Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257641 Unannounced Monitoring 12/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 12:11PM on 12/17/2024, the hot water temperature measured 123.4°F at the bathtub in the bathroom on the second floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. To correct this violation, the water temperature was lowered by the program coordinator on the day of inspection and retested until compliant. 12/23/2024 Implemented
6400.165(c)Individual #1 is prescribed Metformin Tab 500MG with instructions to, "Take 1 tablet by mouth daily with dinner for Type 2 Diabetes Mellitus please crush and put into pudding or applesauce." Staff interviews revealed that the medication is not being crushed prior to administration to Individual#1. There was not a "medication crusher" available at the home.A prescription medication shall be administered as prescribed.To correct this violation, immediately a pill crusher was placed in the home. A training is scheduled for 12/23/2024 to review the steps of medication administration and the importance of administering medications as prescribed. 12/23/2024 Implemented
SIN-00255129 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At 11:34AM on 11/6/2024, the floor at the top of the basement steps in the kitchen is uneven due to different types of flooring posing a tripping and falling hazard. In addition, there is not a threshold installed posing a slipping and falling hazard. At 11:40AM on 11/6/2024, there were two doors that appeared to go to the closet leaning against the wall in Individual #1's bedroom. Floors, walls, ceilings and other surfaces shall be free of hazards.In order to correct these violations, the uneven floor at the top of the basement steps in the kitchen was repaired on November 11, 2024. The Maintenance Supervisor ensured that the transition between the two types of flooring is now smooth and safe, Additionally, to address the violation regarding the two closet doors leaning against the wall, it was clarified that this occurred in a bedroom at 7120 and not in the location cited in this violation. Nonetheless, the doors were promptly reinstalled to their proper location to ensure no safety hazards remain. Maintenance staff inspected the installation and confirmed that the doors are secure and functional. 11/11/2024 Implemented
6400.76(a)At 11:52AM on 11/6/2024, the middle drawer on the left side of the six-drawer dresser in Individual #1's bedroom was off the track and sitting on top of the bottom drawer. Furniture and equipment shall be nonhazardous, clean and sturdy. In order to correct this violation, the six-drawer dresser in Individual #1's bedroom, which had a middle drawer off the track and sitting on top of the bottom drawer was replaced on November 18, 2024. The new dresser was inspected to ensure it was fully functional and free of any defects, 11/18/2024 Implemented
6400.181(e)(1)Individual #1's assessment, completed 4/12/2024, did not address functional needs. The assessment must include the following information: Functional strengths, needs and preferences of the individual. In order to correct this violation, Individual #1's assessment, originally completed on April 12, 2024, was updated on November 11th, 2024, to include a thorough review and documentation of their functional needs. This update involved reassessing Individual #1's functional needs. The revised assessment was reviewed by the Program Coordinator to ensure all required elements were addressed and that it complies with regulatory standards. 11/11/2024 Implemented
6400.166(a)(4)Individual #1's November 2024 Medication Administration Record did not include the name of Zonisamide 300MG.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.To correct this violation, the medication was updated on November 29, 2024, to reflect data from the pharmacy label. 11/29/2024 Implemented
6400.166(a)(7)Individual #1 is prescribed Zonisamide 100MG with instructions to, "take 3 Capsules (300MG) by mouth every evening." Individual #1's November 2024 Medication Administration Record documents the medication strength as 300MG.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.To correct this violation, the medication administration record was updated on November 29, 2024 to reflect data from the pharmacy label. 12/20/2024 Implemented
6400.182(c)Individual #1's assessment, completed 4/12/2024, states they are able to safely use and avoid poisonous materials independently. Individual #1's Individual Support Plan, last updated on 10/16/2024, states, "cleaning products are safely stored and monitored. When the individual does laundry or cleans, the staff manage and supervise all chemicals. The individual can use the products independently with line of sight supervision at all times and verbal assistance as needed."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The individual had an ISP meeting on 10/15/2024. A request was made to correct the inidividual support plan during the meeting. Immediately an email was sent to the support coordinator to update the poisionous materials status. 12/20/2024 Implemented
SIN-00240262 Renewal 03/05/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 11:25AM on 3/6/2024, Individual #1's bedroom had a very strong, foul odor. When the bedroom door opened, Medical Coordinator #1 stated "Whew, That's strong" When the licensing representative stepped forward to enter the bedroom, there was a very strong urine smell that made it difficult to breathe. The smell was so strong that Medical Coordinator #1 opened the bedroom window to allow fresh air into the room to make the smell more bearable. Medical Coordinator #1 stated that Individual #1 has incontinence issues and frequently soils the bed. The mattress has plastic cover; however, there is carpet in the bedroom. Medical Coordinator #1 stated that the urine will often go onto the floor and soak into the carpet.Clean and sanitary conditions shall be maintained in the home. The carpet in Individual #1¿s bedroom has been removed and the floor was sanitized, sanded down and sealed. 04/15/2024 Not Implemented
