls, and accident prevention during 2025.
81b. Wheelchairs and mobility devices were not secure; a trash bag was found under a sink in a common bathroom creating a hazard.
101j. A resident's bedroom lacked an operable lamp or light source reachable from the bedside.
103e. Leftover food items in refrigerators were not labeled or dated as required by food safety standards.
130e. A resident with hearing impairment was not provided with a signaling device approved by a fire safety expert to alert them in case of fire.
171b. The first aid kit in the home's bus used for resident transport lacked a breathing barrier and eye protection.
190a. Medication administration staff did not have complete documentation of required medication administration observations and record reviews.
190c. Training records for medication administration requalification were incomplete; observations had not been completed.
225c. Resident assessments did not indicate use of bedside mobility devices or needs related to hearing impairment and smoking safety monitoring.
227d. Resident support plans lacked documentation of risks associated with mobility devices and did not address multiple unwitnessed falls or safety plans.
Report Facts
Residents Served: 40
Current Hospice Residents: 5
Residents Age 60 or Older: 40
Residents with Mobility Need: 9
Total Daily Staff: 49
Waking Staff: 37
Notice — Nov 14, 2025
Date: Nov 14, 2025
Visit Reason
The document serves as a response to a waiver request to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications in a personal care home.
Findings
The waiver outlines specific training and competency requirements for direct care staff administering GLP-1 agonist injections, including completion of Department-approved courses, in-person training, annual training hours, and facility policies for monitoring and clinical contact availability.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Oct 2, 2025
Annual Inspection
Date: Oct 2, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing regulations and to address violations found during prior inspections.
Complaint Details
The inspection included complaint investigation elements as indicated by the reason for visit being 'Renewal, Complaint'. Specific substantiation status is not stated.
Findings
Multiple violations were identified including unsigned resident contracts, incomplete criminal background checks, insufficient overnight staffing, lack of CPR/First Aid certified staff on certain shifts, missing annual training for staff, unlabeled food items, incomplete emergency preparedness documentation, hearing impairment accommodations, smoking area violations, missing posted menus, incomplete first aid kits in transport vehicles, medication administration errors, incomplete medication records, and incomplete resident assessments and records.
Citations (19)
25b Contract Signatures: Five resident contracts were not signed by the residents during the annual survey.
51 Criminal Background Check: A staff member was hired without a completed Pennsylvania State Police Criminal Background Check.
60a Staff/Support Plan: Overnight staffing was insufficient to safely evacuate all residents, with only two staff members present during overnight hours.
63a First Aid/CPR Training: No staff certified in First Aid and CPR were working during several shifts despite a census of 42 residents.
65g Annual Training Content: A staff member did not receive required annual training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention during 2024.
101j7 Lighting/Operable Lamp: A resident did not have access to a source of light that can be turned on/off at bedside.
103e Left Overs: Unlabeled and undated leftover food items were found in the kitchenette refrigerator and kitchen freezer.
107d Procedure Emergency Management Agency Submission: The home lacked documentation of annual review, update, and submission of emergency preparedness plan to the local emergency management agency.
130e Hearing Impairment: A resident unable to hear the fire alarm system was not provided with a signaling device approved by a fire safety expert.
144c1 Smoking Area Guidelines: Cigarette butts and used matches were found near the facility entrance and smoking area.
162c Menus Posted: No menus were posted for two weeks, preventing residents from reviewing food options.
171b5 First Aid Kit: The vehicle used to transport residents lacked a breathing shield and eye protection in the first aid kit.
182b Prescription Medication: Staff administered medications without completing the Department-approved medication administration training.
187a Medication Record: Medication administration records did not indicate units administered for a resident on sliding scale insulin.
190a Completion Medication Course: A med-tech administered medication without a waiver or proper training.
190c Record of Training: Medication administration training records lacked staff signatures and dates of completion.
225a Assessment 15 Days: A resident's initial assessment was not completed within 15 days of admission.
225c Additional Assessment: A resident's bedside mobility device was not noted in the significant change assessment.
252 Record Content: A resident's most recent photograph in the record was outdated.
Report Facts
Residents Served: 42
Current Hospice Residents: 9
Resident Support Staff: 3
Total Daily Staff: 57
Waking Staff: 43
Residents Age 60 or Older: 42
Residents with Mobility Need: 12
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nadiyah Bellamy | RA | Staff Privacy Coding |
| Brittany Strunk | MT | Staff Privacy Coding |
| Ciara Shore | MT | Staff Privacy Coding |
| Nicole Griesemer | MT/Bus. Office Mgr | Staff Privacy Coding |
| Gabrielle Radatti | MT | Staff Privacy Coding |
| Candy Olesh | MT | Staff Privacy Coding |
| Patricia Hannum | MT | Staff Privacy Coding |
| Heather Adamietz | MT/concierge | Staff Privacy Coding |
| Ashley Delong | MT | Staff Privacy Coding |
| Danielle Ford | MT | Staff Privacy Coding |
| Lance Weaver | MT | Staff Privacy Coding |
| Ketura Toussaint | MT | Staff Privacy Coding |
| Chelsea Holcomb | MT | Staff Privacy Coding |
| Susan Hetrick | MT | Staff Privacy Coding |
Inspection Report — Feb 20, 2025
Follow-Up
Date: Feb 20, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection to review the submitted plan of correction for the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to annual training and medication administration compliance. The report details two specific violations regarding annual falls and accident prevention training and medication course certification, both of which were corrected with ongoing monitoring plans.
