Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00293493 Renewal 07/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)At 10:41AM on 7/31/2026, there was a wasp nest with live wasps flying out of it in the top right corner of the window next to the bathtub in the bathroom on the second floor of the home. At 10:42AM, there was an ordinate amount of deceased flies on the windowsills in the vacant bedroom on the second floor of the home.There may not be evidence of infestation of insects or rodents in the home. The provider immediately removed the wasp nest from the upper right corner of the window next to the bathtub in the second-floor bathroom. Lives wasps were eliminated from the area, and the window and surrounding bathroom area were inspected to confirm that no additional wasp activity was present. The deceased flies observed on the windowsills in the vacant second-floor bedroom were removed; the windowsills were cleaned and sanitized; and the room was inspected to identify and eliminate any condition that could allow insects to enter or remain in the home. 08/18/2026 Implemented
6400.71At 11:15AM on 7/31/2026, the telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were not on or near the phone in the staff office on the first floor of the home. [Repeat Violation, 7/23/2025]Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. he required telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center were posted on or near the telephone with an outside line in the first-floor staff office. The Site Supervisor verified that the posted emergency contact list was visible, legible, accurate, and located by the telephone used by staff. 08/18/2026 Implemented
6400.72(b)At 10:41AM on 7/31/2026, the screen in the window in the second-floor hallway bathroom was cut in half along the entire width leaving the bottom half of the window exposed to insects. [Repeat Violation, 7/23/2025] Screens, windows and doors shall be in good repair. The damaged screen in the second-floor hallway bathroom window was replaced, and the Site Supervisor verified that the full window screen was intact, properly secured, and in good repair to prevent insect entry. 08/20/2026 Implemented
6400.73(a)At 10:15AM on 7/31/2026, the exterior, wooden stairs leading from the back deck of the home were loose and wobbled when in use. Additionally, the first anchor toward the top of the stairs was not secured to the base of the stairs. At 10:17AM, there was no railing on the seven, exterior, concrete stairs leading to the patio in the back yard of the home. At 10:18AM, there was no railing on the three, exterior, concrete stairs on the left side of the patio in the backyard of the home. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Tombura LLC has been engaged to install a well-secured handrail for the seven exterior concrete steps leading to the patio in the backyard of the home, remove the three concrete stairs on the left side of the patio and fill the area with concrete, and reinforce the first anchor toward the top of the exterior wooden stairs so the stairs are secured to the base. Upon completion, the Site Supervisor will verify that the wooden stairs are stable, the anchor is secured, and all outside steps exceeding two steps have a well-secured handrail. Status: Pending contractor completion and provider verification. 08/31/2026 Implemented
6400.73(b)At 10:15AM on 7/31/2026, there was no railing surrounding the patio in the back yard of the home that was twenty-six inches from the ground.Each porch that has over an 18-inch drop shall have a well-secured railing.Tombura LLC has been engaged to install a well-secured railing surrounding the backyard patio where there is a drop greater than 18 inches. Upon completion, the Site Supervisor will verify that the patio railing is installed around the required area, is well secured, and corrects the cited condition. 08/31/2026 Implemented
6400.82(e)At 10:40AM on 7/31/2026, there was no nonslip mat in the bathtub in the hallway bathroom on the second floor of the home. Bathtubs and showers shall have a nonslip surface or mat. A nonslip mat was placed in the bathtub in the hallway bathroom on the second floor of the home. The Site Supervisor verified that the bathtub had a nonslip surface or mat in place and that the cited condition was corrected. 08/18/2026 Implemented
6400.82(f)At 10:40AM on 7/31/2026, there was no trash receptacle in the hallway bathroom on the second floor of the home.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. A trash receptacle was placed in the hallway bathroom on the second floor of the home. The Site Supervisor verified that the bathroom contained a trash receptacle and that the cited condition was corrected. 08/18/2026 Implemented
6400.101At 10:51AM on 7/31/2026, there was a slide lock on the exit door in the staff office on the first floor of the home. [Repeat Violation, 7/23/2025]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The slide lock was removed from the exit door in the first-floor staff office. The Site Supervisor verified that the exit door was free of the slide lock, could be used without obstruction, and that the cited condition was corrected. 08/18/2026 Implemented
6400.106The home's furnace was inspected and cleaned on 7/27/2026. There was no documentation of the furnace previously being inspected and cleaned so compliance could not be measured.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The provider acknowledges that the furnace inspection completed on July 27, 2026, occurred more than 12 months after the previous inspection completed on July 7, 2025. A qualified contractor inspected and cleaned the furnace on July 28, 2026. The provider reviewed its annual preventive maintenance process and adjusted inspection scheduling procedures to ensure future annual inspections are completed prior to the anniversary due date. A copy of both inspection reports has been included as an attachment. 08/31/2026 Implemented
