Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274029 Renewal 09/16/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #4, date of hire 4/3/2025, completed an application for a Pennsylvania criminal history record check on 4/23/2025. Direct Service Worker #4's criminal history record check identified a criminal history. Documentation of the review of the of the provider's consideration of hiring Direct Service Worker #4 was not maintained. The consideration should include the following factors: the nature of the crime, facts surrounding the convictions, time elapsed since the conviction, the evidence of the individual's rehabilitation, and the nature and requirements of the job. Direct Service Worker #6, date of hire 5/3/2024, does not have a record of a criminal background check being 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. HR and CEO completed review on template for staff with reported offenses in PATCH background check. 09/18/2025 Not Implemented
6400.72(b)On 9/16/2025 at 3:23PM, there was a one-fourth-inch gap between the screen and the window across from the door in the vacant bedroom on the first floor of the home. [Repeat Violation, 6/25/2025] Screens, windows and doors shall be in good repair. The screen was inspected on 9/16/25. The screen was taken to screen repairer and request made for fasteners to be added to create snug fit. It is not expected to be completed until Thursday or Friday 10/2/25 or 10/3/25 according to the agency. 10/03/2025 Not Implemented
6400.113(a)Individual #1, admission 1/10/2025, does not have a record of completing fire safety training. 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. Completed record of fire safety training missing from client paper work. CEO conducted fire safety training Sep 16, 2025 with individual. CEO completed Fire Safety training on September 23, 2025. CEO completed train the trainer fire safety course on September 24, 2025 to become instructor that is trained by fire safety expert. All staff completed mandatory fire safety training on September 24, 2025. Individual completed mandatory fire safety training on September 24, 2025. 09/16/2025 Not Implemented
6400.151(a)Direct Service Worker #6's most recent physical examination was completed on 7/31/2023. 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. HR terminated staff member. 09/17/2025 Not Implemented
6400.171On 9/16/2025 at 3:40PM, a partially used, unsealed box of Millville Pancake and Waffle mix was on the shelf in the cupboard in the kitchen of the home. [Repeat Violation, 6/25/2025]Food shall be protected from contamination while being stored, prepared, transported and served. Staff placed pancake waffle mix in ziplock bag. 09/16/2025 Not Implemented
6400.18(b)(2)The provider agency reportedly discovered a medication error that consists of the Individual #1 missing two medication administrations on 8/28/2025. This medication error was reportedly discovered on 9/11/2025 and was not entered into the Department's Incident Management system util 9/16/2025.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.This was a documentation error not a med error as described in the incident report. There was no option to select documentation error; however, moving forward any DOCUMENTATION errors will be entered as optionally reportable events. 09/25/2025 Not Implemented
6400.24On 3/12/2025, Individual #1 reportedly damaged five windows at another home of the provider agency's that was previously occupied by the individual. On 5/8/2025, a consent agreement was signed by Individual #1, Compliance Officer/Direct Service Worker #2 and Direct Service Worker #3 in which Individual #1 agreed to pay damages totaling $2,973.00. Regulation 6100.350b and 6100.350b2 read, "An individual's personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages. The following consent provisions apply unless there is a court-ordered restitution: Consent shall be obtained in the presence of the individual or a person designated by the individual and in the presence of and with the assistance of the support coordinator, base-funding support coordinator or targeted support manager." The signatures on the consent document do not include a support coordinator or manager or a person designated by the individual.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.CEO contacted support coordinator to review documents and request to provide clarification on initiation of paying of damages being from S.C. and Individual #1. CEO also contacted Rep Payee Service to initiate transfer of rep payee service 09/23/2025 Accepted
6400.46(a)Chief Executive Officer/Program Specialist #1 was not trained in the home specific evacuation procedures and the designated meeting by a fire safety expert or agency personnel who have received training by a fire safety expert. Compliance Officer/Direct Service Worker #2, date of hire 1/3/2025, was not trained in the home specific evacuation procedures and the designated meeting by a fire safety expert or agency personnel who have received training by a fire safety expert. Direct Service Worker #3, date of hire 8/18/2025, was not trained in the home specific evacuation procedures and the designated meeting by a fire safety expert or agency personnel who have received training by a fire safety expert. Direct Service Worker #4, date of hire 4/3/2025, was not trained in the home specific evacuation procedures and the designated meeting by a fire safety expert or agency personnel who have received training by a fire safety expert. Direct Service Worker #5, date of hire 5/29/2025, was not trained in the home specific evacuation procedures and the designated meeting by a fire safety expert or agency personnel who have received training by a fire safety expert. [Repeat Violation, 2/13/2025]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.CEO completed Fire Safety training on September 23, 2025. CEO completed train the trainer fire safety course on September 24, 2025 to become instructor that is trained by fire safety expert. All staff completed mandatory fire safety training on September 24, 2025. Individual completed mandatory fire safety training on September 24, 2025. 09/24/2025 Not Implemented