Citations (2)
No documentation was available on site that Staff A completed Falls and Accident Prevention for the 2024 training year.
Staff Member A’s certification to pass medications expired and they were not recertified until after continuing to pass medication out of compliance.
Report Facts
Residents Served: 39
Current Hospice Residents: 6
Total Daily Staff: 63
Waking Staff: 47
Inspection Report — Dec 3, 2024
Renewal
Date: Dec 3, 2024
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including unannounced full inspections on 12/03/2024 and 12/12/2024.
Findings
The facility was found to have multiple regulatory violations including failure to report an abuse allegation, lack of physician certification for hospice residents during fire drills, insufficient overnight staffing for evacuation, incomplete staff training, missing rabies vaccinations for house cats, inadequate fire drill records, missing exit signs, outdated menus, unsecured medications, and incomplete resident records. Plans of correction were accepted and many were implemented by early 2025.
Citations (17)
Failed to report an allegation of abuse to the Licensing Department involving resident #1.
No written physician certification for hospice residents #2 and #3 exempting them from fire drill evacuation.
Insufficient overnight staffing to evacuate all residents during fire emergencies on 11/30/2024 and 12/1/2024.
Staff members A and B did not complete required training topics including infection control and meeting resident needs for 2023.
Two house cats lacked current rabies vaccination certificates.
Fire drill records from 2/16/24 through 11/25/24 did not indicate exit routes used.
No written fire safety expert letter for extended evacuation time; fire drills exceeded 2 minutes 30 seconds.
Residents #2 and #3 were not evacuated during fire drills from 6/26/24 to 11/25/24 without physician certification.
Exit signs missing in dining room egress routes during inspection on 12/3/2024.
Menus were not posted one week in advance; November 2024 menu was still posted on 12/3/24.
Medications and syringes were unlocked and accessible in resident #4's room on 12/12/24.
OTC medications in medication cart were not labeled with resident names.
Resident #4's prescribed medication Famotidine 20mg was not available at time of inspection.
Resident #5's medication administration lacked documentation of vital signs prior to administration on 11/15/24 and 11/16/24.
Staff Members A and B administered medications with expired certifications.
Residents #6 and #7 did not have preadmission screening forms completed by the home.
Resident #6's record lacked identifying marks, eye color, hair color, and religious affiliation documentation.
Report Facts
Residents requiring assistance to evacuate: 26
Staff on overnight shift: 2
Residents on hospice: 3
Staff total daily: 70
Waking staff: 53
Inspection Report — Aug 28, 2024
Follow-Up
Date: Aug 28, 2024
Visit Reason
The inspection visit on 08/28/2024 was a partial, unannounced follow-up inspection triggered by an incident at the facility.
Findings
The facility was found to have implemented the submitted plan of correction related to a medication administration error where a staff member accidentally administered medications to the wrong resident. The error was monitored with no adverse effects reported, and additional staff education and monitoring were put in place.
Citations (1)
Staff Person “A” accidentally administered medications to the wrong resident, violating the requirement to follow prescriber's orders.
Report Facts
Residents Served: 52
Current Residents in Hospice: 9
Residents Age 60 or Older: 52
Residents with Mobility Need: 29
Total Daily Staff: 81
Waking Staff: 61
Inspection Report — Apr 24, 2024
Date: Apr 24, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 04/24/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 51
Current Residents in Hospice: 3
Resident Support Staff: 78
Waking Staff: 59
Residents Age 60 or Older: 51
Residents with Mobility Need: 27
Inspection Report — Jan 24, 2024
Follow-Up
Date: Jan 24, 2024
Visit Reason
The inspection visit on 01/24/2024 was a partial, unannounced follow-up inspection related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. A staff member was found to have intentionally provoked a resident to take a video of the resident's behavior when agitated, resulting in the staff member's suspension and termination. Current employees were re-educated on managing aggressive behaviors and abuse reporting.
Citations (1)
Staff person 'A' intentionally provoked a resident to use their cell phone to take a video of the resident's behavior when agitated, violating the requirement that a resident be treated with dignity and respect.
Report Facts
Residents Served: 55
Current Residents in Hospice: 10
Total Daily Staff: 65
Waking Staff: 49
Residents 60 Years or Older: 55
Residents with Mobility Need: 10
Inspection Report — Dec 12, 2023
Follow-Up
Date: Dec 12, 2023
Visit Reason
The inspection visit on 12/12/2023 was a partial, unannounced follow-up inspection triggered by an incident at the facility.
Findings
The submitted plan of correction related to an abuse incident involving a staff member punching a resident was reviewed and determined to be fully implemented. Continued compliance is required.
Citations (1)
On 12/4/23, a resident was punched in the chest by a staff member, resulting in bruising; the staff member was suspended and terminated following investigation.