6400.110(c)At 10:35AM on 7/31/2026, the three smoke alarms in the basement were in rooms with closed doors. There were no smoke alarms in common areas or hallways on the basement level of the home.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. Cargo Electric has been engaged to install the smoke detectors specified in subsections (a) and (b) in common areas or hallways on the basement level of the home. Upon completion, the Site Supervisor will verify that the basement smoke detectors are located in common areas or hallways, are operational, and that the cited condition is corrected. 08/31/2026 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 11/24/2025, did not address medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. [Repeat Violation, 7/23/2025]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The provider contacted the physician responsible for the individual's physical examination and obtained updated documentation that includes medical information pertinent to diagnosis and treatment in case of an emergency, as required by 55 PA Code Chapter 6400.141(c)(14). The updated emergency medical information was reviewed for completeness and placed in the individual's record. The Team Lead Supervisor verified that the corrected physical examination documentation now contains the required emergency medical information and that the cited omission has been corrected. 08/31/2026 Implemented
6400.142(e)Individual #1 had a dental examination on 9/25/2025 and the dentist ordered a follow up appointment in three months for "periodontal work." Individual #1 did not return to the dentist until 4/15/2026.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The individual was scheduled for and received the periodontal follow-up appointment ordered by the dentist. Documentation of the completed follow-up visit was obtained, reviewed for completion, and added to the individual's medical record. The Team Lead Supervisor verified that the dental follow-up recommended during the 9/25/2025 dental examination was completed and that the cited delay in follow-up dental care has been corrected. 09/15/2026 Implemented
6400.50(a)Direct Service Worker #2, date of hire 4/15/2022, was trained in site specific fire safety on 6/16/2026. This training did not include the name of the trainer or the length of time of the training.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.The provider reviewed the site-specific fire safety training record for Direct Service Worker #2 dated June 16, 2026, and identified that the record did not include the trainer's name or the training length. The training record was corrected to include the required training source information, training content, date of training, length of training, trainer name, and staff person attending. The corrected documentation was reviewed for completeness and placed in Direct Service Worker #2's staff training record. 08/18/2026 Implemented
6400.165(c)Individual #1 was prescribed Lorazepam .5MG with instructions to, "Take one tablet by mouth every night at bedtime for five days for anxiety." This medication was scheduled to be administered from 7/25/2026-7/29/2026. There were no administrations documented and no verification was provided that this medication was administered to Individual #1.A prescription medication shall be administered as prescribed.Direct Care Professionals (DCPs) reported that the individual's prescribed Lorazepam 0.5 mg was administered as ordered during scheduled shifts between July 25, 2026, and July 29, 2026. An investigation determined that the medication had not been properly entered into the electronic Medication Administration Record (eMAR) with the scheduled 8:00 p.m. administration time. The Medical Compliance Coordinator did not enter the newly prescribed medication and its administration schedule into the eMAR/Therap system. As a result, the medication did not appear as a scheduled medication for staff, and the system did not generate a prompt to document administration. Consequently, staff could not document administration in the eMAR, despite reporting that the medication was administered as prescribed. 08/03/2026 Implemented
6400.165(g)Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. A review of Individual #1's medications was completed on 7/11/2025 and then again on 10/17/2025. A review of Individual #1's medications were reviewed on 4/9/2026 and then again on 7/26/2026. [Repeat Violation, 7/23/2025]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The provider acknowledges that Individual #1's psychiatric medication reviews were not completed within the required 3-month timeframe. The provider contacted the prescribing physician and obtained updated psychiatric medication review documentation. The provider reviewed the documentation and placed it in the individual's record. The provider verified that the psychiatric medication review documentation includes the reason for prescribing the medication, the need to continue the medication, and the necessary dosage, as required by 55 PA Code Chapter 6400.165(g). Team Leads were retrained on psychiatric medication, review documentation requirements, and the importance of timely follow-up for individuals prescribed medications to treat symptoms of a psychiatric illness. 09/15/2026 Implemented
6400.167(a)(1)Individual-#1 was prescribed Lorazepam .5MG with instructions to, "Take one tablet by mouth every night at bedtime for five days for anxiety." This medication was scheduled to be administered from 7/25/2026-7/29/2026. There were no administrations documented and no verification was provided that this medication was administered to Individual #1.Medication errors include the following: Failure to administer a medication.The provider reviewed the Lorazepam 0.5 mg order scheduled from July 25, 2026, through July 29, 2026. Direct Care Professionals reported that the medication was administered as ordered; however, no eMAR documentation or other verification was available to confirm administration. The provider investigated the issue and determined that the newly prescribed medication and scheduled 8:00 p.m. administration time had not been entered into the eMAR/Therap system by the Medical Compliance Coordinator. As a result, the medication did not appear as a scheduled medication, the system did not prompt staff to document administration, and administration could not be verified. The provider reviewed the issue with the Medical Compliance Coordinator and the supervisory staff responsible to ensure new medication orders are entered accurately and timely into the eMAR system. 08/18/2026 Implemented