6400.46(d)Direct Service Worker #6's most recent training in first aid, Heimlich techniques, and cardiopulmonary resuscitation was completed on 7/17/2023. [Repeat Violation, 2/13/2025]Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.HR terminated staff member. 09/17/2025 Not Implemented
6400.52(a)(3)Chief Executive Officer/Program Specialist #1 completed eighteen hours of training during the fiscal annual training year, 7/1/2024 through 6/30/2025.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.The CO/Program Specialist #1 has already registered for and completed additional training hours in the area of "ADHD, Behavioral Manifestations of Pain, Communication: Positive Techniques, IED, and Positive Approaches" to fulfill and exceed the 24 hours requirement for the current training year. Documentation of these courses have been uploaded to the training record for audit purposes. 09/29/2025 Not Implemented
6400.163(a)On 9/16/2025 at 3:44PM, Individual #1's prescribed medication, Epinephrine, was not labeled with the label issued by the pharmacy.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.2 EpiPens came in one box and staff took the box along with one EpiPen and left the second epipen. The CEO sent a memo to all staff informing them to keep both EpiPens together in originally labeled box and not to separate from original box/container. 09/19/2025 Not Implemented
6400.165(g)A review of Individual #1's psychiatric medications was completed on 3/11/2025 and then again on 6/24/2025.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 individual had a few cancellation/missed appointments between reviews (due to hospital admissions, homeless leaves). The next review was scheduled 90 days from his previously current 90 day review. However, he missed the appointment and was scheduled for Sep 25. Had his med review and the individual has another appointment scheduled for October to provide status check and med review if necessary. 09/25/2025 Not Implemented
6400.166(b)Individual #1's prescribed medications, Cetirizine HCL 10MG, Levothyroxine 50MCG, Omeprazole DR 20MG and Sertraline HCL 50MG were not initialed as administered at 8:00AM on 9/16/2025.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Current Incident Manager entered EIM. Information entered on back of MAR "successfully administered meds on time, documented on pill pack but late documentation on MAR. 09/16/2025 Not Implemented
6400.169(d)Chief Executive Officer/Program Specialist #1 completed Medication Administration Train the Trainer training on 11/13/2024. The annual training record, for the four required medication administration observations, appeared to be altered from 3/28/2024 to 3/28/2025; therefore, timeliness compliance could not be measured due to the date being altered.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.Original observer was on family vacation during inspection. CEO/Program Specialist asked observer to send statement about observation completed in month and year written. Observer redid form to show dates. 09/18/2025 Not Implemented
6400.194(b)Chief Executive Officer/Program Specialist #1 developed and implemented a Restrictive Procedure Plan for Individual #1 on 8/29/2025. Chief Executive Officer/Program Specialist #1 signed the plan as a Behavioral Specialist. The Human Rights Team did not include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan.The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan.Behavior Specialist according to ODP standard for qualification is being added to HRT. The Behavior Specialist is currently being trained FBA and Positive Behavior Support and will be updated on the individual case after training is complete. 09/26/2025 Not Implemented
SIN-00273249 Unannounced Monitoring 08/28/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 12:01PM, bottles of Clorox Bleach, Lighter Fluid, Lysol, Mr. Clean, Easy Off Oven Cleaner, and other chemicals were unlocked and accessible in a bin in the closet of the vacant bedroom on the second floor of the home. [Repeat Violation, 2/13/2025, 5/15/2025, 6/25/2025]Poisonous materials shall be kept locked or made inaccessible to individuals. Staff locked chemicals in the office day of this inspection. 08/28/2025 Implemented
6400.64(a)At 12:19PM, there was approximately a three-foot by six-inch area of black and brown spots, that appeared to be mold and/or mildew from water damage, on the wall in the corner of the basement of the home.Clean and sanitary conditions shall be maintained in the home. The compliance officer contacted company to come and treat the brown and black spots. The company completed their treatment to the area September 12, 2025. 09/12/2025 Implemented
6400.67(b)At 11:51AM, the metal tack strip in the doorway of the vacant bedroom on the first floor of the home is not secured to the carpet and protruding upward approximately one-half-inch on the left side from the floor posing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The compliance officer contacted maintenance. Maintenance adjusted the carpet issue. 09/03/2025 Implemented
6400.72(a)At 10:48AM, the right side of the screen, in the living room of the home, was separated approximately one-half-inch from the window allowing space for insects to enter the home. [Repeat Violation, 5/15/2025]Windows, including windows in doors, shall be securely screened when windows or doors are open. The compliance officer adjusted the screen the day of inspection. 08/28/2025 Implemented