Report Facts
Residents Served: 55
Current Residents in Hospice: 10
Residents Age 60 or Older: 55
Residents with Mobility Need: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in abuse incident involving punching a resident and subsequent termination | |
| Staff Member B | Witnessed abuse incident involving Staff Member A |
Inspection Report — Nov 7, 2023
Renewal
Date: Nov 7, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 11/07/2023 to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including missing criminal background checks, incomplete annual staff training documentation, lack of operable bedside lamps, expired rabies vaccination for resident pets, combustible materials near heat sources, missing medications, incomplete preadmission screening forms, and incomplete resident record content. All deficiencies had plans of correction accepted and were reported as implemented by 01/02/2024.
Citations (8)
No documentation that a Pennsylvania State Police Criminal Background Check was completed for Staff Member A.
No documentation that staff members B and C completed required annual training for 2022.
An operable lamp or other source of lighting was not found at the bedside in room 104.
The rabies vaccination for pet cat for residents 1 and 2 expired 9/14/22.
A white sock was found lying over the dryer vent in the resident’s laundry room, posing a possible fire hazard.
Resident #6's PRN medication Bisacodyl suppositories 10mg was not available in the home at the time of inspection.
Preadmission Screening forms for Residents #3, #4, and #5 did not indicate if the residents' needs could be met in a Personal Care Home.
Resident records for Residents #1, #3, #4, and #5 did not contain any information regarding identifying marks.
Report Facts
Residents Served: 58
Total Daily Staff: 74
Waking Staff: 56
Current Residents in Hospice: 11
Residents Age 60 or Older: 58
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Inspection Report — Mar 30, 2023
Follow-Up
Date: Mar 30, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previous deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including abuse, treatment of residents, annual medical evaluations, additional assessments, and support plan documentation. Continued compliance and auditing were recommended.
Citations (5)
Resident #1 was neglected and physically moved against their will despite resistance, constituting abuse.
Staff violated the dignity of Resident #2 by yelling at them in the dining room.
A new Durable Medical Equipment (DME) was not completed by the physician for Resident #1.
A significant change assessment and support plan was not completed for Resident #1 after hospice admission.
Hospice services for Resident #2 were not noted in their assessment and support plan.
Report Facts
Residents Served: 50
Current Hospice Residents: 10
Residents Age 60 or Older: 50
Residents with Mobility Need: 16
Total Daily Staff: 66
Waking Staff: 50
Inspection Report — Sep 27, 2022
Renewal
Date: Sep 27, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation component, as indicated by the reason for visit including 'Complaint'. Specific substantiation status is not stated.
Findings
The inspection identified multiple deficiencies including delayed incident reporting, breaches in record confidentiality, delays in assistance with activities of daily living, contract signing delays, sanitary condition issues, safety hazards, medication administration errors, and incomplete resident records. Plans of correction were accepted and implemented with ongoing audits and education planned.
Citations (17)
Delayed reporting of medication errors and resident death to the Department.
Medication administration record binder was accessible to anyone walking by, breaching confidentiality.
Residents waited over an hour for call bell assistance despite needing help with activities of daily living.
Resident did not sign the resident-home contract within 24 hours of admission.
Resident's glucometer had dried blood on it, indicating poor sanitary conditions.
Emergency exit door near room 108 was covered with cobwebs, leaves, and bugs.
Residents in certain rooms did not have operable bedside lamps or lighting.
Food items in dry storage and freezer were not properly sealed or dated.
Exit door near a specified room would not open easily, preventing immediate egress.
A fire drill was not conducted in July 2022.
Fire drill evacuation times exceeded the 8-minute limit on two occasions.
Resident medical evaluation did not indicate resident's weight.
Medication Administration Record (MAR) transcription errors of blood glucose readings for multiple residents.
Resident's MAR documented incorrect blood glucose reading resulting in incorrect insulin administration.
Preadmission screening forms were completed outside the regulated timeframe for some residents.
Resident assessments were completed outside the required 15-day timeframe for some residents.
Resident records lacked eye and hair color information.
Report Facts
Residents Served: 56
Staffing Hours: 79
Waking Staff: 59
Completion Dates: Multiple dates ranging from 2022-12-01 to 2023-04-28
Inspection Report — Sep 19, 2022
Follow-Up
Date: Sep 19, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility, with follow-up visits to verify the submitted plan of correction.
Findings
A staff person was found to have yelled at a resident to 'Shut up,' violating the requirement to treat residents with dignity and respect. The staff person was removed, suspended, and ultimately terminated. The facility submitted and implemented a plan of correction including staff re-education on resident rights and dignity.
Citations (1)
Staff person yelled at resident to 'Shut up,' failing to treat resident with dignity and respect.
Report Facts
Inspection Report — Sep 14, 2021
Renewal
Date: Sep 14, 2021
Visit Reason
The inspection was a renewal inspection conducted on 09/14/2021 and 09/15/2021 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post current license and inspection summaries, failure to report a resident abuse incident timely, unsigned resident contracts, insufficient staff CPR/First Aid training coverage, incomplete staff training topics, exterior hazards, improper food labeling, lack of emergency procedure submission, incomplete medical evaluations, medication record errors, delayed resident assessments, and incomplete support plans. Plans of correction were accepted and implemented for all deficiencies.
Citations (12)
The home did not have the current license posted and did not post license inspection summaries dated 2/17/21 and 8/31/20 as required.