6400.167(c)Individual #1 was prescribed Lorazepam .5MG with instructions to, "Take one tablet by mouth every night at bedtime for five days for anxiety." This medication was scheduled to be administered from 7/25/2026-7/29/2026. There were no administrations documented and no verification was provided that this medication was administered to Individual #1. The provider agency has not entered this medication error into the Department's incident management system.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).A medication error incident as specified in 6400.18(b) was entered in EIM. Direct Care Professionals (DCPs) reported that the individual's prescribed Lorazepam 0.5 mg was administered as ordered during scheduled shifts between July 25, 2026, and July 29, 2026. An investigation determined that the medication had not been properly entered into the electronic Medication Administration Record (eMAR) with the scheduled 8:00 p.m. administration time. The Medical Compliance Coordinator did not enter the newly prescribed medication and its administration schedule into the eMAR/Therap system. As a result, the medication did not appear as a scheduled medication for staff, and the system did not generate a prompt to document administration. Consequently, staff could not document administration in the eMAR, despite reporting that the medication was administered as prescribed. 08/18/2026 Implemented
6400.169(a)Direct Service Worker #2, administered medication to Individual #1 at 8:00PM on 7/5/2026. Direct Service Worker #2 has not been trained in Medication Administration.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).The provider acknowledges that documentation verifying Direct Service Worker #2's successful completion of the Department-approved Medication Administration Training Course, including required renewal requirements, was not available at the time the assessment was conducted. The provider obtained a copy of the Pennsylvania Department of Human Services Medication Administration Training Course documentation showing completion on April 11, 2026. The documentation was reviewed and placed in the staff training record to verify that Direct Service Worker #2 met the medication administration training requirement. 08/11/2026 Implemented
6400.181(f)Program Specialist #1 sent Individual #1's assessment to the plan team on 3/25/2026. Program Specialist #1 did not sign the assessment until 4/2/2026.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The Program Specialist acknowledged that the assessment was distributed to the Individual Plan team on March 25, 2026, before it was signed on April 2, 2026. The Program Specialist subsequently finalized and electronically signed the assessment after confirming that it was complete. The provider verified that the signed assessment is complete and maintained in the individual's record. The Program Specialist team received targeted guidance on assessment workflow sequencing to ensure assessments are completed, reviewed, finalized, and signed before distribution to Individual Plan team members. 08/28/2026 Implemented
6400.186At 10:16AM on 7/31/2026, a Farberware Knife Block with nine knives was on the counter near the sink in the kitchen of the home. Individual #1's plan, last updated 7/30/2026, "[Individual #1] does not know how to use a sharp knife properly and needs to be monitored if this does happen. [Individual #1] also will grasp some objects and [their] hand will clasp over it which could be safety risk if it was a sharp knife."The home shall implement the individual plan, including revisions.The Farberware Knife Block with nine knives was removed from the residence. The Site Supervisor verified that sharp knives were no longer accessible in the kitchen and that the individual plan restriction regarding monitored use of sharp knives was implemented. 08/18/2026 Implemented
SIN-00270850 Renewal 07/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency's self-assessment completed for this home between 7/11/25 to 7/14/25, did not provide a written summary of corrections for the following regulation item identified as a violation: .68b.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. A hot water tank was adjusted to the required temperature. 07/24/2025 Implemented
6400.21(a)Program Specialist #1's date-of-hire is 1/20/25. The agency completed a Pennsylvania criminal history check to the State Police on 3/21/25.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. HR staff must now submit criminal history checks by the date of hire or no later than the fifth business day, with documentation logged in a centralized tracker. A Criminal History Submission Log was created to record staff name, date of hire, date of submission, submission method, and confirmation number. HR and hiring managers were retrained on: - The requirements of § 6400.21(a) - Time-sensitive compliance expectations - Procedures for documenting and verifying submission 09/05/2025 Implemented
6400.63(a)At 1:01 PM on 7/23/25, the hot water temperature at the sink of the ensuite bathroom located in the vacant bedroom on the home's third floor measured 123.6 degrees Fahrenheit. At 1:09 PM, the hot water temperature at the sink of the bathroom located in the hallway on the home's fourth floor measured 122.3 degrees Fahrenheit. [Repeated Violation-7/30/24 et al.]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. The HVAC professional who installed the new water tank in June 2025 adjusted the temperature to prevent fluctuations in water temperature throughout the home. The water temperature was tested five times and remained below 120 degrees Fahrenheit. 07/24/2025 Implemented
6400.64(a)At 12:21 PM on 7/23/25, there were fried food particles from what appeared to be chicken skin lining the base of the air fryer cooking tray.Clean and sanitary conditions shall be maintained in the home. The air fryer and its cooking tray were cleaned and put away until new residents are licensed and approved for the home. A picture of the air fryer was taken and sent to the Department. 07/24/2025 Implemented
6400.64(e)At 12:42 PM on 7/23/25, located in the laundry room of the home's game room, a trash can containing several items of refuse, and measuring 30 inches in height, did not have a lid.Trash receptacles over 18 inches high shall have lids. The trash can without a lid was discarded. 07/23/2025 Implemented
6400.67(b)At 12:35 PM on 7/23/25, extending from a glass block window in the staff office located in the home's game room, was a dryer-vent pipe, measuring approximately one foot in length, with an exposed, creased, sharp metal end. [Repeated Violation-7/30/24 et al.] Floors, walls, ceilings and other surfaces shall be free of hazards.Legacy Residential Services removed and discarded the exposed dryer-vent pipe. A photocopy of the area where the pipe was exposed will be sent to the Department. 09/01/2025 Implemented