6400.72(b)At 11:46AM, the window on the left side of Individual #1's bedroom on the first floor of the home was broken. There were two pieces of Styrofoam covering leaving a two-inch by one-inch gap on each side of the window that would allow space for insects to enter the home. At 12:20PM, there was a crack across the full width of the window near the furnace in the basement of the home . [Repeat Violation, 6/25/2025] Screens, windows and doors shall be in good repair. The compliance officer had already contacted team to complete repair and repairs were finally completed by August 29 09/29/2025 Not Implemented
6400.80(b)At 10:15AM, there were plastic bottles and other miscellaneous articles of trash on the ground near the sides of the porch in the front of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.351 shares a parking area with neighbors who don't have same standards of cleanliness; however, compliance officer did remove debris from the site. 08/28/2025 Implemented
6400.105At 12:19PM, there was a quarter-inch thick accumulation of lint in the lint trap of the dryer in the basement of the home. [Repeat Violation, 5/15/2025]Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The compliance officer removed the lint on the date of inspection. 08/28/2025 Implemented
6400.110(e)At 12:07PM, the smoke detector on the first floor of the home was not interconnected to the smoke detectors in the basement and the second floor of the home.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. The compliance officer adjusted the smoke detectors and they were all functioning interconnected before inspectors left. 08/28/2025 Implemented
6400.171At 11:37AM, a bottle of previously opened Lime Juice with instructions to, "refrigerate after opening" was on the shelf in the cabinet in the kitchen of the home. A bottle of previously opened Burman's Soy Sauce, with the date 1/25/2025 handwritten on it, that included instructions that read, "... once opened, keep refrigerated and consume within one month." [Repeat Violation, 6/5/2025]Food shall be protected from contamination while being stored, prepared, transported and served. The staff member placed his lime juice in his bag upon returning home and the soy sauce was thrown out. A memo from CEO went out about remembering to check food. 08/28/2025 Not Implemented
6400.214(b)At 1:05PM, the most recent copies of Individual #1's Support Plan and incident reports were not present on site. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The compliance officer printed copies of ISP and incident reports and put in the folder at the site. 08/28/2025 Implemented
6400.163(d)At 11:41AM, Individual #1's prescribed medication, Lorazepam .5MG, which is a controlled substance was inside a toolbox on the shelf of a locked cabinet in the dining room of the home. The key to the toolbox was inside the lock rendering the toolbox accessible and the controlled medication was not double locked. [Repeat Violation, 2/13/2025]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 compliance officer locked the med box and removed key and placed in office and locked. Memo went out about removing key. 08/28/2025 Not Implemented
6400.163(h)At 11:41AM, Individual #1's prescribed medication, Olanzapine 10MG, was inside a toolbox in the dining room of the home. This medication was previously discontinued. [Repeat Violation, 2/13/2025]Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The compliance officer removed and disposed of old medication according to agency policy. 08/28/2025 Not Implemented
6400.165(c)Individual #1 is prescribed Ondansetron 4MG, with instructions to, "dissolve one tablet by mouth every six hours as needed for nausea and vomiting." This medication was not available in the home. Staff and individual interviews revealed that Individual #1 has recently been experiencing nausea and vomiting and does not have access to the prescribed medication to treat the symptoms.A prescription medication shall be administered as prescribed.CEO contacted pharmacy to order new meds and they were delivered and placed at site and adjusted on MAR. 09/01/2025 Not Implemented
6400.166(a)(10)Individual #1 is prescribed Trazodone with instructions to, "take one tablet by mouth at bedtime as needed." Individual #1's August 2025 Medication Administration Record reads, "Take one tablet by mouth everyday as needed." [Repeat Violation, 2/13/2025]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The agency has had issues with the Axiscare platform and decided to switch over to paper MAR temporarily on September 1, 2025 to ensure proper meds are kept. A Memo went out about this. 09/01/2025 Not Implemented
6400.166(a)(13)Staff interviews revealed that Direct Service Worker #1 administered Individual #1's 8:00AM medications on 8/28/2025. Direct Service Worker #2 was incorrectly documented as the administrator of Individual #1's 8:00AM medications. [Repeat Violation, 2/13/2025]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.EIM entered by incident manager. A verbal warning was given to two staff members. 08/28/2025 Not Implemented
6400.167(a)(1)Individual #1 is prescribed Risperidone 3MG with instructions to, "take one tablet by mouth twice daily for adult ADHD." This medication was not administered at 8:00AM on 8/28/2025. [Repeat Violation, 2/13/2025]Medication errors include the following: Failure to administer a medication.EIM entered by incident manager and staff received reprimand from HR along with modules to review for medication administration. 08/28/2025 Not Implemented
