Inspection Reports for
Heartful Hands LLC
514 MITCHELL AVENUE,, CLARITON, PA, 15025
Back to Facility Profile18 Reports
Notice — Aug 25, 2026
Date: Aug 25, 2026
Visit Reason
The document serves to grant a waiver for a personal care home administrator to delay completion of the required training course due to needing additional time to complete the personal care home administrator training.
Findings
The waiver is granted with specific conditions including enrollment and completion deadlines for the training course and competency test, attendance at an orientation session, documentation requirements, and supervision until compliance is met.
Report Facts
Waiver deadlines: 100
Competency test deadline: Competency-based training test with passing score to be completed by October 14, 2026
Orientation session dates: Orientation session scheduled for October 23, 2026 or November 20, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — Jul 16, 2026
Renewal
Date: Jul 16, 2026
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection included a complaint investigation component, but the report does not state the substantiation status of the complaint.
Findings
The facility had multiple deficiencies including failure to provide quarterly financial accounts to residents, incomplete staff orientation and training, maintenance issues with building surfaces and safety features, and incomplete or untimely resident medical evaluations and assessments. Plans of correction were submitted and implemented by the facility.
Citations (14)
20b. The home failed to provide quarterly accounts of financial transactions to residents #1 and #2 in 2026.
65a. Ancillary staff person A did not receive orientation on fire safety and emergency preparedness topics including evacuation procedures and use of fire extinguishers.
65b. Ancillary staff person A did not receive training on resident rights, emergency medical plan, and mandatory abuse reporting.
65f. Direct care staff person B did not receive training on meeting residents' needs as described in preadmission screening and support plans during the 2025 training year.
65g. Direct care staff person B did not receive training on the Older Adult Protective Services Act during the 2025 staff training year.
88a. Facility surfaces including bathroom air return grill, exhaust fan, shower floor drains, and shower surrounds were dirty, rusty, unattached, or peeling.
93b. Wooden railings and deck landing at second-floor emergency exit were unstable and moved approximately an inch and a half.
94b. Only ten of nineteen steps on the 2nd floor outside deck had nonskid surfaces.
100a. Exterior building steps were unstable with dry rotted, spongy wooden stair treads and cracked cleats; debris including rusty grill and garbage bags were found on the grounds.
132f. Fire drill records showed only certain exits were used for four consecutive drills, limiting alternate exit route use.
141a. Residents #3 and #4 had initial medical evaluations missing required medical professional information and assistance/supervision details.
141b1. Resident #5’s medical evaluation lacked required medical professional information and assistance/supervision details; similar omissions for resident #6.
225a. Resident #3’s initial assessment omitted numerous diagnoses; resident #4’s initial assessment was untimely and incomplete.
225c. Residents #5 and #6 had medical evaluations with diagnoses not included in their assessments.
Report Facts
Residents Served: 30
Staffing Hours - Resident Support Staff: 2
Staffing Hours - Total Daily Staff: 34
Staffing Hours - Waking Staff: 26
Number of Steps on Deck: 19
Steps with Nonskid Surface: 10
Fire Drills Using Limited Exits: 4
Inspection Report — Apr 20, 2026
Complaint Investigation
Date: Apr 20, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection of the facility on 04/20/2026.
Complaint Details
The inspection was complaint-driven and unannounced. The submitted plan of correction was reviewed and found fully implemented as of 04/20/2026.
Findings
The inspection found deficiencies related to hearing impairment accommodations and incomplete resident assessments. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Citations (3)
23b - Instrumental Activities of Daily Living Assistance: The resident's support plan indicated hearing loss and lack of a hearing aid. A temporary hearing device and alarm system were provided with plans for permanent hearing aid fitting.
130e - Hearing Impairment: The resident was deaf and unable to hear the fire alarm system, and the home lacked a fire safety expert-approved signaling device. An alarm system including a bed shaker, pager, alarm, and sensor was purchased and planned for installation.
225a - Assessment 15 Days: The resident's initial support plan did not indicate transfer abilities or toileting assistance needs, leaving these assessment boxes blank. An audit of all files was planned to ensure accurate assessments.
Report Facts
Residents Served: 32
Resident Supplemental Security Income: 32
Residents Age 60 or Older: 25
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report — Jan 9, 2026
Follow-Up
Date: Jan 9, 2026
Visit Reason
The visit was a partial, unannounced follow-up inspection to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented corrective actions for prior deficiencies related to sanitary conditions, emergency telephone numbers, furniture and equipment, medical evaluations, and medication administration records. Ongoing compliance measures and staff training were established.
Citations (6)
85a Sanitary Conditions: Two unlabeled toothbrushes, an unlabeled comb, and an unlabeled brush were found in a shared resident bathroom.