6400.80(b)At 12:30 PM on 7/23/25, there was a cut-off electrical lighting fixture line with an exposed wire end hanging outside of the kitchen exterior door that leads to the back porch. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The exposed wire end hanging outside the kitchen exterior door, which leads to the back porch, was removed by a licensed professional. A photocopy will be sent to the Department. 08/26/2025 Implemented
6400.101At 12:51 PM on 7/23/25, the home's front entry door was equipped on the inside with a standard doorknob locking assembly and a sliding chain lock, creating a blocked egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Legacy Residential Services removed the doorknob locking assembly from the home¿s front door. A photocopy of the front door showing the chain has been removed will be sent to the Department. 08/19/2025 Implemented
6400.51(a)(1)Program Specialist #1's date-of-hire is 1/20/25. Program Specialist #1's orientation was incomplete, as required training in recognizing and reporting incidents as well as job-related knowledge and skills regarding individual-specific reviews of behavior support plans and restrictive procedure plans, remain outstanding. Additionally, required orientation content areas in the application of person-centered practices, community integration, and supporting individuals to develop and maintain relationships were completed on 7/14/25, which is beyond thirty days of Program Specialist #1's date-of-hire.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Legacy Residential Services has hired a new HR Recruiter who will be responsible for ensuring that all required orientation content and training are completed within thirty days. 09/05/2025 Implemented
6400.51(b)(5)Program Specialist #1's date-of-hire is 1/20/25. Their orientation training did not include completion of job-related knowledge and skills regarding individual-specific reviews of behavior support plans and restrictive procedure plans.The orientation must encompass the following areas: Job-related knowledge and skills.The Program Specialist will receive supplemental orientation training focused on individual-specific behavior support plans (BSPs) and restrictive procedure plans (RPPs). The orientation curriculum was revised to include reviewing and understanding individuals' BSPs and RPPs. A copy of the training will be sent to the Department. 09/05/2025 Implemented
6400.52(b)(4)Program Specialist #1's date-of-hire is 1/20/25. Program Specialist #1's orientation did not include completion of required training in recognizing and reporting incidents.The following shall complete 12 hours of training each year: Volunteers who work alone with individuals.Legacy Residential Services has hired a new HR Recruiter who will be responsible for ensuring that all required orientation content and training are completed within thirty days. A copy of the Program Specialist training in recognizing and reporting incidents will be sent to the Department. 09/05/2025 Implemented
6400.163(d)At 12:22 PM on 7/23/25, the following unlocked, over-the counter and prescription medications were found in the upper kitchen cabinet located to the left of the stove: a six-ounce bottle of Mucinex Sever Cold/ Flu medicine; a twelve-fluid ounce bottle of NyQuil Severe Cold/ Flu medicine; a 225-caplet bottle of Tylenol PM; President/ Chief Financial Officer #2's prescribed, Lansoprazole 30 MG DR Capsules---Take 1 capsule by mouth every morning before a meal; a 42-capsule box of Zegerid OTC (Omeprazole 20 MG); a 25-chewable tablets bottle of Rite Aid Zinc Cold Therapy; and a bottle of Nature's Way Milk Thistle---Selenium Blend.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The provider removed all over the counter and prescription medications from the cabinet and discarded them. A copy of the area where the medications were stored at the unoccupied site will be sent to the Department. 07/23/2025 Implemented
6400.163(h)At 12:22 PM on 7/23/25, the following expired over-the counter medications were found in the upper kitchen cabinet located to the left of the stove: a 225-caplet bottle of Tylenol PM with an expiration date: 5/2025; a 25-chewable tablets bottle of Rite Aid Zinc Cold Therapy with an expiration date of 10/2022; and a bottle of Nature's Way Milk Thistle---Selenium Blend with an expiration date of 9/30/23.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Legacy Residential Services removed all over-the-counter and prescription medications from the cabinet and disposed of them. A copy of the area where the medications were stored at the unoccupied site will be sent to the Department. 07/23/2025 Implemented
SIN-00249605 Renewal 07/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. On the self-assessment provided, with an end date of "August 2024," the following regulations were left blank: Physical Site 6400.77(b) - 77(c).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. To correct the violation, LRS will implement a physical site inspection checklist that the team leads for each location will complete monthly to maintain all sites in compliance. LRS will also begin the self-assessment on March 1st, six months before the certification of the compliance expiration date. The self-assessment must be completed in its entirety and forwarded to President of the agency, by May 31, 4 months before the certification of the compliance expiration date. The self-assessment will include the beginning and end dates on which the assessment was conducted. The completed self-assessments with supporting documentation will be maintained in the LRS shared drive. 08/26/2024 Implemented
6400.63(a)On 7/31/2024, at 1:02pm, the water temperature at the kitchen sink measured 132.2 degrees Fahrenheit.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. LRS adjusted the temperature dial on the hot water tank counterclockwise from "hot" to "low" to resolve the issue at the new site that was added to its license in July 2024. 09/04/2024 Implemented
6400.65On 7/31/2024, at 12:35pm, the powder room adjacent to the front door did not have mechanical ventilation and the window in the bathroom was non-operable. On 7/31/2024, at 1:09pm, the mechanical ventilation in the basement bathroom was non operable. This mechanical ventilation was the only form of ventilation in the basement bathroom.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. An operational ventilation system has been installed in the powder room next to the front door. Additionally, a new ventilation system has replaced the non-operational mechanical ventilation in the basement bathroom. Furthermore, a dryer vent has been installed outside the building to address dust and air concerns. 08/15/2024 Implemented
