| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's service plan, last updated 9/18/2025 reads, "[Individual #1] needs support with money management. [Individual #1] requires caregivers to help [them] budget [their] money and avoid being exploited financially by others." Individual #1's assessment, completed 8/15/2025, reads, "[Individual #1] requires assistance to safely maintain [their] funds. [Individual #1] requires assistance to budget and understand the cost of items compared to what [Individual #1] has available to spend." Staff interviews revealed that the provider agency has been dispersing funds to Individual #1 for personal use. The provider agency is not maintaining an up-to-date financial ledger of disbursements made to Individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | QCH Director created a financial ledger for Individual #1 and all program Individuals. This was created on 10/20/2025 and Includes all fund disbursements, receipts, and balances. All past transactions for the previous 60 days were reviewed, reconciled, and entered into the financial record. All house managers have been trained on the completion of the ledgers as well as DSP Staff on 10/30/2025. QCH staff (House Manager) will monitor and review financial ledger weekly to ensure proper records are kept. These records will be turned into Human resources at the end of the month who will review the Ledger an additional time for completion and accuracy. |
10/14/2024
| Implemented |
| 6400.22(d)(2) | Individual #1's service plan, last updated 9/18/2025 reads, "[Individual #1] needs support with money management. [Individual #1] requires caregivers to help [them] budget [their] money and avoid being exploited financially by others." Individual #1's assessment, completed 8/15/2025, reads, "[Individual #1] requires assistance to safely maintain [their] funds. [Individual #1] requires assistance to budget and understand the cost of items compared to what [Individual #1] has available to spend." The provider agency is not maintaining an up-to-date financial ledger of disbursements made to or for Individual #1. | (2) Disbursements made to or for the individual.
| QCH Director created a financial ledger for Individual #1 and all program Individuals. This was created on 10/20/2025 and Includes all fund disbursements, receipts, and balances. All past transactions for the previous 60 days were reviewed, reconciled, and entered into the financial record. All house managers have been trained on the completion of the ledgers as well as DSP Staff on 10/30/2025. |
10/20/2025
| Implemented |
| 6400.67(a) | On 10/8/2025 at 10:41AM, there was a two-inch by four-inch hole in the cement floor in front of the exit door in the basement of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 10/13/2025, QCH maintenance staff filled and sealed the 4-inch hole in the cement floor of the basement door using industrial-grade concrete patching compound to ensure a smooth, safe surface. The repaired area was inspected by the Program Supervisor on 10/15/2025 and verified to be in good condition with no remaining hazards. |
10/13/2025
| Implemented |
| 6400.67(b) | On 10/8/2025 at 11:05AM, the outlet cover, next to the bed in Individual #1's bedroom, was broken with a small piece of plastic left attached by a screw in the middle, with a jagged edge on the top and bottom posing a laceration hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 10/13/2025, the damaged outlet cover was immediately removed by QCH maintenance to eliminate the hazard. A new outlet cover was installed by maintenance staff on 10/13/2025, ensuring the area was safe and free of sharp edges as well as verified that the outlet and surrounding area were in safe and proper condition. QCH maintenance completed a walk through with QCH Compliance officer to document the completion of the repair and that the floors, walls, ceilings and other surfaces are free of hazards. |
10/13/2025
| Implemented |
| 6400.72(a) | On 10/8/2025 at 11:06AM, there were six windows in the bedroom connected to Individual #1's bedroom. Four of the windows had accordion screens that did not securely fit the windows and two of the windows did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | . QCH- CFO has started the licensing process for another home to relocate the individual. QCH House manager was retrained on 55 PA CODE CHAPTER: 6400.72(a) on 10/9/2025. Individual #1 educated and notified of their rights regarding the transition. |
10/13/2025
| Implemented |
| 6400.72(b) | On 10/8/2025 at 10:58AM, the window, in the bathroom on the second floor of the home, slid down when opened. | Screens, windows and doors shall be in good repair. | QCH- CFO has started the licensing process for another home to relocate the individual. QCH House manager was retrained on 55 PA CODE CHAPTER: 6400.72(a) on 10/9/2025. Individual #1 educated and notified of their rights regarding the transition. QCH staff will monitor the usage of the window and assist individual with the window. |
10/13/2025
| Implemented |
| 6400.73(a) | On 10/8/2025 at 10:37AM, there was no handrail on the three interior stairs leading to the basement of the home. At 10:41AM, there was no handrail on the three, exterior, concrete stairs on the right side of the home. At 10:43AM, there was no handrail on three of the six exterior, concrete stairs on the right side of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | On 10/13/2025, Quick Care Homes (QCH) Maintenance Department installed secure handrails on the following areas of the home.: The three interior stairs leading to the basement, The three exterior concrete stairs on the right side of the home, The remaining three of the six exterior concrete stairs on the right side of the home, All handrails were properly anchored, tested for stability, and verified to meet safety standards. |