91 Telephone Numbers: The telephone numbers posted in the medication room did not include the Personal Care Home complaint hotline number.
95 Furniture and Equipment: A mirror in a resident's bedroom was cracked in two places at the bottom left corner.
141a Medical Evaluation: A resident's initial medical evaluation form did not indicate whether the resident's needs could be safely met or if the resident was Nursing Facility Clinically Eligible.
187a Medication Record: Medications discontinued were still indicated on residents' January 2026 medication administration records.
187b Date/Time of Medication Administration: Medication administration times were not documented at the time of administration, and exceptions were not entered when residents were absent during scheduled medication times.
Report Facts
Residents Served: 34
Total Daily Staff: 34
Waking Staff: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Isaiah Witcher | Trained on start-of-day and end-of-shift facility checks including bathroom checks and removal of unlabeled items. | |
| Deb Morgan | Notified of medical evaluation error and involved in correction process. |
Notice — Nov 19, 2025
Date: Nov 19, 2025
Visit Reason
The document serves to notify Heartful Hands LLC that their request to waive specific Pennsylvania Code requirements regarding admission and medical evaluation forms has been granted.
Findings
The waiver allows Heartful Hands LLC to use the medical evaluation form from Tabula Pro instead of the Department's form. The Department will review compliance with this waiver during its annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Nov 10, 2025
Renewal
Date: Nov 10, 2025
Visit Reason
The inspection was conducted as a renewal, provisional licensing inspection to verify compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to have multiple deficiencies including sanitary conditions, ventilation, water pressure, emergency telephone postings, missing mirrors, food safety, emergency supplies, fire safety inspections, medical evaluations, medication labeling and administration documentation. Plans of correction were submitted and implemented by early 2026.
Citations (20)
85a Sanitary conditions were not maintained; six used unlabeled toothbrushes were found in a shared bathroom medicine cabinet.
86b The ventilation fan in a shared resident half-bathroom was inoperable.
89a Hot water at the hand sink in the shared resident bathroom did not exceed 82.2°F after running for five minutes.
91 Emergency telephone numbers were not posted by the cordless telephone in the dining area.
101j6 A resident's bedroom lacked a mirror.
103e Leftover food was uncovered, undated, and unlabeled in the kitchen cooler.
107c The home did not maintain a 3-day supply of emergency drinking water for residents.
132b The most recent fire safety inspection and fire drill were not conducted annually as required.
141a Resident medical evaluations did not indicate if needs could be safely met at the home or if resident was Nursing Facility Clinically Eligible.
184a Prescription medication containers lacked accurate pharmacy labels with correct dosage and administration instructions.
187a Medication records showed discrepancies between prescribed and administered medications for multiple residents.
191 Resident education on the right to refuse or question medication was not documented.
224a Resident preadmission screening forms did not indicate the date screening was completed.
251c Standardized forms were not used to record resident information as required by the Department.
85a Two unlabeled toothbrushes, an unlabeled comb, and an unlabeled brush were found on a shelving unit in a shared resident bathroom.
91 Telephone numbers posted in the home's medication room did not include the Personal Care Home complaint hotline number.
95 The mirror attached to the bedroom wall of resident #15 was cracked in two places.
141a Resident medical evaluation forms were incomplete regarding safe care determinations.
187a Medication records included discontinued medications still listed and lacked proper documentation of medication refusals or missed doses.
187b Medication administration times were not recorded at the time of administration for multiple residents, and exceptions were not entered when residents were absent.
Report Facts
Residents Served: 33
Emergency Drinking Water Supply: 8.26
Emergency Drinking Water Required: 99
Staff: 35
Waking Staff: 26
Inspection Report — Jul 17, 2025
Monitoring
Date: Jul 17, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit conducted on 07/17/2025 and 07/18/2025 to review compliance with regulatory requirements and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including lack of criminal background checks for staff, inadequate medication administration staffing, incomplete staff orientation and training, improperly stored fire extinguisher, incomplete fire drill records, and medication record errors. The submitted plan of correction was accepted and fully implemented by 09/03/2025.
Citations (8)
Staff person A did not have a criminal history background check completed.
No qualified staff person to administer medications on the 11:00 p.m.-7:00 a.m. shift.
Staff person A did not receive orientation in required fire safety and emergency preparedness topics on the first day of work.
Staff person A did not receive orientation training within 40 scheduled working hours as required.
An unlocked, improperly stored fire extinguisher was accessible to residents, causing a safety hazard.
Fire drill record did not include the amount of time to evacuate.
Resident's medication administration record did not include a prescribed medication for pain or fever.
Resident did not receive prescribed insulin dose despite blood glucose reading indicating need.