Resident #1 swung a cane and hit resident #2; the incident was not reported to the area agency on aging or the department's regional office timely.
Contracts for residents #3 and #4 were not signed by the residents.
On 9/5/21 and 9/11/21, there were shifts with insufficient staff certified in First Aid and CPR; the home requires at least 2 certified staff per shift.
Staff person A did not have required training on meeting the needs of residents as described in preadmission screening, support plan, and medical evaluation for the 2019 training year.
Sidewalk near exit door by room 108 was obstructed by overgrown lavender plants.
Activity area refrigerator had unlabeled and undated foil wrapped soft pretzels stored in the freezer.
The home did not have documentation that emergency procedures were reviewed and submitted to the local emergency management agency in 2020.
Resident #1's medical evaluation incorrectly indicated need for secure dementia care; the resident no longer required it.
Medication record for resident #5 included PRN medications not currently ordered and not in the medication cart.
Resident #4 did not have an initial assessment completed within 15 days of admission.
Resident #1's support plan did not list the significant change reason or hospice caregiver services.
Report Facts
Residents Served: 53
Current Residents on Hospice: 6
Residents Age 60 or Older: 53
Residents with Mobility Need: 23
Total Daily Staff: 76
Waking Staff: 57
Deficiencies Cited: 12
Inspection Report — Aug 18, 2021
Complaint Investigation
Date: Aug 18, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to incidents of resident abuse and other regulatory concerns at the facility.
Complaint Details
The complaint investigation substantiated incidents where staff held resident #1's arms to provide care causing bruising, and staff member E was observed providing rough and aggressive care to resident #2. Delays in reporting these incidents were noted. Staff involved were suspended and/or terminated. Follow-up audits and education were planned to ensure compliance.
Findings
The investigation found multiple violations including failure to immediately report suspected abuse, physical abuse and rough handling of residents, use of manual restraints, and failure to update resident support plans to reflect anxiety diagnoses and related care needs. Staff members involved were suspended or terminated, and corrective actions including staff education and audits were implemented.
Citations (4)
Failure to immediately report suspected abuse of residents.
Physical abuse and rough handling of residents during care.
Use of manual restraint by holding resident's arms during care.
Failure to update resident support plan to reflect anxiety diagnosis and care needs.
Report Facts
Residents Served: 53
Current Residents in Hospice: 7
Residents with Mobility Need: 21
Completion Date for Abuse Plan of Correction: Nov 19, 2021
Completion Date for Abuse Audit: Nov 12, 2021
Completion Date for Manual Restraint Audit: Nov 12, 2021
Completion Date for Support Plan Audit: Nov 12, 2021
Inspection Report — Jun 30, 2021
Renewal
Date: Jun 30, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/30/2021 for the facility Amity Place.
Findings
No regulatory citations were identified as a result of this licensing inspection.
Inspection Report — Jun 7, 2021
Complaint Investigation
Date: Jun 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Amity Place on 06/07/2021.
Complaint Details
The visit was complaint-related with the reason stated as Complaint, Incident. The deficiencies pertain to Resident #1's medical evaluation and preadmission screening documentation.
Findings
The inspection found deficiencies related to medical evaluation and preadmission screening for Resident #1, including failure to complete a medical evaluation within the required timeframe and lack of a preadmission screening form. The submitted plan of correction was accepted and fully implemented.
Citations (2)
Resident #1's documented medical evaluation was not completed within 60 days prior to admission or within 30 days after admission.
Resident #1's preadmission screening form was not completed within 30 days prior to admission and could not be found in the resident's record.
Report Facts
Residents Served: 51
Current Residents in Hospice: 2
Resident Support Staff Hours: 68
Total Daily Staff: 136
Waking Staff: 102
Residents with Mobility Need: 17
Inspection Report — Mar 11, 2021
Follow-Up
Date: Mar 11, 2021
Visit Reason
The visit was a follow-up inspection to verify that the previously submitted plan of correction was fully implemented following an incident-related partial inspection.
Findings
The facility was found to have implemented the plan of correction related to enabler bars attached to residents' beds, ensuring they were covered to prevent entrapment. The support plan for Resident #1 was updated to document the use and placement of the enabler bar. Ongoing audits and staff training were established to maintain compliance.
Citations (2)
Residents #1 and #2 had enabler bars attached to their beds that were not covered to protect from possible entrapment.
Resident #1's support plan did not indicate the placement of the enabler bar or the reason for its use.
Report Facts
Residents Served: 51
Current Hospice Residents: 4
Total Daily Staff: 59
Waking Staff: 44
Residents with Mobility Need: 8
Residents Age 60 or Older: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Care Services Manager | Named as responsible for covering enabler bars, conducting audits, and updating support plans | |
| Executive Director | Provided education to Care Services Manager and staff on relevant regulations |
Inspection Report — Feb 17, 2021
Plan of Correction
Date: Feb 17, 2021
Visit Reason
The inspection was a partial, unannounced incident review conducted on 02/17/2021 to evaluate compliance and the implementation of a submitted plan of correction.
Findings
The report found a violation where a staff member was overheard making disrespectful comments to a resident requiring toileting assistance. The plan of correction was accepted, the employee was no longer employed, and staff re-education and ongoing resident interviews were planned to ensure dignity and respectful treatment.
