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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | On 8/27/2025, at 11:32 AM, the hot water temperature measured 129.3 degrees Fahrenheit at 11:32AM at the bathtub in the ensuite bathroom in Individual #1's bedroom. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Immediate Corrective Action Taken:
· The hot water heater thermostat was immediately adjusted to ensure that water temperatures do not exceed 120°F.
· Staff verified the water temperature throughout that day at all bathtubs, sinks and showers using a calibrated thermometer.
· Documentation of water temperature checks was completed and submitted to the Operations Manager for review.
· Policy on water temperature checks increased in frequency from weekly to twice per week. Site checklist was updated to twice a week for DSPs and once a week from site supervisor. It also states all temperature checks must be done from individual's tub. If no tub, from individual's bathroom sink.
Preventative Measures:
1. Ongoing Monitoring:
o Water temperatures will be tested and documented twice per week by residential staff using a calibrated thermometer at each bathtub or bathroom sink if no tub.
o Water temperatures will be tested weekly by site supervisor and recorded on temperature log
o Results will be reviewed and signed off by the Residential Supervisor and Operations Manager monthly.
2. Staff Training:
o All residential staff re-trained on 55 PA Code § 6400.68(b) and the importance of maintaining water temperatures below 120°F to protect individual health and safety.
o Staff instruction and modeling on how to properly test and document water temperatures.
3. Maintenance Protocol:
o Any fluctuation in water temperature above 120°F will be reported immediately to the Operations Manager.
o A professional, qualified repairman will be contacted if adjustments are not sufficient to maintain compliance. |
10/10/2025
| Implemented |
| 6400.171 | On 8/27/2025 at 11:34AM, an unsealed, partially eaten package of hotdogs with part of a hot dog exposed and discolored was on the shelf in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Immediate Corrective Actions Taken:
· The unsealed and discolored hotdog package was immediately discarded at the time of discovery.
· Staff were instructed on proper food storage practices, including the need to seal and label all opened food items and to discard any food showing signs of spoilage.
· The refrigerator was inspected, and all other food items were checked to ensure compliance with safe storage standards.
Preventative Measures:
· Staff Training: All staff will receive refresher training in GACS policy for food safety practices, including proper sealing, labeling, dating, and discarding of perishable items. Training records will be maintained.
· Weekly Refrigerator Checks: Weekly refrigerator check will be added to the Residential Supervisor weekly walk-through inspections protocol to ensure all food is sealed, labeled, and free of contamination or spoilage. Results will be documented and corrective feedback provided immediately if issues are found.
· Ongoing Monitoring: During monthly health and safety inspections, supervisors will review food storage compliance and document findings in the inspection report. |
09/26/2025
| Implemented |
| 6400.32(r)(5) | On 8/27/2025 at 11:20AM, there was a turn locking mechanism on the inside with a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. Staff did not have a key to unlock Individual #1's bedroom door in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Immediate Corrective Actions Taken:
1. Keys for all locking bedroom doors, including Individual #1's, were immediately confirmed, labeled, and tested to ensure proper function.
2. Staff were informed and shown the location of the key for Individual #1's bedroom on the same day as the inspection.
3. The keyed lock was tested in front of staff to demonstrate access and ensure no barriers to emergency entry exist.
Preventative Measures:
1. Key Inventory & Labeling: All keys for bedroom doors have been inventoried, labeled, and placed in a designated secure but accessible staff area.
2. Staff Training: All staff will receive training on the regulatory requirement that staff must have immediate access to unlock bedroom doors in case of emergency. Training will include practical demonstrations of key use.
3. Secondary keys have been placed on the car key ring so there is a copy on the site key ring as well as on the car key ring.
4. Ongoing Monitoring: Residential Supervisor will conduct checks during their weekly walk through to ensure keys are present, labeled, and staff can identify and use them. Results will be documented. |
09/26/2025
| Implemented |
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