10/13/2025
| Implemented |
| 6400.80(a) | On 10/8/2025 at 10:40AM, the exterior, concrete walkway at the back of the home was uneven with large areas of cracked, broken pieces of concrete posing a tripping hazard. Additionally, there were several pieces of broken glass on the walkway. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | On 10/8/2025, the QCH House Manager immediately restricted access to the uneven and damaged section of the rear walkway to prevent potential injury to residents and staff. All broken glass and loose debris were removed by the House Manager, ensuring that the area was temporarily safe and obstruction-free. The landlord was notified of the cracked and uneven concrete, and the QCH Chief Financial Officer (CFO) initiated contact with an external contractor to replace and repair the affected area. In the interim, staff continue to ensure that the damaged area remains clearly marked and restricted until permanent repairs are completed. The CFO has also initiated the licensing process for an alternate property for potential relocation of the individual for long-term safety and compliance.
Individual #1 has been educated and notified on their rights and the transition. |
10/08/2025
| Implemented |
| 6400.80(b) | On 10/8/2025 at 11:30AM, the left, exterior side of the home had overgrown grass and trash strewn about the yard. At 11:31AM, there were miscellaneous articles of trash, in the small patch of grass, to the right 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. | The House Manager will conduct weekly environmental site checks to ensure that all outdoor walkways, driveways, and entryways are free of hazards such as cracks, debris, or obstructions. All findings will be documented on the Environmental and Safety Checklist and submitted weekly to the QCH Compliance Officer for review. The Compliance Officer will conduct bi-weekly re-inspections to verify the safety of all outdoor walkways and ensure prompt reporting of any needed repairs. Any maintenance or safety concerns identified during inspections will be reported immediately to the Program Director and CFO for corrective action. |
10/13/2025
| Implemented |
| 6400.81(k)(3) | On 10/8/2025 at 11:04AM, there was a pillow with no pillowcase or covering on bed in Individual #1's bedroom. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | On 10/8/2025, the Direct Support Professional (DSP) immediately placed a clean pillowcase on the uncovered pillow in Individual #1's bedroom. On the same date, the QCH Human Resources Department provided retraining to the House Manager regarding compliance with Chapter 6400.81(k)(3), emphasizing the importance of ensuring that each individual's bedroom is properly equipped with clean and appropriate bedding at all times. The House Manager also reviewed expectations with all DSP staff to ensure awareness and accountability for maintaining adequate bedroom supplies and cleanliness. |
10/08/2025
| Implemented |
| 6400.101 | On 10/8/2025 at 10:40AM, there were two slide latch locks on the exit door in the basement of the home. At 10:41AM, there was a storm door with a slide lock on the exit door in the basement. At 11:13AM, there was a slide latch lock on the inside of the door to the vacant bedroom on the second floor of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 10/14/2025, the QCH House Manager immediately removed all slide latch locks from the interior basement exit door, the basement storm door, and the vacant bedroom door on the second floor to confirm that all exits and passageways were unobstructed and accessible. The QCH Human Resources Department provided retraining to the House Manager on 10/14/2025, emphasizing the requirements of Chapter 6400.101 regarding maintaining unobstructed exits and pathways at all times for the safety of residents and staff. All staff were reminded that any locks, obstructions, or barriers that restrict exit access are strictly prohibited unless |
10/13/2025
| Implemented |
| 6400.110(a) | On 10/8/2025 at 10:50AM, there was no operable smoke detector on the first floor of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | On 10/13/2025, the Quick Care Homes (QCH) House Manager installed interconnected smoke detectors on all required levels of the home --- including the basement, first floor, and second floor --- to confirm complete coverage and compliance with regulatory fire safety standards. The QCH Human Resources Manager provided retraining to the House Manager on 10/13/2025, reinforcing the requirements of Chapter 6400.111(a) and the importance of maintaining functional and properly located smoke detectors throughout the home. All detectors were tested upon installation to verify that they were operable and interconnected for immediate activation in case of an emergency. |
10/22/2025
| Implemented |
| 6400.110(b) | On 10/8/2025 at 10:51AM, there was no operable smoke detector within 15 feet of Individual #1's bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | On 10/13/2025, the Quick Care Homes (QCH) House Manager installed interconnected smoke detectors within 15 feet of Individual #1's bedroom, for compliance with Chapter 6400.110(b). The QCH Human Resources Manager provided retraining to the House Manager on 10/13/2025 regarding fire safety requirements, including proper placement and maintenance of smoke detectors in proximity to all bedrooms. The House Manager verified that all other bedrooms in the home also had operable smoke detectors within the required distance, ensuring full compliance across the property. |
10/22/2025
| Implemented |