SIN-00271438 Unannounced Monitoring 07/24/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 10:41AM, a spray bottle of Resolve Urine Destroyer was unlocked and accessible in the cabinet under the sink in the bathroom on the second floor of the home. At 10:47AM, a thirty-two-ounce bottle of Flame Glo Charcoal Lighter Fluid was unlocked and accessible on the deck outside the exit in the back of the home. [Repeat Violation, 2/13/2025, 5/15/2025]Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials, including cleaning supplies and flammable liquids, were immediately removed from accessible areas by staff. Resolve Urine Destroyer and charcoal lighter fluid have been secured in a locked cabinet outside of individual access. 07/24/2025 Not Implemented
6400.67(a)At 10:32AM, there was a circular area of flaking and peeling paint, measuring approximately one foot in diameter, located on the ceiling above the showerhead in the bathroom on the first floor of the home. Additionally, there were 4 small circular spots of blistered, peeling paint on the ceiling above the back end of the bathtub area in the bathroom located on the first floor of the home. At 10:52AM, the weather stripping on the lower right side of the exterior kitchen door was detached from the frame in an area measuring approximately one foot in length.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance has been contacted by compliance officer and they will come to repair the peeling paint above the shower by August 20, 2025. The paint will be scraped and repainted with moisture-resistant coating. The weather stripping will be repaired by August 17, 2025. The weather stripping will be reattached securely, 08/20/2025 Implemented
6400.74At 10:03AM, there was no nonskid surface on the one wooden, exterior step leading to the front porch of the home.Interior stairs and outside steps shall have a nonskid surface. Compliance officer applied non-skid material to the wooden exterior step to the front porch August 13, 2025. 08/13/2025 Implemented
6400.76(a)At 10:40AM, the faceplate of the bottom drawer of the dresser was detached from the left side of the drawer in the vacant bedroom on the second floor of the home. Furniture and equipment shall be nonhazardous, clean and sturdy. The compliance officer and CFO removed the dresser entirely from the vacant bedroom on the second floor of the home to ensure there is no furniture and equipment that is hazardous and that is clean and sturdy. 08/12/2025 Implemented
6400.81(k)(1)Individual #1 has an adjustable hospital bed that belonged to an Individual that previously lived in the home. The mattress is extremely thin and has an ordinate amount of rips. Indvidual #1 does not have physician's orders to utilize this medical equipment.In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. The CEO scheduled an appointment with the individual's PCP to request physician order due to hip issue. The individual attended PCP appointment on 29th and obtained a physician order. 07/29/2025 Implemented
6400.82(f)At 10:33AM, there were no individual clean paper or cloth towels int he bathroom on the first floor of the home. At 10:42AM, there was no trash receptacle in the 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. Staff added clean cloth towels to the bathroom on the date of inspection. The compliance officer obtained and placed trash receptacle in the bathroom on the second floor of the home. 07/25/2025 Implemented
6400.83(c)At 10:38AM, a soiled, glass bowl with dried pieces of noodles and a soiled fork was in the top drawer of the dresser in the vacant bedroom on the second floor of the home.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.Staff removed the soiled glass bowl on the day of inspection. 08/04/2025 Implemented
6400.214(b)At 12:10PM, Individual #1's psychological evaluation was not present in the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The psychological was obtained by compliance officer and placed in the individual's home file. 07/25/2025 Not Implemented
6400.163(d)At 10:38AM, a bottle of Omeprazole Tablets was unlocked and accessible in the top drawer of the dresser in the vacant bedroom on the second floor of the home. At 10:49AM, a bottle of Aller-Flo Nasal Spray was unlocked and accessible was on top of the cabinet in the living room of the home. [Repeat Violation, 2/13/2025]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 staff removed and destroyed expired and unlocked medication per policy. All other medications are stored in a locked box with a key that the staff have access to. 07/24/2025 Not Implemented
6400.163(h)At 10:38AM, a bottle of Omeprazole Tablets with an expiration date of 3/2025, was unlocked and accessible in the top drawer of the dresser in the vacant bedroom on the second floor of the home. At 10:49AM, a bottle of Aller-Flo Nasal Spray with an expiration date of 3/2025, was unlocked and accessible was on top of the cabinet in the living room of the home. [Repeat Violation, 2/13/2025]Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The staff removed and destroyed expired and unlocked medication per policy. All other medications are stored in a locked box with a key that the staff have access to. 07/24/2025 Not Implemented
6400.166(a)(10)Individual #1's July 2025 Medication Administration Record did not the administration times for Individual #1's prescribed medication, Lotrimin AF Powder Spray. The Medication Administration Record only stated "AM" and "PM." [Repeat Violation, 2/13/2025]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The CEO updated the MAR for the Lotrimin AF Powder Spray to include exact administration times instead of AM and PM from the physician order and prescription label. 07/24/2025 Not Implemented
SIN-00269602 Unannounced Monitoring 06/25/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1's financial ledger did not include actual receipts for the following purchases: $16.02 at McDonalds on 6/2/2025, $15.11 at Brookline Toba on 6/2/2025, $25.66 at McDonalds on 6/9/2025, $25.00 at CVS Pharmacy on 6/9/2025, $23.33 at Chipotle on 6/17/2025, $15.24 at Fox's Pizza on 6/24/2025. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. The compliance officer printed out the expense records for the individual's true link financial card. The expense record has details that include: date, time, vendor (location), type and amount. 07/25/2025 Implemented