Report Facts
Residents Served: 29
Total Daily Staff: 30
Waking Staff: 23
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelley Martin | Conducts file audits for staff compliance | |
| Nyhemia | Reviews medication administration records and medication cart three times per week | |
| Shannon | Reviews medication administration records and medication cart three times per week | |
| JU | Staff trained explicitly on medication administration |
Inspection Report — Mar 13, 2025
Renewal
Date: Mar 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation with multiple visits between March and July 2025, followed by a renewal inspection in April 2025 and a partial incident-related inspection in June 2025.
Complaint Details
The complaint investigation was triggered by multiple issues including sanitary conditions, staff qualifications, medication administration, and resident care concerns. The investigation included unannounced visits on March 13, 20, and 31, 2025, with an exit conference on March 31, 2025.
Findings
The facility was found to have multiple deficiencies including sanitary conditions, staff training and qualifications, medication administration issues, incomplete resident records and assessments, fire safety violations, and failure to post required documents. Several plans of correction were submitted but many were not implemented by the follow-up dates.
Citations (20)
Brownish, sticky substance and grime on container and floor; power strips and extension cords covered in grime and dust.
Latch on resident's bedroom door did not catch; buildup of dirt and grime on floors, baseboards, and furniture.
Bottom drawer of metal filing cabinet rusted and unusable.
Resident medical evaluations and assessments not current or missing.
Resident support plans inaccessible and not updated.
Licensing inspection summaries not posted in a conspicuous place.
Incident of resident altercation not reported timely to Department.
Staff persons without completed criminal background checks employed.
Administrator present less than required 20 hours per week.
No qualified staff to administer medications overnight shift.
Staff list incomplete, missing contact information.
Administrator has not completed required training.
Staff persons without required orientation and annual training.
Emergency procedures not posted; fire drills not conducted monthly or during sleeping hours; fire drill records incomplete; evacuation procedures not fully followed.
Resident prescribed medication (Mounjaro) administered by uncertified staff.
Resident medication (Diphenhydramine) not available in home.
Medication administration records incomplete or not updated.
Staff persons administering insulin injections without current diabetes education.
Preadmission screening forms and resident assessments missing or incomplete.
Resident records missing or incomplete.
Report Facts
Inspection dates: 7
Residents served: 26
Staffing hours: 20
Staffing hours: 27
Total daily staff: 55
Deficiency counts: 20
Follow-up dates: 7
Notice — Jul 10, 2024
Date: Jul 10, 2024
Visit Reason
This document grants a waiver to Heartful Hands, LLC for delaying completion of the personal care home administrator training course and outlines conditions for compliance.
Findings
The waiver allows the administrator to serve while completing required training by specified deadlines. The Department will review compliance with these conditions during the annual inspection.
Inspection Report — Apr 4, 2024
Complaint Investigation
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 04/04/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 32
Total Daily Staff: 33
Waking Staff: 25
Residents Receiving Supplemental Security Income: 32
Residents 60 Years or Older: 21
Residents Diagnosed with Mental Illness: 24
Residents Diagnosed with Intellectual Disability: 4
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Inspection Report — Oct 20, 2023
Renewal
Date: Oct 20, 2023
Visit Reason
The inspection visits on July 28, 2023, August 18, 2023, and October 20, 2023, were conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes for license renewal purposes.
Findings
The facility was found to be in compliance with applicable regulations during the inspections. As a result, a regular license is being issued.
Inspection Report — Jul 28, 2023
Renewal
Date: Jul 28, 2023
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and incident review process for Heartful Hands LLC, a personal care home.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 after multiple inspections. Several deficiencies were identified related to safety, training, sanitary conditions, equipment, and record keeping, all of which had plans of correction accepted and were implemented by November 13, 2023. A follow-up partial inspection on October 20, 2023 found no deficiencies.
Citations (17)
Carbon monoxide alarms were installed too close to gas furnaces and batteries were not labeled with installation dates.
Staff persons present were not certified in first aid or CPR during certain evening hours.
Orientation training documentation for a staff person was not dated, making timely completion unverifiable.
Staff person did not receive required resident rights training during the 2022 training year.
Unsanitary conditions observed including tobacco on resident's sheets, dusty bathroom fan, soiled incontinence pad on bathroom floor, and grime on staircase banister.
Overhead light in bedroom #12 was inoperable.
Resident #2's bedside table was damaged with exposed sharp staples.
Concrete landing at front steps was deteriorated presenting a trip hazard.
Resident #3's mattress was torn and springs were visible.
Bedroom #12 had only 2 chairs for 3 residents.
Residents #1, #5, and #6 had no operable bedside lamps.
Lint trap in clothes dryer was caked with lint, creating a fire hazard.
The home did not have the emergency preparedness plan for the local municipality posted.
During a fire drill, one resident refused to evacuate due to fear, requiring reassessment and wheelchair use.