| 6400.110(e) | On 10/8/2025 at 10:50AM, the smoke detectors on each floor of the home were not interconnected. | 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. | On 10/22/2025, the Quick Care Homes (QCH) House Manager installed interconnected smoke detectors on the basement, first floor, and second floor of the home to confirm that all smoke detectors activate simultaneously and are audible throughout the residence in accordance with Chapter 6400.110(e). Following installation, all smoke detectors were tested and verified as fully operational and interconnected by the House Manager and Maintenance staff. On 10/13/2025, prior to the installation completion, the QCH Human Resources Manager provided retraining to the House Manager on state requirements for smoke detector placement, interconnection, and maintenance. |
10/22/2025
| Implemented |
| 6400.112(f) | The front door was used as the exit route for all fire drills from 10/2024 through 9/2025. | Alternate exit routes shall be used during fire drills. | On 10/16/2025, Quick Care Homes (QCH) staff (DSPs) conducted a fire drill using an alternate exit route to verify compliance with state requirements. The QCH House Manager was retrained on 10/13/2025 by the Program Director on proper fire drill procedures, including the importance of utilizing alternate exits.
Documentation of the fire drill, including exit routes used, was completed and reviewed by the House Manager to for accurate recordkeeping. |
10/16/2025
| Implemented |
| 6400.141(b) | Individual #1's physical examination, completed 5/1/2025, was not signed by a physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Quick Care Direct Support Professionals (DSPs) will obtain and physically review each individual's physical examination form immediately upon completion of each appointment. This review will ensure that the form is fully completed, signed, and dated by a licensed physician, certified nurse practitioner, or licensed physician's assistant. |
11/06/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, completed 5/1/2025, did not include the physical limitations of the individual. This section was left blank. | The physical examination shall include: Physical limitations of the individual. | Quick Care Direct Support Professionals will obtain and physically review each physical examination form prior to the conclusion of each appointment. This review will verify that the physical form includes the physical limitations of the individual. If any required sections are incomplete, DSP staff will immediately request that the attending provider complete the necessary information before the form is finalized, effective immediately. Any issues with obtaining the requested documentation will be reported immediately to the House Manager and Program Specialist.
Additionally, the QCH House Manager has been retrained on the critical importance of ensuring all physical examination forms are accurate and
complete before submission. This retraining emphasized the necessity of proper documentation to support regulatory compliance and continuity of care. |
10/15/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 5/1/2025, did not address medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank. [Repeat violation: 1/14/25.] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Quick Care Direct Support Professionals will obtain and physically review each physical examination form prior to the conclusion of each appointment. This review will verify that the physical form includes the medical information pertinent to diagnosis and treatment in case of an emergency. If any required sections are incomplete, DSP staff will immediately request that the attending provider complete the necessary information before the form is finalized, effective immediately. Any issues with obtaining the requested documentation will be reported immediately to the House Manager and Program Specialist. Additionally, the QCH House Manager has been retrained on the critical importance of ensuring all physical examination forms are accurate and complete before submission. This retraining emphasized the necessity of proper documentation to support regulatory compliance and continuity of care. |
10/20/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 8/15/2025, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The OCH Program Specialist has ensured that all assessments include a complete lifetime medical history for each individual. On 10/9/2025 the lifetime medical documents were stabled to the annual assessment. Moving forward these will be completed together and include all pertinent information is available for review to ensure compliance. The QCH Program Director and Associate Program Director provided retraining (10/13/25) to the Program Specialist on the required assessment information, emphasizing the importance of thorough documentation. |
10/30/2025
| Implemented |
| 6400.214(b) | On 10/8/2025 at 11:25AM, the most recent copy of the Service Plan and psychiatric evaluation for Individual #1 was not kept in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| QCH Program Specialist provided physical copies of the most current record information to be kept at the residential home on 10/8/2025. All DSP staff and house managers have been trained on where the physical records are kept in the home and how to access through the electronic record keeping website |
10/30/2025
| Implemented |
| 6400.163(g) | On 10/8/2025 at 10:13AM, there was a half tablet of Individual #1's prescribed medication, Perphenazine inside a pill cutter in the medication box. At 10:18AM, there were two, loose tablets of Individual #1's prescribed medication, Clonidine, in the bottom of Individual #1's medication box. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | QCH CFO destroyed medication immediatley. QCH DSP staff will double-check each prescription medication both prior to and following administration to ensure accuracy and prevent errors. Effective immediately all checks will ensure prescription medications are stored in a clearly organized and secure manner, under conditions that meet proper sanitation, temperature, moisture, and light standards, in full compliance with manufacturer guidelines. The Program Director will conduct a mandatory retraining session for all QCH DSP staff on medication storage protocols, emphasizing regulatory compliance and best practices |