6400.66On 7/31/2024, at 1:13pm, the two light fixtures for the rear garage egress was not operable. These two light fixtures were the only light sources at this egress.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Cargo Electric, Inc. was contacted to address operational lights near all exit points. Two motion detectors with switches were installed to replace the old wiring, and new lights were installed. 08/15/2024 Implemented
6400.67(a)On 7/31/2024, at 12:48pm, the second-floor master bedroom with the ensuite bathroom contained a hole in the exterior wall, across from the ensuite bathroom door, from the removal of an air conditioning unit. The wall had been patched with a piece of drywall, but the repair had not been finished and painted. On 7/31/2024 at 12:52pm, the ceiling in the second-floor bedroom, adjacent to the attic stairs, had peeling drywall and paint. According to President and CFO #1, the surface was previously damaged by a leaking condenser in the attic.Floors, walls, ceilings and other surfaces shall be in good repair. The removal of an air conditioning unit that extended to the outside damaged the wall in the second-floor master bedroom. New stucco paneling was installed in July 2024. Pictures of the damage to both bedrooms were sent to a drywall contractor, on July 30, 2024, to arrange for the necessary repairs. 08/09/2024 Implemented
6400.67(b)On 7/31/2024 at 1:17pm, a garden hose was on the basement floor in the laundry area running from the dehumidifier, located on the wall across from the dryer, leading to the floor drain. The hose was not secured to the floor and posed as a potential tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.To prevent potential tripping hazards, the hose was fastened to the floor using strong black Gorilla tape. 09/02/2024 Implemented
6400.68(b)On 7/31/2024, at 1:05pm, the water temperature in the second-floor hall bathroom measured 132.8 degrees Fahrenheit at the bathtub. Hot water temperatures in bathtubs and showers may not exceed 120°F. The temperature dial on the hot water tank was adjusted counterclockwise from "hot" to "low" to resolve an issue at the new site that was added to our license in July 2024. The water temperature readings on 9/5 and 9/4 measured 117.2 degrees Fahrenheit. 09/04/2024 Implemented
6400.71On 7/31/2024, at 1:19pm, the cordless telephone located on the kitchen counter did not contain the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center on or near the device. [Repeat violation 8/15/23, et. al.]Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Although the cordless telephone on the kitchen counter did not contain the telephone numbers, the numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were on the counter next to the phone. 07/31/2024 Implemented
6400.77(b)On 7/31/2024, at 1:07pm, the first aid kit did not contain scissors or a thermometer. [Repeat violation 8/15/23, et. al.] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. To correct the violation, scissors and a thermometer were acquired and inserted into the first aid kit. 09/03/2024 Implemented
6400.82(e)On 7/31/2024, at 12:47pm, the ensuite bathroom in the second-floor master bedroom did not have nonslip surface or mat in the shower. On 7/31/2024, at 12:50pm, the second-floor hall bathroom did not have nonslip surface or mat in the shower. On 7/31/2024, at 12:56pm, the attic bathroom did not have nonslip surface or mat in the shower. On 7/31/2024, at 1:09pm, the basement bathroom did not have nonslip surface or mat in the shower. Bathtubs and showers shall have a nonslip surface or mat. Four shower mats and nonslip surface mats were acquired and placed in the second-floor master bedroom, the second-floor hall bathroom, the attic bathroom, and the basement bathroom. Pictures of the nonslip surface mats in the shower and bathroom floor have been uploaded in the shared drive. 09/02/2024 Implemented
6400.107On 7/31/2024, at 12:53pm, a Lasko portable space heather was observed in the bedroom adjacent to the attic stairwell on the second floor of the home. On 7/31/2024 at 1:15pm, a LifeSmart portable space heather was observed in the basement office.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The Lasko LifeSmart portable space heaters were donated to Goodwill on July 31, 2024, at 2:50 PM. A video showing the donation of both space heaters will be uploaded to the shared drive. 07/31/2024 Implemented
6400.111(f)On 7/31/2024, at 1:01pm, the fire extinguishers located under the kitchen sink, in the second-floor hallway, in the attic hallway, and in the basement hallway did not contain the inspection dates on the devices. It could not be verified that the fire extinguishers were inspected and approved by a fire safety expert. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguishers were acquired on 7/30/2024 and taken to ABC Fire Extinguisher Company on 4641 Peoples Rd, Pittsburgh, PA 15237 to be inspected and properly dated. A photo of ABC inspecting the extinguishers was taken and will be uploaded to the shared drive. 08/27/2024 Implemented
SIN-00179215 Renewal 10/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff person #1, also the Chief Executive Officer, date of hire 11/1/2018, had a Pennsylvania criminal history record check requested on 12/4/18; however, this request exceeded 5 working days after the person's date of hire. Program Specialist #2, date of hire 11/1/2018, had a Pennsylvania criminal history record check requested on 10/24/2020; however, this request exceeded 5 working days after the person's date of hire.