| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Was unable to locate two year attestation for staff one, two, four, five pertaining to regulatory discussion as follows: Discussion:
Employees who do not currently reside in Pennsylvania or who have not held permanent residency in Pennsylvania for the two consecutive years prior to beginning employment also need a report of federal criminal history record information from the Federal Bureau of Investigation ("FBI check"). | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| As part of the Post-Employment on-boarding requirements and screenings, potential employees must successfully complete the required Background Checks and Attestation form.
Form 417-PA Attestation of Residency in Pennsylvania was created to supplement the application and added as an item to the Form 147-HR New Hire Packet Checklist and Cover Sheet which states SUBMIT PACKET with all required documentation to HRInbox@sunrisegroup.org
This Attestation of Residency in Pennsylvania will be completed and signed by the potential employee. Persons who are not residents of Pennsylvania for at least 2 years will require an FBI Background Check. This completed and signed form must be submitted to HRInbox@sunrisegroup.org and filed in the Employee Personnel Record.
The Office Manager and Residential Manager are responsible to ensure all new hires have the required documentation to complete the onboarding process. All current staff including Staff #1,2,4, and 5have now completed the attestation form which has been entered into their file. New staff will be required to complete and sign the form along with the application. Staff #1did not have the required consecutive residency and submitted their documentation to Identogo for an FBI check 3/27/25. |
03/27/2025
| Implemented |
| 6400.68(b) | The running water in the kitchen and bathrooms returned with temperatures of 126.5F, 122.5F and 126.9, respectively; exceeding the allowable threshold of 120F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Each staff will be trained on Sunrise procedure 6203-ALL-E Bathroom and Water Temperatures. 5 Immediate Reporting of Temperature over 110 degrees Fahrenheit
5.5.1 Unless otherwise regulated by local authority, if water temperature is over 110 degrees Fahrenheit, the staff must:
¿ Immediately and directly notify the Area Director, Director of Residential Services, and Director of Day &
Community Services in person or by telephone to report the problem so that equipment can be adjusted
or repaired.
¿ Report to immediate supervisor immediately and all employees at the program location so that risk of
injury from hot water can be avoided.
¿ Label Do Not Use / Water Exceeds Acceptable Temperature on affected area.
¿ Take faucet out of service immediately.
Failure to comply with this policy will result in corrective action up to and including dismissal. |
03/31/2025
| Implemented |
| 6400.72(b) | The window in Individual Three's room opens but does not retract. | Screens, windows and doors shall be in good repair. | The Residential Manager has checked that all windows, screens and doors have operable mechanisms and are in good repair. A contractor was contacted on 3/20 to repair Individual#3's window.
The contractor responded that the window located in Individual #3's bedroom, needs to be replaced completely. The window is being ordered. |
04/30/2025
| Implemented |
| 6400.81(k)(6) | Individual One does not have a mirror in his room. Correction was made later during inspection day by sending a picture of the mirror on individual's dresser. | In bedrooms, each individual shall have the following: A mirror. | Each person shall have a mirror unless by choice the person refuses to have one. Any person choosing not to have a mirror will have their choice recorded in their plan. All plans have been checked to ensure they contain people's preferences regarding mirrors and other regulations. It has been recorded in Individual#1plan that although a mirror has been purchased, he chooses not to have one. |
03/24/2025
| Implemented |
| 6400.104 | Was unable to locate any written notices to the local fire department informing of name of the individuals needing assistance and location of their respective bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The Residential Manager has called and sent numerous requests to the fire Marshall of Cheltenham Scott Lynch, with no response and his assistant stating he is very busy. The Residential Manager will hand deliver the letter to the Fire Marshall's office. |
05/01/2025
| Implemented |
| 6400.112(d) | Individuals should be able to evacuate the entire building within 2.5 minutes unless otherwise specified by a fire safety expert. Fire Drills completed in the following months were timed greater than 2.5 minutes:
May 2024; July 2024; Sept 2024-Feb 2025 | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The Residential Manger and other key staff were trained on Fire Safety Train the Trainer from a certified fire expert from the Lockton company on 4/10/25. It was a comprehensive training that our managers can add to the specific home fire training for the individuals and staff. In addition, each home has fire sprinklers in addition to fire alarms to ensure safety and extra time for slower evacuation times if necessary. We continue to request assistance from the local fire department.