10/08/2025
| Implemented |
| 6400.163(h) | On 10/8/2025, Individual #1's prescribed medication, Fluticasone, expiration date 8/2025, was in Individual #1's medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | QCH CFO removed the medication immediately from the box on 10/8/25 and has ensured that all prescription medications that were discontinued or expired have been destroyed in a safe and compliant manner, adhering strictly to all applicable Federal and State statutes and regulations. Effective immediately, all medication boxes will be checked daily before and after administration to ensure that only current, unexpired medication are present, properly labeled, and securely stored in accordance with Federal and state statues and regulations. |
10/09/2025
| Implemented |
| 6400.166(a)(4) | Individual #1's October 2025 Medication Administration Record does not include the name of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the name of the medication administered. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(5) | Individual #1's October 2025 Medication Administration Record does not include the strength of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the strength of medication. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the strength. The Program Director has retrained the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(6) | Individual #1's October 2025 Medication Administration Record does not include the dosage form of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the dosage form of medication. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the dose. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(7) | Individual #1's October 2025 Medication Administration Record does not include the dose of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the dose of medication. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the dose. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(8) | Individual #1's October 2025 Medication Administration Record does not include the route of administration of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the route of administration for the medication. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the route of administration. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(9) | Individual #1's October 2025 Medication Administration Record does not include the frequency of administration of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the frequency of administration for the medication. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the frequency of administration. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(10) | Individual #1's October 2025 Medication Administration Record does not include the administration times of Nystop Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the administration times for the medication. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the times of administration. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(a)(11) | Individual #1's October 2025 Medication Administration Record does not include the diagnosis or purpose for Fluticasone, Perphenazine and Nystop Powder. | 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. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the diagnosis or purpose for the medication, including pro re nata. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop including the diagnosis. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.166(d) | Individual #1 is prescribed Nystop Powder with instructions to, "Apply topically twice a day." This prescription was filled by the pharmacy on 7/16/2025. There is no record of this medication being administered to Individual #1. | The directions of the prescriber shall be followed. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall include, at minimum, the directions of the prescriber. QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop beyond the July Mar unless written instructions are received to stop or administer as a PRN. The Program Director has retrained (10/13/25) the QCH House Manager on the proper procedures for accurately completing the MAR to ensure compliance and accuracy moving forward. |
10/09/2025
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Nystop Powder with instructions to, "Apply topically twice a day." This prescription was filled by the pharmacy on 7/16/2025. There is no record of this medication being administered to Individual #1. | Medication errors include the following: Failure to administer a medication. | QCH DSP staff will ensure that a medication record is maintained for each individual receiving prescription medication. This record shall be strictly followed to prevent failure to administer any medication. The QCH House Manager has updated the Medication Administration Record (MAR) to include Nystop beyond the July MAR. Based on the instructions, medication should continue until written instructions are received to stop or administer as needed (PRN). QCH manager was retrained by the Program Director on 10/9/2025 and 10/13/25 regarding how to properly fill out the MAR and follow directions as prescribed. Additionally, when to escalate to Program Specialist to inform when a medication is no longer needed in order to receive written instructions to stop or change to PRN. |
10/09/2025
| Implemented |