Citations (1)
Staff person A was overheard telling resident #1 that they shouldn't drink because then they have to go to the bathroom too much; resident #1 requires assistance with toileting.
Report Facts
Residents Served: 55
Staffing Hours - Total Daily Staff: 55
Staffing Hours - Waking Staff: 41
Hospice Current Resident Count: 13
Inspection Report — Feb 5, 2021
Renewal
Date: Feb 5, 2021
Visit Reason
The document summarizes the results of multiple licensing inspections conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, at the facility on various dates in January and February 2021.
Findings
No regulatory citations were identified as a result of the inspections conducted on the specified dates.
Report Facts
Inspection dates: 7
Inspection Report — Jan 28, 2021
Routine
Date: Jan 28, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report. |
Notice — Sep 18, 2020
Date: Sep 18, 2020
Visit Reason
This document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Amity Place' following receipt of the renewal application dated September 16, 2020.
Findings
No inspection findings are reported in this document. It advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Aug 31, 2020
Follow-Up
Date: Aug 31, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction related to a staff member's unprofessional behavior was fully implemented. Continued compliance must be maintained.
Citations (1)
42c - Treatment of Residents: Staff A called resident A a derogatory name and spoke in an unprofessional manner on 8/23/20. The facility implemented corrective actions including staff discipline and re-education on dignity and respect.
Report Facts
Residents Served: 58
Current Residents in Hospice: 3
Total Daily Staff: 80
Waking Staff: 60
Inspection Report — Sep 24, 2019
Renewal
Date: Sep 24, 2019
Visit Reason
The inspection was an annual renewal inspection combined with incident review conducted on September 24, 2019.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with posting licenses, resident confidentiality breaches, incomplete quality management plan reviews, hospice care fire drill procedures, staff training deficiencies, medication administration, and resident record documentation.
Citations (25)
Regulation 2600.3.c: The licensing inspection summary dated 9/7/18 was not posted in a public conspicuous area of the home.
Regulation 2600.17: Resident privacy coding documents exposing confidential information were posted in the lobby.
Regulation 2600.26.b: The home lacked documentation of the annual quality management plan review within the last 12 months.
Regulation 2600.29.a.b.1: Resident #1 lacked written physician certification for exemption from fire drill evacuation.
Regulation 2600.29.a.b.2: Resident #1 lacked written informed consent from resident or POA regarding fire drill non-evacuation.
Regulation 2600.29.a.b.4: Staff did not inform Resident #1 or responsible staff that the fire drill alarm was a drill, not an actual fire.
Regulation 2600.29.a.b.5.i: Staff did not access or use appropriate transportation equipment during Resident #1's fire drill evacuation simulation.
Regulation 2600.29.a.b.5.ii: Staff did not reasonably simulate the effort required to evacuate Resident #1 during the fire drill.
Regulation 2600.29.a.b.10: Resident #1's assessment and support plan did not address exclusion from fire drill evacuation due to active dying status.
Regulation 2600.29.a.b.11: Fire drill record lacked hospice agency license, physician certification, informed consent, and bedroom relocation consideration for Resident #1.
Regulation 2600.42.c: Private duty staff hired by family slapped Resident #2 on the arm and did not treat the resident with dignity and respect.
Regulation 2600.65.a: Ancillary staff member C did not complete first day fire safety orientation until 6 days after hire.
Regulation 2600.65.e: Direct care staff D and E completed only 11 of 12 required annual training hours for 2018.
Regulation 2600.65.f: Direct care staff D and E did not receive required training in medication self-administration, resident needs, and safe management techniques for 2018.
Regulation 2600.65.g: Staff D did not receive training in resident rights and Older Adult Protective Services Act; staff F did not receive training in falls and accident prevention for 2018.
Regulation 2600.107.d: The home did not complete an annual review of emergency procedures for 2018.
Regulation 2600.109.b: Two resident cats had expired rabies vaccinations.
Regulation 2600.124: Notice to fire department incorrectly reported 21 residents with mobility needs; actual number was 23.
Regulation 2600.132.e: Fire drill during sleeping hours was not conducted within required 6-month interval.
Regulation 2600.182.b: Direct care staff D, E, and G only completed tests but not full medication administration training.
Regulation 2600.183.b: Medication carts were left unlocked in medication room accessible to untrained staff.
Regulation 2600.185.a: Narcotic count sheets were not signed by oncoming and off-going staff on 9/8/19 and 9/21/19 shifts.
Regulation 2600.227.d: Resident #3's record lacked notes or summary addendum regarding discharge circumstances.
Regulation 2600.227.g: Resident #4's support plan was not signed by the resident nor documented refusal or inability to sign.
Regulation 2600.252.3: Resident #4 and #5 had photographs in records older than 2 years.
Report Facts
Residents Served: 68
Current Hospice Residents: 5
Residents with Mobility Need: 23
Residents with Physical Disability: 3
Staff Count: 91
Waking Staff: 68
Deficiencies Cited: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gress | Executive Director | Named in multiple findings and plans of correction including posting licenses, confidentiality, quality management, fire drill procedures, staff training, medication administration, and record documentation. |
Notice — Aug 1, 2019
Date: Aug 1, 2019
Visit Reason
The document is a renewal notice for the operation of a Personal Care Home and includes a certificate of occupancy with a maximum capacity of 100 persons. It informs the licensee that a regular annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a notification of license renewal and upcoming annual inspection requirements.