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. There shall be a requested Pennsylvania criminal history record check within 5 working days after the person¿s date of hire specified in subsection (a). This regulation is important because it reduces potential risks and verifies claims made by job seeker. Based on the licensing inspection Summary, the Chief Executive Officer was beyond 5 working days after the date of hire. To correct this violation the Program Compliance Director submitted all employees Pennsylvania criminal history record checks on 10-24-20. The CEO will be trained to comply with 55 PA. Code Chapter 6400 regulation specified in subsection 21 (a). The training included the importance of all perspective employees have submitted a PA criminal history within 5 working days. Furthermore, the Program Compliance Director will update the organizations Staff training Employee checklist to include training, documenting and monitoring of PA criminal history checks. The checklist follows the employee through the hiring process. The CEO and Program Director will ensure all newly hired candidates¿ criminal record checks are requested within 24-48hrs of job offer. [Immediately, the CEO, or designee, will be trained on the requirements, including timeliness, of completing employee criminal background checks within 5 working days from the date of hire, as required by 6400.21(a)-(e). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall conduct an audit of employee files to ensure that criminal background checks are completely timely. DPOC by HDKP, HSLS on 1/28/2021]. 10/24/2020 Implemented
6400.63(a)The hot water temperature in the kitchen sink measured 134.0 degrees Fahrenheit at approximately 1:00 PM.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. There shall be proper heat sources that do not exceed past 120.0 degrees Fahrenheit. This regulation is important because it reduces safety risks surrounding burns and other fire hazards. Based on the licensing Inspection Summary the hot water temperature in the kitchen sink measured 134.0 degrees Fahrenheit at approximately 1:00 PM. To correct the violation the CEO hired a HVAC company annual furnace cleanings and to regulate hot water temperature to 110.0 degrees Fahrenheit. An HVAC, hot water digital thermometer was purchased for the home. The Program Compliance Director and CEO will be trained on how to properly assess water temperatures to comply with 55 Pa Code Chapter 6400 regulations specified in subsections 63(a). LRS Agency Maintenance Supervisor trained Direct Care Staff on how to properly check the water temperature to ensure the temperature does not exceed 120.0-degree Fahrenheit. LRS staff checked three times a day to ensure the water temperature did not exceed 120.0 degrees Fahrenheit for one week in the home. Hot water weekly checks will be completed and documented by the LRS Agency Maintenance Supervisor. The CEO will review documentation to ensure compliance. [Immediately, the CEO, or designee, shall train all staff on heat sources, to include the maximum water temperature of 120 degrees Fahrenheit. At least weekly, for a period of 6 months, the agency shall ensure the heat sources, to include water temperature, do not exceed 120 degrees Fahrenheit. Documentation of weekly temperature checks shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 11/02/2020 Implemented
6400.106The furnace of the home was not inspected and cleaned by a professional furnace cleaning company. Staff person #1, also the CEO, stated that the furnace was not inspected or cleaned.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. There will be a HVAC company hired to perform the annual furnace cleaning. This regulation is important because it reduces potential safety risks and hazards surrounding the heating and cooling system in the home. Based on the Licensing Inspection Summary the furnace of the home as not inspected and cleaned by a professional furnace cleaning company. Staff person #1, also the CEO, stated that the furnace was not inspected or cleaned. To correct the violation, SPURK HVAC was hired to inspect the boiler, clean furnace and adjust hot water heaters domestic water temperature. LRS Agency Maintenance Supervisor trained the CEO and Program Director on how to properly inspect for 6400 regulation specified in subsection 106. Agency Maintenance Supervisor will ensure that HVAC inspections will be completed and documented annually to ensure compliance. [Immediately, the CEO, or designee, shall train all staff responsible for furnace inspections on the requirement of furnace inspections and cleanings, to include required timeframes, as required by 6400.106. Documentation of training shall be kept. Immediately, the agency shall develop and implement a tracking system for furnace inspections and cleanings to ensure they are completed timely. DPOC by HDKP, HSLS on 1/28/2021]. 11/02/2020 Implemented
6400.110(h)The agency "Emergency Disaster Policy" does not include a procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperable. There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative.The Emergency Disaster Policy will be updated for smoke detector monitoring and documenting. To correct the violation, the CEO created a monitoring and documentation form. This regulation is important because it reduces potential fire hazards and safety risks. The Program Director will be properly trained on how to inspect smoke detectors ensure compliance with 55 PA Code Chapter 6400 regulation specified in subsection 110(h). All LRS Direct Care Staff will be trained how all homes will perform and document routine smoke detector checks. The CEO will audit staff documentation to ensure fire safety compliance. [The agency's Emergency Disaster Policy has been updated and reviewed to include a fire safety monitoring procedure in the event that the smoke detector or fire alarm is inoperative on 1/10/2021. The agency's created fire safety monitoring form has been verified on 1/10/2021. Immediately, the CEO, or designee, shall train all staff working in any home on the updated Emergency Disaster Policy, the new fire safety monitoring procedure, and the use of the fire safety monitoring procedure form. Documentation of training shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 11/02/2020 Implemented
6400.111(a)The 3-story home did not have a fire extinguisher with a 2-A rating within the home. The fire extinguishers, located in the kitchen, basement, and second floor, were rated 5-BC. [Repeat violation 8/19/2019]There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. To correct the violation Agency Maintenance Supervisor purchased and had three 2-A rating fire extinguishers serviced and placed on each floor. This regulation is important because it reduces risk and potential fire safety hazards. LRS Fire and Safety policies and procedures were updated to include the 8-month maintenance check of the 2- A rating fire extinguishers on each floor. The CEO will inspected all fire extinguishers to ensure they remain in compliance. [Fire Extinguishers with the rating 2A-10BC were purchased for the home. Photographs of the fire extinguishers in the home were verified on 1/10/2021. Immediately, the CEO, or designee, shall train all staff whom work in the homes on the requirements of a fire extinguishers, to include minimum rating of 2A and required placement, as required by 6400.111(a)-(f). Documentation of training shall be kept. Quarterly, for a period of at least one year, the CEO, or designee, shall audit all homes to ensure the proper placement and minimum rating of all fire extinguishers. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 10/30/2020 Implemented