6400.62(a)On 6/25/2025 at 11:08AM, a 110 fluid ounce cannister of Trufuel Engineered Fuel and Oil was on the floor next to the deep freezer in the basement of the home. [Repeat Violation, 2/15/2025, 5/15/2025]Poisonous materials shall be kept locked or made inaccessible to individuals. Staff took the canister and appropriately disposed of it. 07/03/2025 Not Implemented
6400.67(a)On 6/25/2025 at 10:23AM, there were three, six-inch cracks at the top of the panel on the right side of the vanity mirror in the bathroom on the first floor of the home.Floors, walls, ceilings and other surfaces shall be in good repair. The compliance officer has taken the mirror to a hardware store to be fixed. We are waiting for the repair to be completed. The hardware stated that it would not be ready until 8/13/25 due to a delay at the store. 08/13/2025 Not Implemented
6400.67(b)On 6/25/2025 at 10:21AM, there was new carpet laid over the hardwood flooring in the living room of the home. The carpet and the padding underneath the carpet was not sufficiently trimmed and tacked down around the vent on the floor in the living room and at the doorways leading to the dining room and the hallway posing tripping hazards. Floors, walls, ceilings and other surfaces shall be free of hazards.The compliance officer, CFO, and team with assistance from hardware store worked together to ensure the carpet was sufficiently trimmed and tacked down. 06/27/2025 Implemented
6400.72(b)On 6/25/2025 at 10:10AM, there was an air conditioning unit in the window in the dining room of the home that was not firmly secured to the window leaving several, one-half inch gaps between the window and the air conditioning unit, allowing space for insects to enter the home. At 10:26AM, the screen in the window in the vacant bedroom on the first floor of the home was not secured to the window, leaving a one-inch gap between the screen and the window on the left side and a quarter-inch gap on bottom, allowing space for insects to enter the home. Screens, windows and doors shall be in good repair. Maintenance was contacted to help seal the unit. Due to slow response time the air conditioner was removed from the window July 25, 2025. 07/25/2025 Not Implemented
6400.81(k)(3)On 6/25/2025 at 10:28AM, there were three soiled pillows without pillowcases linens, on the bed and on the floor in Individual #1's bedroom on the first floor of the home.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.The pillows were disinfected and pillowcases put back on to his pillows by staff. The individual has a pair of sheets and comforter in the linen closet. The CEO ordered a third pair of linens and comforter for the individual August 7, 2025. 06/25/2025 Implemented
6400.82(f)On 6/25/2025 at 11:01AM, there was no trash receptacle in the 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. CEO ordered trash receptacles and they were delivered and placed in the bathroom 7/29/25. 07/29/2025 Implemented
6400.171On 6/25/2025, there was an uncovered plastic bowl, containing used cooking oil with food chards and a dead fly, on the counter next to the sink in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. Staff removed the uncovered plastic bowl containing used cooking oil and disposed of the oil due to the contamination. 06/25/2025 Not Implemented
SIN-00266684 Unannounced Monitoring 05/15/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 requires assistance with managing personal funds. The provider agency has not maintained a financial ledger of disbursements made to or for Individual #1.(2) Disbursements made to or for the individual. The individual received a new rep payee that utilizes true link financial which keeps an electronic statement of disbursements and purchases. 05/30/2025 Not Implemented
6400.62(a)On 5/15/2025 at 10:15AM, a spray bottle of Lysol was unlocked and accessible on the shelf in the bathroom on the first floor of the home. At 10:12AM, spray bottles of Great Value Glass Cleaner, Lysol, Clorox Bleach, Easy-Off Cleaner and Febreeze, containers of Fabuloso Cleaner, Clorox Clinging Bleach Gel, Ajax and Pine Sol and a box of Combat Roach Killing Bait were in the cabinet under the sink in the kitchen. There was a large, wire lock on the handles of the cabinets that allowed the doors to be almost fully opened rendering the cleaning products unlocked and accessible. [Repeat Violation, 2/13/2025]Poisonous materials shall be kept locked or made inaccessible to individuals. The house manager made the poisonous materials inaccessible to the individual and the program manager verified they were inaccessible. 05/15/2025 Not Implemented
6400.63(a)On 5/15/2025 at 11:16AM, the hot water temperature measured 123.2F at the sink in the kitchen of the home. [Repeat Violation, 2/13/2025]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 house manager turned down the hot water heater to bring the temperature down. 05/15/2025 Implemented
6400.64(f)On 5/15/2025 at 10:01AM, a large trash receptacle with no lid containing white, plastic bags of miscellaneous discarded items, as well as, other articles of trash on the ground next to it was next to the porch in the front of the home.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.A new lid was purchased and placed on the trash can. 05/20/2025 Implemented
6400.105On 5/15/2025 at 11:31AM, the lint trap in the dryer in the basement of the home had a half-inch thick accumulation of lint and debris posing a fire hazard.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The house manager removed the lint from the lint trap in the dryer on 5/15/25. 05/15/2025 Implemented