Inspection Report — Jun 10, 2019
Complaint Investigation
Date: Jun 10, 2019
Visit Reason
The inspection was conducted as a result of an incident reported at the facility, triggering a complaint investigation.
Complaint Details
The visit was complaint-related due to an incident involving rough treatment of a resident by a home health employee. The employee was suspended and terminated. Training was completed and monitoring was implemented.
Findings
The investigation found that a home health employee was rough and disrespectful to a resident during personal care, violating the requirement to treat residents with dignity and respect. The home health employee was suspended and terminated by their agency, and training was provided to staff to prevent recurrence.
Citations (1)
42c - Treatment of Residents: A home health employee was observed being rough and disrespectful to Resident #1 during personal care, including forcing the resident to stand and pushing the resident's forehead down. The employee was terminated by the home health agency.
Report Facts
Residents Served: 78
Staffing Hours - Total Daily Staff: 105
Staffing Hours - Waking Staff: 79
Residents with Mobility Need: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gress | Executive Director | Signed plan of correction and responsible for monitoring compliance |
| Christine Kline | Administrator | Facility administrator listed in report |
Inspection Report — Apr 29, 2019
Complaint Investigation
Date: Apr 29, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at Amity Place, a personal care home, to assess compliance with 55 Pa. Code Ch. 2600.
Complaint Details
The inspection was triggered by a complaint and incident involving Resident #1's fall and other care concerns. The report includes substantiated violations with plans of correction partially implemented as of 6/17/2019.
Findings
The inspection found multiple violations related to incident reporting, assistance with activities of daily living, following prescriber's orders, preadmission screening, and support plan documentation. Several plans of correction were partially implemented with ongoing monitoring required.
Citations (5)
2600.16c The home failed to report a resident's fall with a hip fracture to the Department's regional office within 24 hours, delaying notification until 4/16/2019.
2600.23a The home did not assist Resident #2 with repositioning every two hours as required by the resident's support plan and home health care notes.
2600.187d The home failed to follow the prescriber's order for a video swallow study for Resident #2, as the study was never conducted due to family refusal.
2600.224a The home did not complete a preadmission screening form for Resident #1 upon admission on 3/28/2019.
2600.227d The resident's support plan did not address the need for mechanical lift use and home health care for Resident #2's sacral wound treatment.
Report Facts
Residents Served: 66
Staffing Hours - Total Daily Staff: 97
Staffing Hours - Waking Staff: 73
Residents with Mobility Need: 31
Residents Age 60 or Older: 66
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gress | Executive Director | Signed plans of correction for multiple violations |
Inspection Report — Mar 6, 2019
Complaint Investigation
Date: Mar 6, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Amity Place Personal Care Home on March 6, 2019.
Complaint Details
The inspection was complaint-driven. No substantiation status was explicitly stated in the report.
Findings
Two violations of 55 Pa.Code Chapter 2600 were cited: the administrator was not present for the required average of 20 hours per week since January 11, 2019, and a resident had not received an annual assessment and support plan within the required timeframe. Plans of correction were submitted and partially implemented as of April 17, 2019.
Citations (2)
55 Pa.Code §2600.56 requires the administrator to be present an average of 20 hours per week. The home lacked a qualified administrator meeting this requirement since January 11, 2019.
55 Pa.Code §2600.227(c) requires the support plan to be revised within 30 days of annual assessment or changes. Resident #1 had no annual assessment and support plan since 10-10-2017, exceeding the required timeframe.
Report Facts
Number of Residents Served: 74
Number of Current Hospice Residents: 3
Residents 60 Years or Older: 74
Residents with Mobility Need: 29
Residents with Physical Disability: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Winslow | Administrator | Named as the administrator who was not present for the required hours and enrolled in training. |
| Christine Kline | Acting Executive Director/Personal Care Home Administrator | Assigned to act as administrator for 20 hours per week starting April 2, 2019. |
Inspection Report — Oct 17, 2018
Complaint Investigation
Date: Oct 17, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The complaint was substantiated based on the finding that staff person A did not treat resident #1 with dignity and respect during night care on 09/22/2018. The employee involved was terminated on 09/24/2018. The Executive Director is no longer employed as of 01/11/2019. Training on abuse and neglect was conducted on 03/06/2019.
Findings
The inspection found a violation of 55 Pa.Code §2600.42(c) where a staff member did not treat a resident with dignity and respect during night care. A plan of correction was submitted including staff training on abuse and neglect and ongoing monitoring.
Citations (1)
55 Pa.Code §2600.42(c) - A resident was not treated with dignity and respect by staff during night time care on 09/22/2018.
Report Facts
Staffing Hours: 107
Waking Staff Hours: 80
Number of Residents Age 60 or Older: 76
Number of Residents with Mental Illness: 4
Number of Residents with Mobility Need: 31
Number of Residents with Physical Disability: 2
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John McGovern | Administrator | Named as facility administrator in report header |
Inspection Report — Sep 7, 2018
Renewal
Date: Sep 7, 2018
Visit Reason
The inspection was a renewal inspection conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on September 7, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection found multiple violations related to staffing adequacy for evacuation, sanitary conditions, fire safety documentation, medication administration, medical evaluations, menu posting, and resident assessment support plans. Plans of correction were submitted with partial implementation progress noted.