See PowerPoint |
04/30/2025
| Implemented |
| 6400.113(a) | Individual Two was admitted to the home on 9/16/24 and fire safety training was not completed until 3/14/25. | 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. | The Residential Managers are responsible to ensure that all individuals will be trained including Individual 2 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. The fire expert will conduct Fire safety training on 4/10/25 at 3:30. |
04/10/2025
| Implemented |
| 6400.142(c) | Individual Two does not have a written plan for dental hygiene. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | The LPN and Program Specialist will ensure all individuals including Individual # 2 have a dental examination, with the dentist's name, procedures completed and follow up treatment. The dental hygiene plan will be kept in the person's file. |
03/31/2025
| Implemented |
| 6400.181(a) | Individual Two was admitted to the home on 9/16/24. His initial assessment was not completed until 1/28/25.
There are a number of items in the assessment that are marked "N/A" rather than indicating the individual's assistance needed with the task (i.e., utensil use, storing food safely, recognizing danger, following street and community signs, etc.). The assessment states that he is independent in caring for his hearing aids and glasses but staff state that he needs physical assistance to care for them.
The assessments lists "N/A" for ability to swim rather than stating whether he has the skill. His ISP indicates that he can swim but his family feels that he should not. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Program Specialist will ensure all individuals will have an initial assessment within 1 year prior to or 60 days after admission to the home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The assessment will include each person¿s level of assistance they require for each item. All person's assessments have been reviewed including Individual #2 to ensure completion.
The Program's Specialist job description and Policy Manual was reviewed with the Program Specialist on 3/21/25. |
03/30/2025
| Implemented |
| 6400.46(a) | With regard to staff training in general fire safety, a roster was provided that listed topic of general fire safety and procedure that was instructed by Staff Two. However, no certificate was provided to display that she was trained by a fire safety expert or that a fire safety expert trained the staff. | 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. | The Area Director and Residential Managers are responsible for ensuring Program Specialists and Direct Support staff including Staff #2 are trained in general fire safety procedures before working with individuals. The certified fire expert will be conducting fire safety training on 4/10/25 at 3:30 pm. Going forward all new staff will be trained on general fire procedures during orientation. |
04/30/2025
| Implemented |
| 6400.46(b) | Was unable to locate current and year prior fire safety training certificate for Staff One and staff three. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | It has been very difficult finding a fire expert. A fire safety expert will be conducting training on 4/10/25 to include Staff 1 and 3. |
04/30/2025
| Implemented |
| 6400.46(c) | Was unable to locate cpr and first aid training certificate for staff one and staff three. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | All new staff will be trained in first aid techniques before working with individuals being transported. Current staff including Staff#1 and Staff 3 will be trained on April15 and 16th. Staff who do not attend the training will receive corrective action up to and including dismissal.
Sunrise has contracted with Relias on 1/1/25 to ensure DSPs and Frontline supervisors receive all required training within regulatory guidelines and time frames. Relias will be partnering with Sunrise to ensure all DPS and Frontline Supervisors will be credentialed through NADSP. We are in the process of setting up the systems to allow staff to have easy access to required training. We should be able to begin by 5/1/25.
The Residential Managers will ensure no staff works with an individual until they receive the required training and Orientation. |
04/01/2025
| Implemented |
| 6400.165(g) | Individual Two is prescribed psychotropic medication. There is not documentation that there has been a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The individual's medications are prescribed by the primary physician who had an appointment with the individual on 4/23/24 for a physical. The next documented appointment was 10/8/24 and then 3/6/25. At the 3/6/25 appointment, the primary physician did recommend that the individual see a psychiatrist. Provider reports he is on a waiting list. | 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 LPN will ensure that all individuals receiving psychotropic medications including Individual # 2 will have a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The Program Specialist will track this review as part of monitoring of the person's plan. |
03/30/2025
| Implemented |
| 6400.169(d) | Was unable to locate medication practicums for staff one and three. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | The Residential Manager and LPN will ensure that all staff administering medications including Staff 1 and 3 will have the initial and annual practicums. The LPN is attending Train the Trainer course to be approved medication trainer which includes observing staff practicums. The LPN will ensure staff pass the practicum before passing medication.
If staff fail the practicum they will be retrained in medication administration procedures. |
04/30/2025
| Implemented |
| 6400.213(1)(i) | Individual Two's record does not list whether the individual has any identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Program Specialist has reviewed all individuals' records including #2 to ensure that each individual¿s record includes:
Name, Sex, Admission date, Birthdate, Social Security number, Race, Height, Weight, Color of hair, Color of eyes, Identifying marks, the language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English, primary language used in the individual¿s natural home, religious affiliation, next of kin, a current, dated photograph.
The Quality Enhancement team review the ISPs and sends out notifications missing items to the Program Specialist and Area Director to ensure compliance. |
03/31/2025
| Implemented |