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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 1:16PM, the hot water temperature measured 124.1 degrees Fahrenheit the kitchen sink. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. Additionally, maintenance will inspect the hot water heater and related pipes to assess if any insulation or protective guards are needed to prevent potential contact with high temperatures. |
12/16/2024
| Not Implemented |
| 6400.64(a) | At 1:33PM, there was dried up feces splattered on the floor and wall next to the toilet in the bathroom on the second floor of the home. | Clean and sanitary conditions shall be maintained in the home. | We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.67(a) | At 1:33PM, the 2nd floor bathroom floor tile had an approximate 1" x 4" gap which exposed the sub flooring. At 1:34PM, the 2nd floor bathroom wall has tile loosely affixed and 2 tile pieces laying on the ground next to the wall. [Repeated violation 7/23/24 et al] | Floors, walls, ceilings and other surfaces shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.72(a) | At 1:18PM, the window, that faces the rear of the home in the living room, did not contain a screen. [Repeated violation 7/23/24 et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.105 | At 1:26PM, three folding chairs with a fabric cushion on the backs and seats were stored within one foot of the natural gas furnace. [Repeated violation [7/23/2024 etal.] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.171 | At 1:12PM, a seedless cucumber that was discolored with what appeared to be mold was in the crisper drawer of the refrigerator. [Repeated violation 7/23/24 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.186 | In the general health and safety risks of Individual #1's Individual plan, last updated on 6/27/24 reads, "[Individual #1] can't be around heat sources, knives, or electrical outlets." At 1:20PM, two knives were unlocked and accessible in a cabinet in the kitchen of the home. [Repeated violation 7/23/24 et al] | The home shall implement the individual plan, including revisions. | All sharp objects, including scissors, knives, and pizza cutters, will be secured in a locked cabinet within the staff office. Thumb tacks will be removed from the walls, and the bag of screws will be securely stored in the staff office. A Residential Site Supervisor will inspect the entire premises to ensure no additional sharp objects or hazardous materials are accessible. |
12/16/2024
| Not Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of the home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| On June 17, 2019, Quinn Williams obtained a copy of the self-assessment of the home.On-Site Companionship Services shall complete a self-assessment of each home the agency operates, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance.Quinn Williams, Jaide Williams and Nataja Noel will complete the assessment on the first day of the third month prior to the expiration date of the agency's certificate of compliance.[Upon completion and prior to 3 months of the expiration of the Certificate of Compliance, the CEO or designee shall audit the self-assessment documentation to ensure the most current self-assessment document is used and completed in its entirety. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
06/17/2019
| Implemented |
| 6400.21(a) | Direct Service Worker/CEO #1, date of hire 5/10/18, did not have a Pennsylvania criminal history record check completed. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| On July 8, 2019, Direct Service Worker/CEO#1, obtained a criminal background check via epatch, control number R21945559.On July 1, 2019 Quinn Williams and Jaide Williams created a document which now includes the epatch as the source of the criminal background checks. This is a part of the checklist necessary for staff to obtain PRIOR TO BEING HIRED.On the first day of every month Quinn Williams and Jaide Williams will check all staff files to ensure that the criminal background checks have been provided within 1 year of the hire date. A copy of the form will be submitted following the completion of this POC. [Direct Service Worker/CEO #1 had a Pennsylvania criminal history record check completed on 7/8/2019. Immediately, upon hire and as stated above, the CEO or designee shall audit all staff persons' criminal history checks to ensure completion, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.46(e) | Direct Service Worker/CEO #1, date of hire 5/10/18, did not have training in the areas of intellectual disabilities, the principles of normalization, rights and program planning and implementation. | Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | On July 1, 2019, Nataja Noel and Andrea Horton, IMMEDIATELY created a document (trainings) that all staff members must complete a total of 24 hours of training that includes areas of intellectual disabilities, the principles of normalization, rights and program planning and implementation. Direct Services Worker/CEO #1, Sean L. Walters, also completed an additional 27 hours of training relating to intellectual development.