SIN-00260604 Renewal 02/13/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 2/13/2025 at 10:43AM, the hot water temperature measured 123.2°F at the sink in the kitchen of the home.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 Maintenance Team adjusted the water heater settings to ensure that hot water remains within the required temperature range across all faucets. 02/14/2025 Implemented
6400.67(a)On 2/13/2025 at 10:53AM, the banister above the staircase on the second floor of the home was not sturdy and wobbled when in use.Floors, walls, ceilings and other surfaces shall be in good repair. To correct this issue, the Maintenance Team was assigned to reinforce and secure the banister, ensuring it is stable and safe for use. The repair was completed by March 4, 2025, and the banister was inspected to confirm compliance with safety standards. 03/04/2025 Implemented
6400.68(b)On 2/13/2025 at 10:57AM, the hot water temperature measured 123.6°F at 10:57AM 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. The Maintenance Team adjusted the water heater settings to ensure that hot water remains within the required temperature range across all faucets. 02/14/2025 Implemented
6400.101On 2/13/2025 at 10:54AM, there were two hook and eye locks on the inside of the door of the vacant bedroom on the second floor of the home. At 10:56AM, there were two chain link locks on the door in the staff office on the second floor of the home. At 11:01AM, there were hook and eye locks on the inside of both of the doors in the bathroom on the second floor of the home. [Repeat Violation, 2/13/2024]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. To immediately correct the issue, the CEO removed the hook and eye locks and chain link locks from all doors on the day of inspection to prevent potential obstruction. Additionally, the Maintenance Team, under the oversight of the Program Director, replaced all locks with one that is compliant. 02/14/2025 Not Implemented
6400.112(a)An unannouced fire drill has not been conducted at the home since Individual #1's admission on 10/9/2024. An unannounced fire drill shall be held at least once a month. To correct this issue, the Program Director and Director of Operations have implemented a fire drill tracking system with a clear timeline for all required fire drills. Staff members are now required to complete fire drills as scheduled and immediately upload the completed documentation to the company¿s designated platform for secure record-keeping. Additionally, the Program Director will conduct monthly audits to verify that all fire drill reports are properly documented and stored. 02/24/2025 Not Implemented
6400.151(a)Direct Service Worker #2, who began working with Individuals on 10/12/2024, has not completed 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 this issue, the agency has developed a compliance tracker to monitor and verify that all staff members have the necessary documentation before providing direct care. The HR Director and Director of Operations are now responsible for verifying the dates of required documents, ensuring compliance before any staff member can engage with an individual. This tracking system was implemented immediately and will be maintained as an ongoing compliance measure. 02/17/2025 Implemented
6400.32(r)(1)On 2/13/2025, there was a pinhole lock on the door leading to Individual #1's bedroom. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.To immediately correct the issue, the Maintenance Team, under the oversight of the Program Director, removed the pinhole lock and replaced it with a compliant lock. A key was also provided for the individual and the staff member on shift to ensure proper access. This corrective action was started February 27, 2025 and completed on March 4, 2025. 03/04/2025 Not Implemented
6400.32(r)(5)On 2/13/2025, there was a pinhole lock on the door leading to Individual #1's bedroom. Staff did not have a designated mechanism to lock and unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.To immediately correct the issue, the Maintenance Team, under the oversight of the Program Director, removed the pinhole lock and replaced it with a compliant lock. A key was also provided for the individual and the staff member on shift to ensure proper access. This corrective action was started February 27, 2025 and completed on March 4, 2025. 03/04/2025 Not Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 10/6/2024. The rights document did not include the following rights: 6400.32p, an individual has the right to choose persons with whom to share a bedroom; 6400.32q, an individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices); 6400.32(s), an individual has the right to have a key, access card, keypad code, or other entry mechanism to lock and unlock an entrance door of the home.-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.To correct this issue, the Chief Executive Officer and Program Director reviewed and revised the Individual Rights Form to ensure it accurately reflects all rights in accordance with 6400.34(a). The updated form was implemented immediately and will now be provided to all individuals upon admission and during their annual rights review. Individuals currently receiving services will also be given the updated form to review and sign by March 14, 2025. 03/14/2025 Not Implemented
6400.46(a)Direct Service Worker #2, who began working with individuals on 10/9/2024, completed an online training in general fire safety on 10/8/2024. This training did not include home specific information.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.To correct this issue, the CEO and Program Director have updated the training attendance documentation to explicitly include home-specific fire safety information for each residence. All staff documentation has been updated to reflect the fire safety training with detailed, site-specific protocols recorded on their attendance forms. This updated documentation process was implemented immediately. 02/17/2025 Not Implemented