Citations (14)
55 Pa.Code §2600.60(a) - Staffing shall meet residents' needs as specified in assessments and support plans. Two staff on night shifts could not safely evacuate all residents with mobility needs during emergency drills.
55 Pa.Code §2600.85(a) - Sanitary conditions shall be maintained. Resident #1's glucometer contained dry blood.
55 Pa.Code §2600.124 - The home must notify the local fire department in writing of the home's address, bedroom locations, and evacuation assistance needs. Notification dated 7/30/18 lacked total capacity and correct resident mobility needs.
55 Pa.Code §2600.132(c) - A written fire drill record must include date, time, evacuation duration, exit route, resident counts, staff participation, and alarm status. The home did not document correct resident evacuation numbers for multiple fire drills.
55 Pa.Code §2600.132(f) - Alternate exit routes must be used during fire drills. The home did not alternate exit routes during monthly fire drills as required.
55 Pa.Code §2600.162(c) - Menus stating specific foods served must be prepared one week in advance and posted conspicuously. The home's dining room menus did not contain the required weeks' menus.
55 Pa.Code §2600.182(b) - Prescription medication shall be administered by authorized personnel. Staff persons A and B did not complete initial medication administration tests and were not properly trained.
55 Pa.Code §2600.183(d) - Medication orders must be current and accurate. Resident #3's medication order was not dated and medication administration observations were incomplete.
55 Pa.Code §2600.186(a) - Medication records must include resident name, allergies, medication name, strength, dosage, route, frequency, administration times, duration, precautions, diagnosis, date/time of administration, and staff initials. The home did not properly maintain Resident #4's medication record; a blood glucose reading was incorrectly transcribed.
55 Pa.Code §2600.187(a) - Resident medication records must be kept current. Resident #3's doctor's order was not updated for a 25 mg medication.
55 Pa.Code §2600.141(a)(2) - Medical evaluations must include DOB, height, weight, pulse, temp, blood pressure, special health/dietary needs, immunizations, health status, and cognitive functioning. Resident #2's evaluation lacked these items.
55 Pa.Code §2600.224(a) - Preadmission screening must be documented to meet service needs. Resident #2's preadmission screening did not indicate if needs could be met by the home.
55 Pa.Code §2600.225(c) - Resident assessments must be completed annually and updated as needed. Resident Assessment Support Plans for residents #2 and #5 were incomplete.
55 Pa.Code §2600.227(g) - Individuals involved in support plan development must sign and date the plan. Resident #5's support plan was not signed by the resident or documented refusal.
Report Facts
Number of Residents Present: 75
Number of Residents with Mobility Needs: 32
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John McGovern | Executive Director | Named as legal entity representative signing plans of correction and involved in findings. |
Inspection Report — Aug 2, 2018
Renewal
Date: Aug 2, 2018
Visit Reason
This document is a renewal application approval and license issuance for the Personal Care Home 'Amity Place' following the renewal application submitted on August 2, 2018.
Findings
The Department of Human Services approved the renewal application and issued a regular license for Amity Place. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — May 18, 2018
Complaint Investigation
Date: May 18, 2018
Visit Reason
The inspection was conducted due to an incident complaint at the facility.
Complaint Details
The complaint involved allegations of abuse against Resident #1 reported on 4/11/18. The home did not contact the local area agency on aging or submit required incident reports timely. The complaint was substantiated by the inspection findings.
Findings
The inspection found violations related to failure to report suspected abuse promptly, failure to report incidents within required timeframes, and failure to treat residents with dignity and respect. Plans of correction were partially implemented with ongoing monitoring responsibilities assigned to the administrator.
Citations (3)
55 Pa.Code §2600.15(a): The home failed to immediately report suspected abuse of Resident #1 to the local area agency on aging as required.
55 Pa.Code §2600.16(c): The home failed to report the incident or condition to the Department's personal care home regional office or complaint hotline within 24 hours as required.
55 Pa.Code §2600.42(c): Staff refused to assist Resident #1 with mobility and treated residents without dignity and respect, including rough treatment and leaving a resident waiting for two hours.
Report Facts
Number of Residents Served: 77
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 13
Total Daily Staff: 93
Waking Staff: 70
Residents Age 60 or Older: 77
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John McGovern | Executive Director | Named in plans of correction and responses to violations |
| Ryan Novak | Department representative conducting inspection |
Inspection Report — Dec 27, 2017
Complaint Investigation
Date: Dec 27, 2017
Visit Reason
The inspection was conducted due to an incident involving a resident discharge and multiple occasions of violating residents' rights.
Complaint Details
The investigation was triggered by an incident where resident #1 was discharged due to multiple violations of residents' rights. The home failed to implement adequate 30-minute monitoring checks after incidents on 8/2/2017 and another date in 2017.
Findings
The facility discharged a resident to a hospital following incidents violating residents' rights and failed to adequately implement 30-minute monitoring checks to prevent further incidents.