6400.32(h)At 11:20AM on 3/6/2024, cameras were observed in the dining room and living room of the home. The agency did not have a current videography recording and retention policy and individuals #1 and #2 had not signed videography consents.An individual has the right to privacy of person and possessions.In order to correct this violation a Videography Policy and Consent form has been developed to ensure compliance with privacy regulations and to obtain explicit consent from individuals regarding videography in their living spaces. Individual #1 has now signed the Videography Policy and Consent form, and a copy has been placed in both the home and the client file for reference. 04/15/2024 Not Implemented
SIN-00186597 Renewal 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Written documentation for the 2019 furnace inspection and cleaning was not kept.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. Family Services United (FSU) recognized the importance of PA Code 6400.106 - 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. [Combustible and flammable materials can be ignited by heat sources, leading to explosions and fires.] Annual furnace inspections promote safety and well-being for individuals residing in the home. Although FSU was able to provide images of the furnace tags for 2019 and 2020 via SharePoint for each home, the documentation for 2019 could not be produced. 04/22/2021 Implemented
6400.181(e)(12)Individual #1's assessment, completed 5/1/2020, did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Individual #1 had an assessment completed on 5/1/2020 that did not include recommendations for specific training, programming, and services. The program specialist received conflicting training guidance from predecessor. To correct this violation, Family Services United (FSU) has retrained the program specialist to complete the assessment in its entirety and updated the program specialist job description. Immediately, the assessment for individual #1 was updated on 4/27/2021 to include recommendations per regulation 6400.181(e)(12) and emailed to the team on 4/27/2021. To prevent the recurrence of this violation, FSU will require the program specialist to submit the annual assessment to the residential director for review of compliance and accuracy. This check will be used when completing current and future assessments for all individuals. The residential director shall review assessments to ensure assessments are completed timely and include required information. Documentation of reviews by the residential shall be maintained. 04/27/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 2/24/2021. The rights document did not include the following rights: 6400.32b, an individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of his choice and practice no religion; 6400.32e, the right to make choices and accept risks; 6400.32g, to control his own schedule and activities; 6400.32j, the right to voice concerns about the services the individual receives; 6400.32k, the right to participate in the development and implementation of the individual plan; 6400.32L, the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the individual's bedroom door; 6400.32s, to have a key, access card, keypad code or other entry mechanism to lock and unlock entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.[Repeat violation 3/4/2020]The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Family Services United (FSU) recognizes the importance of regulation 6400.34(a) [The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter]. As an agency we will ensure that individuals are educated on their rights per regulation. Individual #1 was informed and received explanation of individual rights on 2/24/2021. The state representative received the signature pages only. The agency emailed the additional pages on 4/30/2021. The FSU admission packet was updated on 2/20/2021 to include all the rights listed in regulation 6400.34. Individual #1 and all other individuals residing at FSU signed the updated rights on 2/24/2021 in which the state representative received copies of signature pages for sample individuals via SharePoint. 02/24/2021 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 5/1/2020 to the individual plan team members for an individual plan meeting on 5/27/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Family Services United (FSU) will ensure that assessments are submitted within the specified timeframe per regulations to the entire team. Program Specialist is responsible for submitting the assessment to the team at least 30 days prior to an individual plan meeting. FSU program specialist will discuss with team that ISP meetings will be scheduled at least 30 days after the anniversary dates. Residential director will oversee the entire process to ensure compliance is met. The assessment 30-day window will be placed on the residential director and program specialist calendar as a reminder. The residential director conducted a training refresher with program specialist on April 23,2021. Immediately, the residential director, or designee, shall train all staff responsible for completing any portion of the individual assessment, coordinating the completion of any portion of the assessment, or ensuring the completion of the individual assessment on the required components of an individual assessment, including required content and timelines, as indicated by 6400.181(a-f). Documentation of training shall be kept. 04/23/2021 Implemented
SIN-00172122 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's physical examination completed 8/27/19 did not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. To correct this violation, on 3/13/2020 Individual#1 received a Tetanus shot. FSU added immunizations record check in the preadmission packet. Moving forward the immunization records of individuals being admitted to FSU will be examined by the RN. FSU will not except admissions until immunizations records are checked and documentation is signed off by RN. 03/13/2020 Implemented
SIN-00221743 Renewal 03/28/2023 Compliant - Finalized
SIN-00203736 Renewal 04/12/2022 Compliant - Finalized