6400.151(a)Staff person #1, also the CEO, date of hire 11/1/2018, does not have a physical examination. Program Specialist #2, date of hire 11/1/2018, 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. To correct the violation CEO and Program Specialist both received physical examinations and TB test. This regulation is important because it assures all staff have taken the necessary medical precautions to avoid the spread of a communicable disease. 11-9-2020 and 11-11-20 staff person #1 and staff person #2 both received physical examinations. The Program Compliance Director and CEO training and monitoring shall include the importance of the regulation to comply with 55 PA Code Chapter 6400 regulation specified in subsection 151(a). The CEO will update the organizations Staffing Policy and procedure manuals to include all proper training and monitoring of employee files of physicals and TB test thorough the hiring phase and every two years thereafter. CEO shall audit to assure accurate monitoring that all newly hired employees receive physicals and TB tests within 24- 48 hours and every 2 years thereafter. [CEO #1 had a physical examination dated 11/9/2020, which was verified on 1/10/2021. Program Specialist #2 has a physical examination date 11/13/2020, which was verified on 1/10/2021. Immediately, the CEO, or designee, shall train all staff on the requirements of staff physical examinations, to include required timelines, as required by 6400.151(a)-(c). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all staff medical records to ensure that staff physical examinations are completed timely and include the information as required by regulation 6400.151(c)(1)-(3). Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 11/09/2020 Implemented
6400.151(c)(2)Staff person #1, also the CEO, date of hire 11/1/2018, does not have a Tuberculin evaluation. Program Specialist #2, date of hire 11/1/2018, does not have a Tuberculin evaluation. 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. To correct the violation CEO and Program Specialist both received physical examinations and TB test. This regulation is important because it reduces all medical risks and ensures the individual is cleared to perform all job related duties. On 11-9-2020 and 11-11-20 staff person #1 and staff person #2 both received TB tests. The Program Compliance Director and CEO training will include the importance of the regulation to comply with 55 PA Code Chapter 6400 regulations specified in subsection 151(c) (2). The CEO will update the organizations Staffing policy and procedure manuals to include all proper training and monitoring of employee files of physicals and TB test thorough the hiring phase and every two years thereafter. CEO will audit files to ensure all newly hired employees receive physicals and TB tests within 24- 48 hours of hire date and every 2 years thereafter. [CEO #1 had a Tuberculin evaluation dated 11/11/2020, which was verified on 1/10/2021. Program Specialist #2 had a Tuberculin evaluation dated 11/13/2020, which was verified on 1/10/2021. Immediately, the CEO, or designee, shall train all staff on the requirements of staff physical examinations, to include required timelines, as required by 6400.151(a)-(c). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all staff medical records to ensure that staff physical examinations are completed timely and include the information as required by regulation 6400.151(c)(1)-(3). Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 11/09/2020 Implemented
6400.52(a)(3)Program Specialist #2, date of hire 11/1/2018, did not complete 24 hours of annual training. Zero hours of annual training could be verified.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.To correct the violation, the Program Specialist completed has 24 hours annual training hours on 10/30/20. The completion of the trainings has been documented and filed in the employee personnel file. This regulation is important as it ensure best practice and competence of the employee. The CEO and Program Compliance Director training shall include the importance of the regulation to comply with 55 PA Code Chapter 6400 regulations specified in subsections 52 (a)(3). The CEO will update the Staff Training policy and procedure manual to include proper monitoring and training of annual employee trainings. All LRS employees will complete 24 hours of documented training. The documentation will include training source, content, dates completed and employee/trainer signatures. The CEO will audit employee files for completed and verifiable annual trainings. [Program Specialist #2 completed 24 hours of annual training on 10/30/2020 for annual training year 1/1/2019 to 12/31/2020. Immediately, the CEO shall be trained on the annual training requirements for Program Specialists, to include the number of required annual training hours, as required by 6400.52(a)(1)-(3), and the required training topics, as required by 6400.52(c)(1)-(6). Documentation of training shall be kept. Immediately, the CEO, or designee, shall develop and implement a tracking system for staff training to ensure that all required training hours are obtained, as required by 6400.52(a)(1)-(3), and the required training topics, as required by 6400.52(c)(1)-(6) for training year 1/1/2021 to 12/31/2021. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all staff files to ensure that annual training hours and topics are being completed by staff. Documentation of staff file audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 10/30/2020 Implemented