Citations (1)
55 Pa.Code §2600 discharge regulation was violated when a resident was discharged after multiple rights violations and inadequate monitoring with 30-minute checks.
Report Facts
Number of Residents Served: 74
Total Daily Staff: 104
Waking Staff: 78
Number of Residents 60 Years or Older: 74
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 14
Number of Residents with Mobility Need: 30
Number of Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John McGovern | Executive Director | Named as Legal Entity Representative and Administrator |
| Amy Deluca | Department representative on-site during inspection | |
| Jason Harvey | Department representative on-site during inspection |
Inspection Report — Oct 6, 2017
Renewal
Date: Oct 6, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on October 6, 2017, for the Personal Care Home Amity Place.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident privacy, staff certification, administrator training, emergency medical plan, fire safety, and documentation of hospice services. Plans of correction were submitted for each violation.
Citations (9)
55 Pa.Code 2600.17 - Privacy coding documents exposed confidential resident information and were removed on the inspection date to ensure compliance.
55 Pa.Code 2600.63(a) - The home serves 75 residents but did not have two staff certified in first aid and CPR on every shift as required.
55 Pa.Code 2600.64(c) - Administrator completed only 13 hours of required 24 hours of annual training for 2015.
55 Pa.Code 2600.65(b) - Direct care staff failed to receive training in emergency medical plan and reporting of reportable incidents within first 40 hours of work.
55 Pa.Code 2600.121(a) - Exit to activity courtyard was locked with chain and lock, preventing immediate egress in emergency.
55 Pa.Code 2600.130(h) - Emergency procedures did not specify actions when smoke detector or fire alarm is inoperable.
55 Pa.Code 2600.132(f) - Fire drills used same four exit routes repeatedly without rotation or documentation of blocked routes.
55 Pa.Code 2600.143(a) - The home lacked a written emergency medical plan.
55 Pa.Code 2600.227(d) - Resident's service plan was not updated to reflect hospice services for over two months.
Report Facts
Number of Residents Served: 75
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 15
Total Daily Staff: 102
Waking Staff: 77
CPR Training Attendees: 18
Administrator Training Hours Completed: 13
Administrator Training Hours Completed (Make-up): 8
Administrator Training Hours Scheduled: 3
Resident Hospice Service Delay Days: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Geiger | Executive Director | Named as legal entity representative and responsible for plans of correction. |
| Ryan Novak | Department representative conducting inspection. | |
| Anne O'Haire | Department representative conducting inspection. |
Inspection Report — Sep 7, 2017
Complaint Investigation
Date: Sep 7, 2017
Visit Reason
The inspection was conducted as a complaint and incident investigation at Amity Place Personal Care Home on September 7, 2017.
Complaint Details
The visit was complaint-related and substantiated based on observations of suspected abuse and neglect involving residents #1 and #2.
Findings
The inspection found violations related to suspected resident abuse, neglect, and failure to update resident support plans. Specifically, staff observed inappropriate sexual contact between residents and inadequate documentation of behavioral incidents and support plans.
Citations (3)
55 Pa.Code §2600.15(a) requires immediate reporting of suspected resident abuse. Staff observed resident #1 sexually assault resident #2, but the facility failed to report this incident to the local Area Agency on Aging timely.
55 Pa.Code §2600.42(b) prohibits neglect, intimidation, abuse, and corporal punishment. Staff observed resident #1 touching resident #2 without consent, indicating neglect and abuse.
55 Pa.Code §2600.227(d) requires documentation of behavioral services in resident support plans. Resident #1's assessment and support plan were not updated to reflect sexual behavior and how the facility would meet resident needs safely.
Report Facts
Number of Residents Served: 74
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Geiger | Administrator | Named in facility header information |
| John McGovern | Executive Director | Signed plan of correction documents |
| Jesse Hummel | Department representative conducting inspection |
Inspection Report — Jul 10, 2017
Renewal
Date: Jul 10, 2017
Visit Reason
The document is a renewal application and license issuance for Amity Place Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It primarily communicates the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Apr 11, 2017
Complaint Investigation
Date: Apr 11, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The inspection was triggered by an incident and the violation regarding the missed fire drill was substantiated.
Findings
The facility failed to conduct an unannounced monthly fire drill for residents and staff as required by regulation. The violation was identified during an audit of the Fire Drill Log for February 2017.
Citations (1)
55 Pa.Code §2600.132(a) requires an unannounced fire drill at least once a month. The facility did not conduct the required fire drill in February 2017 as confirmed by the administrator.
Report Facts
Number of Residents Served: 65
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 12
Number of Residents 60 Years or Older: 65
Number of Residents with Mobility Need: 16
Number of Residents with Physical Disability: 1
Inspection Report — Oct 7, 2016
Original Licensing
Date: Oct 7, 2016
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the personal care home facility.
Findings
The facility was found to be in substantial compliance with applicable regulations under 55 Pa.Code Ch. 2600. The licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
Document — August 31, 2021
Date: August 31, 2021
Visit Reason
The document includes a Certificate of Compliance granting permission to operate a Personal Care Home and a letter acknowledging receipt of a renewal application with notice of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported; the documents confirm issuance of a regular license and state that an annual inspection will be conducted within the next twelve months.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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