Quinn Williams and Jaide Williams will work with Nataja Noel and Andrea Horton on the first day of every month with a checklist ensuring that staff has the proper hours of training and the necessary amount of time, 24 hours, for the trainings. [Documentation submitted to the Department for training on 6/18/19 and 2/18/2019 training for DSW/CEO #1. Immediately, the CEO or designee shall develop and implement a training plan and tracking system to ensure all staff person have training in all required areas and training is completed timely and documented as required. Upon hire and at least quarterly, the CEO or designee shall audit all staff persons training records to ensure all trainings are completed as required and documentation is maintained and available for review upon request by the Department. Documentation of audits shall be kept. 9DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.46(f) | Direct Service Worker/CEO #1, date of hire 5/10/18, did not receive training before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of a fire, smoking safety procedures if individuals or staff smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Between June 18, 2019 - June 24, 2019 Sean L. Walters, Direct Services Worker/CEO #1, IMMEDIATELY completed an additional 27 hours of training along with the 24 hours of training necessary for the annual training. This is a total of 51 hours for the year.This additional training is to correct not having the necessary training prior to being hired by On-Site Companionship Services. Nataja Noel and Andrea Horton will continue to check the status of the training(S) necessary for each staff member on the first day of each month[Documentation submitted to the Department for training on 6/18/19 and 2/18/2019 training for DSW/CEO #1. Immediately, the CEO or designee shall develop and implement a training plan and tracking system to ensure all staff person have training in all required areas and training is completed timely and documented as required. Upon hire and at least quarterly, the CEO or designee shall audit all staff persons training records to ensure all trainings are completed as required and documentation is maintained and available for review upon request by the Department. Documentation of audits shall be kept. 9DPOC by AES,HSLS on 7/30/19)] |
06/24/2019
| Implemented |
| 6400.46(j) | Program Specialist #2's orientation document, containing several orientation dates, does not contain the source or the content of the training for the topics covered during the orientation. The topics include, but are not limited to: Positive Approaches, ISP training, The Fatal Four, and fire safety. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | On July 1, 2019, Nataja Noel and Andrea Horton, IMMEDIATELY prepared a new document that establishes the EXACT SOURCE of the training material that coincides with specific language in Chapter 6400. Dates, length of training and persons attending will continue to be outlined as it is in the previous document.Training will be administered on a quarterly basis, and there will be one training for each staff member on the first of every month. The training will be administered by Nataja Noel.Training will also be checked on the first of every month by Andrea Horton to ensure that the records of training and orientation include the training source, content, dates length of training and staff persons attending.[Documentation submitted to the Department for training on 6/18/19 and 2/18/2019 training for DSW/CEO #1. Immediately, the CEO or designee shall develop and implement a training plan and tracking system to ensure all staff person have training in all required areas and training is completed timely and documented as required. Upon hire and at least quarterly, the CEO or designee shall audit all staff persons training records to ensure all trainings are completed as required and documentation is maintained and available for review upon request by the Department. Documentation of audits shall be kept. 9DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.113(a) | Individual #1, date of admission 2/18/19, was instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside of the building or within the fire safe area, and smoking safety procedures on 2/20/19. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | On July 1, 2019 Nataja Noel, Program Specialist, IMMEDIATELY placed the general fire safety instructions, evacuation procedures, responsibilities during fire drills and designated meeting places on the FRONT PAGE of the Fire Safety Binder.This will ensure that all clients will receive the necessary training UPON ADMISSION and not a day later.On the first day of the month, Nataja Noel and Andrea Horton, House Manager, will check the Fire Safety Binder of all clients to ensure that the necessary training is provided to all clients and signed UPON ADMISSION. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are instructed in fire safety upon admission and annually with all required information. Documentation of aforementioned audits of fire safety training shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 5/17/19, does not include information pertinent to diagnosis and treatment in case of an emergency. This section of the form was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On July 1, 2019, individual #1's physical examination includes information pertinent to diagnosis and treatment in the case of emergency. "CALL 911"Nataja Noel, Program Specialist, will ensure that this section is completed by all physicians for any/all clients during appointments.On the first day of the month Nataja Noel will check all client Medical Binders to ensure that this section of the form is completed and not left blank. [Immediately, the CEO or designee shall educate the staff persons' responsible for auditing individuals' physical examinations of the required information and the aforementioned auditing procedures. Documentation of trainings and audits of physical examinations shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.151(a) | Direct Service Worker/CEO #1, date of hire 5/10/18, did not have a physical examination. Program Specialist #2, date of hire 2/18/19, had a physical examination on 5/13/19. Direct Service Worker #3, date of hire 4/22/19, does not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | On July 8, 2019, Sean L. Walters Direct Service Worker/CEO#1, obtained a physical from his physician. Direct Service Worker #3, Charles Walker, obtained a physical examination from his physician on July 5, 2019.