6400.52(b)(1)Staff person #1, also the CEO, date of hire 11/1/2018, did not complete 12 hours of annual training. Zero hours of annual training could be verified.The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.To correct the violation the CEO completed 12 hours of annual trainings on 10-30-20. Documentation of completion can be found in employee file. This regulation is important as it ensures best practices and competence. The CEO and Program Compliance Director training shall include the importance of the regulation to comply with 55 PA Code Chapter 6400 regulations specified in subsections 52 (b)(1). The CEO will update the Staff Training policy and procedure manual to include proper monitoring and training of annual employee trainings. Management employees will complete 12 hours of documented training. Documentation of completion will include training source, content, dates and employee/ trainer signatures. Documentation will be filed in employee personnel file. The CEO will audit files for completed documentation of verifiable annual training. [CEO #1 completed 12 hours of annual training on 10/30/2020 for annual training year 1/1/2019 to 12/31/2020. Immediately, the CEO shall be trained on the annual training requirements for management, program, administrative and fiscal staff persons, to include the number of required annual training hours, as required by 6400.52(b)(1)-(5), and the required training topics, as required by 6400.52(c)(1)-(6). Documentation of training shall be kept. Immediately, the CEO, or designee, shall develop and implement a tracking system for staff training to ensure that all required training hours are obtained, as required by 6400.52(b)(1)-(5), and the required training topics, as required by 6400.52(c)(1)-(6) for training year 1/1/2021 to 12/31/2021. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all staff files to ensure that annual training hours and topics are being completed by staff. Documentation of staff file audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. 10/30/2020 Implemented
SIN-00161152 Initial review 08/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the basement of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. August 23, 2019 ¿ A list of telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center was placed by each phone with an outside line at the site. An additional phone was acquired on 9/9/19 and will be placed in kitchen along with the list of emergency numbers on or near the kitchen telephone.Each physical site will have a list of the specified numbers at or near each phone with a land line.All employees will be required to complete a mandatory emergency disaster planning training session upon hire. Community Home Managers will place a telephone number list for each new site and thereafter will be responsible for updating and maintaining the list. The Residential Home Manager will be responsible for ensuring compliance.See Exhibit C ¿ A picture showing the phone and emergency numbers and a copy of the receipt from Best Buy. [Upon hire, the CEO or designee shall educate all staff persons of the required telephone numbers and the location of the telephone numbers. Documentation of trainings shall be kept. At least monthly, the CEO or designee shall check to ensure all required telephone numbers are on or by each telephone in the community homes. Documentation of checks shall be kept. (DPOC by AES, HSLS on 9/17/19)] 08/23/2019 Implemented
6400.77(b)There was not a first aid kit in the home. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. August 30, 2019 ¿ A Premium 300 Piece First Aid Kit, including the items required under PA Code Chapter 6400.77 (b) was delivered and placed in a secured area of the home. The package was opened and inspected to ensure all items were in place. All LRS, LLC physical sites will have the required first aid kit.Valid First Aid and CPR certifications are required to be an employee with LRS.Each Community Home Manager and/or Residential Director will monitor and maintain each secured and accessible site kit. See Exhibit D for a copy of the receipt and applicable pictures. [Upon hire, the CEO or designee shall educate all staff persons of the requirements of the first aid kit and the location of the first aid kit and the replacement and replenishment procedures. Documentation of trainings shall be kept. At least monthly, the CEO or designee shall check to ensure all required items are in each first aid kit. Documentation of checks shall be kept. (DPOC by AES, HSLS on 9/17/19)] 08/30/2019 Implemented
6400.110(e)The smoke detectors on each of the four floors including the basement of the home were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. August 23, 2019 - A licensed Electrician installed 8 smoke detectors and 2 carbon monoxide detectors throughout the site. The smoke detectors are interconnected and were tested to ensure that they automatically set off all other detectors and are audible throughout the site.All LRS, LLC physical sites will have interconnected smoke detectors per floor with testing completed at installation.All employees will have successfully completed mandatory fire safety training upon hire. Each Community Home Manager for all physical sites will ensure all smoke detectors are checked monthly and is responsible for initiating mandatory spontaneous site fire drills. See Exhibit B - A copy of the invoice from Cargo Electric is attached. [Documentation of fire safety training shall be kept. Documentation of monthly checks of the fire alarm and smoke detector systems shall be kept. (DPOC by AES, HSLS on 9/17/19)] 08/23/2019 Implemented
6400.111(a)The fire extinguishers each of the four floors of the home were not a minimum of a 2-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. August 21, 2019 ¿ Kidde fire extinguishers with a minimum 2-A rating were received and placed on each floor, including the basement and attic. The fire extinguishers are rated and listed by Underwriters Laboratories. All LRS, LLC physical sites will have a minimum 2-A rated fire extinguisher on each floor.Each Community Home Manager for all physical sites will ensure that the fire extinguishers are inspected semiannually by a fire safety expert and be responsible for initiating mandatory spontaneous site fire drills.See Exhibit A ¿ A photo and receipt from Amazon showing the purchase date and delivery receipt to Pittsburgh PA 15235. For ease of reference, a copy of LRS, LLC Annual Training Plan and Emergency Disaster Policy is attached. [At least monthly, the CEO or designee shall check all fire extinguisher to ensure operability and date of inspection is on each extinguisher as required. Documentation of the checks shall be kept. (DPOC by AES,HSLS on 9/17/19)] 08/21/2019 Implemented