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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | At 11:38AM on 9/3/2026, there was an inordinate amount of live gnats in the kitchen of the home. At 11:47AM, there was an inordinate amount of live and deceased gnats in Individual #1's bedroom. | There may not be evidence of infestation of insects or rodents in the home. | Immediate Corrective Action:
Upon identification of the gnat activity, the residence was inspected to determine the source. Based on the inspection and maintenance review, the issue was determined to have originated from buildup within the drainpipes and was not the result of poor housekeeping, lack of routine cleanliness, or unsanitary living conditions within the residence. Maintenance was contacted for assistance and pest-control guidance. Because the drains were identified as the source, the dishwasher was run in accordance with the apartment complex maintenance department's recommendation, as the dishwasher is used infrequently due to the Agency's practice of promoting individual autonomy by supporting individuals to wash dishes independently or with assistance. As an added precaution, the affected kitchen area and Individual #1's bedroom was thoroughly re-cleaned and sanitized in accordance with normal operating procedures. Eco solution was ordered and applied to the drains to address the buildup within the pipes, which was identified as the source of the gnats'/fruit flies.
The residence was also inspected to identify the possible source of the gnats, including food-storage areas, trash receptacles, drains, sinks, bathrooms, bedrooms, windows, and other areas in which insects could enter or breed. No other areas aside from the drains were identified by Global staff or apartment complex maintenance. Pest-control intervention will be obtained when routine cleaning and sanitation measures do not adequately eliminate the presence of insects.
Preventive/Systemic Corrective Action:
To prevent recurrence, the Agency will incorporate routine drain-maintenance practices into the home's environmental monitoring process. This will include running the dishwasher at least once weekly to promote regular water flow through the connected drain lines, maintaining the Agency's regular cleaning schedule, and applying Eco solution to drains when early signs of gnats/fruit flies are observed. These preventive measures are intended to address potential buildup within the drain pipes, which was identified as the source of the gnat activity, and are not related to any finding of poor routine cleanliness or unsanitary living conditions in the residence.
Staff will continue to maintain the residence in a clean and sanitary condition and will be re-instructed to complete the following routine preventive practices:
1. Monitor sinks, drains, bathrooms, bedrooms, and other areas for moisture accumulation via our installed moisture monitoring systems
2. Inspect bedrooms sinks for pest activity while maintaining each individual's privacy and rights.
3. Immediately notify the House Supervisor or management when live insects, evidence of infestation are identified.
4. Document and promptly address identified Pest-control concerns.
The weekly supervisor walk-through list will be updated so that the House Supervisors will conduct routine environmental inspections of the residence to ensure that the home remains free of excessive insects. Any identified concerns will be corrected promptly and escalated to the Operations Manager when additional intervention, maintenance, or professional pest-control services are required. |
09/14/2026
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Hydroxyzine Pam Cap, 50 MG per day. The medication and the September 2026 Medication Administration Label read, "Take 1 capsule by mouth daily as needed for Anxiety." The Medication Administration Record did not include written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of a Pro Re Nata psychotropic medication. | 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. | Plan of Correction
Global Adult Care Services, LLC respectfully notes that Hydroxyzine Pamoate is pharmacologically classified as an antihistamine and is not primarily classified as a psychotropic medication and that the client has never requested the PRN therefore it was never given during the 6-month time frame. As can cooperated by the inspector who verified this by going back 6 months on the MAR. Hydroxyzine may, however, be prescribed for multiple clinical purposes, including the symptomatic treatment of anxiety. In this instance, Individual #1's physician prescribed Hydroxyzine Pamoate 50 mg PRN specifically for anxiety.
The Agency further notes that the September 2026 MAR identified the purpose of the medication as "anxiety." Nevertheless, to ensure full compliance with licensing expectations regarding PRN medications prescribed for symptoms associated with a psychiatric diagnosis, Global Adult Care Services will implement the following corrective measures. Global also notes that the medication has expired as of 9/3/2026 and because the Individual has never requested to take it, therefore the medication is no longer prescribed.
Immediate Corrective Action:
The Program Specialist will review all current Psychotropic PRN medications for all individuals residing in the home. The review will verify that:
1. The medication name, strength, dose, route, frequency, and purpose/diagnosis correspond with the current physician's order.
2. The purpose or diagnosis for each medication, including PRN medications, is accurately reflected on the MAR.
3. When a PRN medication is prescribed for symptoms associated with a psychiatric diagnosis, specific written instructions will be obtained from the prescribing practitioner identifying the circumstances and observable symptoms for administration.
4. On-site Staff do not independently determine criteria for the administration of a Psychotropic PRN medication. They must follow the agency protocol and contact the Operations manager for approval prior to administration.
Staff Training:
Medication-administration staff will be retrained regarding PRN pyscotropic medication requirements, including verification of the medication's purpose, physician-ordered administration parameters, and the requirement to obtain clarification whenever an order does not provide specific direction for safe and consistent PRN administration.
Training will also clarify that medication classification and medication purpose are not necessarily the same. Hydroxyzine is an antihistamine that may be prescribed for anxiety; therefore, staff must follow the documented indication and instructions of the prescribing practitioner rather than independently classifying the medication or determining when it should be administered. |
09/04/2026
| Implemented |
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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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