6400.46(b)Chief Executive Officer #1, who began working with Individuals on 10/9/2024, most recently completed fire safety training on 1/9/2024.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).To correct this issue, the CEO and Program Director have reviewed and updated fire safety training records to accurately reflect the most recent training conducted in 2024 and 2025. Moving forward, all fire safety training sessions will be documented immediately upon completion, with clear timestamps and details of the training content. This corrective action was completed immediately upon identification of the issue. 02/14/2025 Not Implemented
6400.46(c)Direct Service Worker #2, who began working with individuals on 10/12/2024, did not complete training in basic first aid.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.To correct this issue, the agency has developed a compliance tracker to monitor and verify that all staff members have the necessary documentation before providing direct care. The HR Director and Director of Operations are now responsible for verifying the dates of required documents, ensuring compliance before any staff member can engage with an individual. This tracking system was implemented immediately and will be maintained as an ongoing compliance measure. 02/17/2025 Implemented
6400.51(b)(1)Direct Service Worker #2 began working with individuals on 10/12/2024 and the orientation did not include job related knowledge and skills.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.To correct this issue, WellCared Services has incorporated a compliance tracker to ensure all staff members have documented proof of their training, including job-related knowledge and skills. The HR Director and Director of Operations will verify and approve all training records before allowing staff to engage with individuals. Additionally, training documentation has been updated to explicitly outline the job-related knowledge and skills covered to prevent any ambiguity in compliance records. 02/19/2025 Not Implemented
6400.166(a)(4)Individual #1's January 2025 Medication Administration Record did not include the name of Dakin's Solution.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 issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(5)Individual #1's January 2025 Medication Administration Record did not include the strength of Dakin's Solution.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(6)Individual #1's January 2025 Medication Administration Record did not include the dosage form of Dakin's Solution.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(7)Individual #1's January 2025 Medication Administration Record did not include the dose of Dakin's Solution. Individual #1 is prescribed Polyethylene Glycol 3350 with instructions to, "Dissolve 17 grams in 8 ounces of water and drink by mouth daily as needed for constipation." Individual #1's January 2025 Medication Administration Records reads, "give one scoop by mouth as needed daily for constipation."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 issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). Additionally, the Med Trainer will conduct monthly audits to ensure medication directions on the MAR match the orders from the doctor as well as what appears on the medication label. 03/12/2025 Not Implemented
6400.166(a)(8)Individual #1's January 2025 Medication Administration Record did not include the route of administration of Dakin's Solution.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(9)Individual #1's January 2025 Medication Administration Record did not include the frequency of administration of Dakin's Solution.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(10)Individual #1's January 2025 Medication Administration Record did not include the administration times of Dakin's Solution.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(11)Individual #1's January 2025 Medication Administration Record did not include the diagnosis or purpose for Dakin's Solution.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). 03/12/2025 Not Implemented
6400.166(a)(13)Direct Service Worker #2 administered Individual #1's prescribed medications from 1/15/2025 through 1/19/2025. Direct Service Worker #2's name was not on Individual #1's January 2025 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.To correct this issue, a medication retraining session was conducted on February 19, 2025, reinforcing the importance of accurately completing the MAR, including initialing and signing with the full name after each medication administration. All DSPs were required to participate in this retraining to ensure compliance moving forward. 02/19/2025 Implemented
6400.167(a)(1)Indivdiual #1 was discharged from an inpatient stay in the hospital on 1/15/2025 with a prescribed bottle of Dakins Topical Solution Full Strength with instructions to "Give 1 application topically daily." The provider did not administer this medication from 1/15/2025 through 1/19/2025.Medication errors include the following: Failure to administer a medication.To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). Additionally, an incident was entered in the EIM and APS was contacted for neglect failure to provide medication management. 03/12/2025 Not Implemented