Fire drill during sleeping hours was overdue, with the last conducted in May 2023.
Resident #7's record did not include a photograph no more than 2 years old.
Resident #1 and #4 had beds without pillow cases.
Report Facts
Residents present during inspection: 33
Total daily staff: 34
Waking staff: 26
Residents receiving Supplemental Security Income: 32
Residents 60 years or older: 22
Residents diagnosed with mental illness: 18
Residents diagnosed with intellectual disability: 4
Residents with mobility need: 1
Inspection Report — May 19, 2023
Follow-Up
Date: May 19, 2023
Visit Reason
The inspection was an unannounced partial review conducted for provisional, incident, and fine reasons, including a follow-up on a previously submitted plan of correction.
Findings
The report found a substantiated incident of inappropriate touching between residents, deficiencies in fire drill record documentation, and the need for updated resident assessments. The submitted plan of correction was accepted and fully implemented by the follow-up date.
Citations (3)
Resident #1 intentionally touched resident #2's buttocks inappropriately multiple times, constituting abuse.
Fire drill records lacked required details such as the date of the drill and contained inaccurate time descriptions.
Resident #1's additional assessment was outdated and did not reflect recent behavioral issues.
Report Facts
Total Daily Staff: 35
Waking Staff: 26
Residents Receiving Supplemental Security Income: 31
Residents Aged 60 or Older: 25
Residents Diagnosed with Mental Illness: 19
Residents Diagnosed with Intellectual Disability: 3
Residents with Physical Disability: 2
Two Hour Checks for Resident #1: Resident #1 was placed on two-hour checks from 05/20/2023 to 06/15/2023.
Notice — May 4, 2023
Date: May 4, 2023
Visit Reason
This document grants a waiver to Heartful Hands, LLC for delaying completion of the 100-hour standardized Department-approved administrator training course due to needing additional time to complete the training.
Findings
The waiver is granted with conditions including enrollment in the training course starting May 8, 2023, completion of a competency-based test, documentation maintenance, and supervision by a qualified administrator until training completion.
Report Facts
Training course duration: 100
Training course start date: May 8, 2023
Training course end date: Jun 9, 2023
Inspection Report — Mar 21, 2023
Complaint Investigation
Date: Mar 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance at Heartful Hands LLC.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was reviewed and determined to be fully implemented as of June 20, 2023.
Findings
The facility was found to be non-compliant with administrator staffing requirements, as no qualified administrator was present an average of 20 hours per week. A plan of correction was submitted and fully implemented by June 20, 2023.
Citations (1)
No current, qualified administrator present in the home an average of 20 hours per week.
Report Facts
Residents Served: 35
Total Daily Staff: 38
Waking Staff: 29
Supplemental Security Income recipients: 30
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 30
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 0
Inspection Report — Dec 28, 2022
Complaint Investigation
Date: Dec 28, 2022
Visit Reason
The inspection was a complaint investigation conducted on December 28, 2022, as part of a licensing inspection of Heartful Hands LLC.
Complaint Details
The inspection was complaint-related as explicitly stated. No substantiation status was provided.
Findings
The inspection found violations related to hot water temperatures exceeding the allowed maximum of 120°F in multiple bathrooms. A second provisional license was issued based on an acceptable plan of correction. The facility was required to correct violations by specified dates to avoid fines.
Citations (1)
Hot water temperature in areas accessible to residents exceeded 120°F, with measurements ranging from 146.2°F to 152.4°F in multiple bathrooms.
Report Facts
Fine per day: 5
Calculated Fine per day: 175
Mandated Correction Date: 5
Inspection Report — Jul 12, 2022
Original Licensing
Date: Jul 12, 2022
Visit Reason
The inspection was conducted due to a change in legal entity for the personal care home, Heartful Hands, LLC, and was a partial licensing inspection as this is a new legal entity operating the home.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection. Citations were found related to lighting at bedside and monthly fire drills, which required correction.
Citations (2)
Resident #1 does not have a source of lighting that can be turned on/off at bedside.
Unannounced fire drills were not conducted during the months of March and April 2022.
Report Facts
Residents Served: 33
Total Daily Staff: 33
Waking Staff: 25
Residents Receiving Supplemental Security Income: 33
Residents Age 60 or Older: 24
Residents Diagnosed with Mental Illness: 18
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Current Hospice Residents: 0
Inspection Report — Jul 12, 2022
Original Licensing
Date: Jul 12, 2022
Visit Reason
The inspection was conducted as part of the initial licensing process for Heartful Hands LLC, a new legal entity operating a personal care home.
Findings
The facility was found to be in substantial compliance with 55 Pa. Code Ch. 2600 regulations, but the licensing inspector was unable to complete a full inspection. Citations were found and must be corrected by specified dates to maintain compliance.
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