To prevent hiring staff before we obtain the proper documentation, Quinn Williams and Jaide Williams have created a document that establishes, among other things, a checklist of documentation needed PROIR TO BEING HIRED. This will prevent hiring individuals, as in the case of Program Specialist #2, Nataja Noel, before first obtaining the necessary documents. On the first day of every month, Quinn Williams and Jaide Williams, will check all staff files to ensure that all of the necessary documentation is in compliance. A copy of the physical examination forms for Sean L. Walters and Charles Walker will be emailed upon completion of this POC. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all staff persons have a physical examination completed, timely. Immediately, upon hire and as specified above, the CEO or designee shall audit all staff persons' records to ensure all staff persons have a current physical examination completed with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/08/2019
| Implemented |
| 6400.151(c)(2) | Program Specialist #2, date of hire 2/18/19, had a Tuberculin testing on 5/10/19. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | On July 1, 2019, Quinn Williams and Jaide Williams created a document that includes, among other things, a checklist of required documents that all potential staff must obtain PRIOR TO BEING HIRED. One of the requirements is a Tuberculin skin testing. On the first day of every month Quinn Williams and Jaide Williams will check all staff files to ensure that the TB testing is in compliance. A copy of the checklist will be email upon completion of this POC. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all staff persons have Tuberculin testing completed, timely. Immediately, upon hire and as specified above, the CEO or designee shall audit all staff persons' records to ensure all staff persons have a current physical examination completed with all required information including Tuberculin testing. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.151(c)(3) | Program Specialist #2, physical examination completed 5/13/19 does not address communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | On July 1, 2019, Program Specialist #2, Nataja Noel obtained a copy of her physical examination form from her physician. It establishes that Nataja Noel is free of any communicable diseases.Quinn Williams and Jaide Williams, Human Resource Specialists, have created a document that all staff can use when scheduling their physical examinations. The form establishes, among other things, that the individual is free from any communicable diseases.On the first day of every month Quinn Williams and Jaide Williams will check all staff files to ensure that the physical examinations are in compliance. A copy of the aforementioned document will be emailed upon completion of this POC. [Program specialist #2's physical examination documentation from 5/13/19 was updated to include "yes" to "Individual is free of contagious disease." Updated information is not dated or signed. Immediately, the CEO or designee shall educate the staff persons' responsible for auditing staff persons' physical examination of the required information and the aforementioned auditing procedures. Documentation of trainings and audits of physical examinations shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.163(c) | Individual #1, date of admission 2/18/19, is prescribed medications to treat a diagnosed psychiatric illness; however, the individual has not a review of medications by a licensed physician. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | On July, 1, 2019, Program Specialist and Andrea Horton, created a document that includes columns/fields for medication, reason for the medication, dosage, frequency, need to continue Y or N, and note taking for the Physician. This document makes it easier to review every 3 (three) months and document the psychiatric medical needs of the client(s). If there any appointment changes Program Specialist will obtain a letter from the physician reflecting the change. Every 3 (three) months Program Specialist or House Manager and the client(s) will be taken to the physician for their psychiatric medical review with the aforementioned document. [On 7/3/19 and 7/24/19, Individual #1 had a medication review; however the medication review does not include the reason for prescribing the medication. Missing information shall immediately be obtained. Immediately, the CEO or designee shall educate the staff persons' responsible for supporting individuals' in medication review of diagnosed psychiatric illness and auditing the documentation of the requirements to ensure timely completion with all required information. Documentation of trainings and audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
| 6400.168(e) | Documentation of the medications administration training for the trainers who trained Direct Service Worker/CEO #1 and Direct Service Worker #3 was not available. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | On July 1, 2019, CCO, obtained the Trainer Certification from Medication administration trainer regarding the medication administration training for Direct Care Worker #3. All other staff members that have been medication trained by VW are certified pursuant to VW's certification. When new staff are employed by On-Site Companionship Services, Steven C Williams III will ensure that the medication administration training certification is available and in the possession of the agency. A verification email will be submitted upon completion of this POC with the medication training certification attached. [Medication trainer is certified to train until 9/11/21. Immediately, and upon completion and at least quarterly, the CEO or designee shall audit all staff persons' medication training documentation and the medication trainer's training documentation to ensure documentation of the dates and location of the medications administration training for trainers and person and annual practicum for staff persons is kept and available for review upon request by the Department. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
07/01/2019
| Implemented |
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