6400.167(a)(4)Individual #1 is prescribed Hydroxyzine Pam 50MG Cap with instructions to, "take 1 capsule by mouth 3 times day in the morning, at 3:00PM and at bedtime. This medication was administered at 12:00PM from 1/16/2025 through 1/19/2025.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.To correct this issue, WellCared Services has hired a Medication Trainer who will be responsible for verifying that the MAR, pharmacy records, doctor¿s orders, and medication labels are fully aligned before medication administration. If any discrepancies are identified, the Medication Trainer will immediately contact the pharmacy to ensure corrections are made to both the MAR and medication labels. Additionally, the updated information will be entered into the electronic Medication Administration Record (eMAR) system to maintain accuracy. 02/19/2025 Not Implemented
6400.169(a)Chief Executive Officer #1 completed the Train the Trainer medication administration training on 11/13/2024. The four medication administration observations required to administer medications were not completed. Chief Executive Officer #1 administered Individual #1's prescribed medications from 1/16/2025 through 1/19/2025. Direct Service Worker #2 completed medication administration training on 1/3/2025. Verification of this training and the four required observations was not provided. Direct Service Worker #2 administered Individual #1's prescribed medications from 1/15/2025 through 1/19/2025.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).To correct this issue, the agency has printed out documentation of course completion certificates available for all staff who have successfully completed the training at WellCared. These certificates are only issued once all course requirements, including the mandatory observation component, have been successfully fulfilled. Staff members who have not yet completed this requirement are not permitted to administer medications until they do so. 02/14/2025 Not Implemented
SIN-00239433 Initial review 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65On 2/13/2024 at 10:52 AM, the bathroom located on the top floor of the home was not ventilated by at least one operable window or by mechanical ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Mechanical ventilation has been installed in the bathroom located on the top floor of the site as of 2/16/24. 02/16/2024 Implemented
6400.66On 2/13/2024 at 10:21 AM, the front porch light was not operable. On 2/13/2024 at 10:35 AM, the basement exterior exit did not have a light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A light bulb was installed on the front porch 2/14/24 and is now operable. A solar paneled light was installed above the basement exterior exit as of 2/16/24 and is now operable. 02/14/2024 Implemented
6400.67(a)On 2/13/2024 at 10:42 AM, the closet ceiling located in the first bedroom on the right of the first-floor hallway has a hole that is approximately 2 inches by 4 inches and a second hole that is approximately 1 inch by 4 inches. On 2/13/2024 at 10:55 AM, the bottom step on the exterior stairway on the side of the home had multiple pieces of wood peeling from the step, causing a tripping hazard.Floors, walls, ceilings and other surfaces shall be in good repair. The ceiling located in the first bedroom on the right of the first floor hallway was patched and in good repair as of 2/14/24. The bottom step on the exterior stairway on the side of the home was sanded down and painted to ensure no tripping hazard as of 2/14/24. 02/14/2024 Implemented
6400.72(a)On 2/13/2024 at 10:23 AM, the living room window located to the right of the front door did not have a screen installed. On 2/13/2024 10:37 AM, the window located in the first bedroom on the right of the first-floor hallway did not have a screen installed.Windows, including windows in doors, shall be securely screened when windows or doors are open. As of 2/16/24, a new screen was delivered and installed for the living room window located on the right of the front door. As of 2/16/24, a new screen was delivered and installed for the window located in the first bedroom on the right of the first-floor hallway. 02/16/2024 Implemented
6400.72(b)On 2/13/2024 at 11:00 AM, the screen door located on the top floor of the home has a tear shaped like an "L" that is approximately 2 inches by 2 inches. Screens, windows and doors shall be in good repair. As of 2/14/24 the screen door located on the top floor of the site was repaired so that there is no tear. 02/14/2024 Implemented
6400.73(a)On 2/13/2024 at 10:36 AM, the handrail located on the interior stairway leading to the basement of the home can be moved 1 inch back and forth and is not well-secured. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. As of 2/14/24 the handrail located on the interior stairway leading to the basement of the site was cemented so that it cannot move and is well secured. 02/14/2024 Implemented
6400.101On 2/13/2024 at 10:25 AM, the closet located in the living area of the home had a latch lock located on the right side of the outside of the door. This is unable to be unlocked from the inside of the closet. On 2/13/2024 at 10:47 AM, the bedroom closest to the bathroom on the first floor of the home has a closet with a latch lock located on the left side of the outside of the door. This is unable to be unlocked from the inside of the closet. On 2/13/2024 at 11:05 AM, the closet located in the hallway on the top floor of the home has a latch lock located on the left side of the outside of the door. This is unable to be unlocked from the inside of the closet.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. As of 2/14/24, the latch lock was removed on the right side of the outside door for the closet located in the living area to ensure a person can open the closet from the inside. As of 2/14/24 the latch lock was removed on the left side of the outside door for the bedroom closest to the bathroom on the first floor of the site to ensure a person can open the closet from the inside. As of 2/14/24 the latch lock was removed on the left side of the outside door for the bedroom closest located in the hallway on the top floor of the site to ensure a person can open the closet from the inside 02/14/2024 Implemented