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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 contacted their mother on 11/5/2025 and advised that they were not feeling well. Individual's mother arrived at their group home to check on them, and it was decided by Individual's mother to contact 911 due to Individual experiencing shortness of breath and hypoxia. EMS transported the Individual to Lancaster General Hospital Emergency Department. Individual's mother followed the ambulance to the hospital; Faithful Homes LLC staff did not accompany the Individual to the hospital. Faithful Homes LLC did not provide EMS or Individual's mother with their emergency medical information. Per hospital records, the hospital then contacted Faithful Homes LLC on 11/5/2025 at 9:30pm and spoke with Faithful Homes LLC staff who advised that they would have their "boss fax over patients MAR." At 9:58pm staff reportedly emailed Individual #1's MAR to the patient's mother -- not the hospital. At 10:22pm, hospital received email from patient's mother with pictures of medications and last doses given, however photographs were extremely blurry and could not be read as this is what was provided by the provider. The physician notes also state that discharge was delayed for Individual #1 as the group home could not be reached. The hospital documentation states that they contacted Staff #4 (Operations Manager). Health Alert issued on 10/2/2024 states that it is critical for Community Home staff to accompany individuals to the hospital, stay informed about treatments, be actively involved in discharge arrangements, and understand follow-up care required. Faithful Homes LLCs' failure to provide medical information and facilitate discharge during Individual #1's Emergency Department visit and subsequent admittance to the hospital is neglectful and jeopardizes the individual's continuity of care. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | ZB passed away on 7/21/26. All of our CAP will be in regards to future occurrences for other individuals. |
08/14/2026
| Accepted |
| 6400.144 | Individual #1's most recent physical exam completed on 10/16/2025 states that they have a biPAP machine. Individual #1's hospital documentation from November 2025 states that they have a cPAP machine and Individual #1 has reported use of it. Individual #1 has a history of refusing to use the positive airway pressure machine. Faithful Homes LLC does not have a protocol to address issues of compliance with the prescribed machine. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Faithful Homes house manager personnel will review all homes that are not staffed with LPN's for accessory equipment such as a CPAP or BPAP. This will be completed by August 30, 2026. Additionally, the program specialist will review the same houses ISP's to ensure we have all the equipment listed in the ISP by August 30, 2026. If any equipment is identified a training on the use of the equipment will be implemented by September 4, 2026. This training will be will be implemented by the house manager and the house manager will collect attendance records from the DSP staff. The house manager and the DSP staff will also be required to sign an acknowledgement that they understand how to use the equipment properly and when to use the equipment.
As new staff are onboarded in these houses, new staff will also be required to sign an acknowledgement that they understand how to use the equipment properly and when to use the equipment. |
09/04/2026
| Accepted |
| 6400.18(f) | On January 16, 2026, Individual #1 encountered a medical emergency characterized by shortness of breath, cough and ear pain. This individual has a history of similar episodes that have previously necessitated hospital admission. The diagnoses for Individual #1 include autism, obesity, hypovitaminosis D, type 2 diabetes, elevated triglycerides, obstructive sleep apnea, severe lymphedema, depression, reduced mobility, self-care deficit, morbid obesity, binge eating disorder, nocturnal enuresis, anxiety, and pulmonary hypertension. When the individual experienced breathing difficulties, Staff #1 opted to transport them to LG Health Urgent Care on Duke Street rather than contacting 911. It is noteworthy that Staff #1 underwent ODP Health Alert training on October 17, 2025, which clearly instructs that 911 should be called when an individual is experiencing breathing difficulties or shortness of breath. By failing to contact 911 and instead choosing to transport the individual to urgent care, Staff #1 did not provide the necessary prompt medical attention, which constitutes a failure to take immediate action. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | The root cause was that staff did not recognize a medical emergency. A medical emergency per the ODP Health Alert states:
Any event that threatens someone's life or limb in such a way that immediate medical care is needed to prevent death or serious impairment of health, such as severe pain, serious injury, serious illness, or a medical condition that is quickly getting worse.
Faithful Homes will retrain the Operation Managers and the House Managers on the Fatal Five training. (Aspiration, Dehydration, Seizures, Constipation, Sepsis) as well as the ODP Health Alert focusing on (1) Recognizing a medical emergency (2) Seeking immediate attention for the emergency. This training will be conducted by the Managing Adminstrator and documentation of the training will be collected. This training will be completed by August 25, 2026. |
08/25/2026
| Accepted |
| 6400.44(b)(1) | Individual #1 arrived in the Emergency Department of the Lancaster General hospital on 11/5/2025 at 7:41pm. Hospital documentation from physician notes state that the patient arrived alone with no one else available for supplemental information. Per hospital records, the hospital then contacted Faithful Homes LLC on 11/5/2025 at 9:30pm and spoke with Faithful Homes LLC staff who advised that they would have their "boss fax over patients MAR." At 9:58pm staff reportedly emailed Individual #1's MAR to the patient's mother -- not the hospital. At 10:22pm, hospital received email from patient's mother with pictures of medications and last doses given, however photographs were extremely blurry and could not be read. Individual #1's Emergency Medical Plan states the instructions at the hospital are for staff to tell the doctor what happened at the time of the issue, symptoms, list of medication resident is taking, family to be contacted, etc. Staff failed to implement the Emergency Medical plan as staff did not provide important medical information to the hospital upon arrival in the Emergency Department and subsequent admittance. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | Faithful Homes staff will accompany the individual to all urgent care and hospital visits going forward for all homes and all individuals. |
08/14/2026
| Accepted |
| 6400.52(c)(6) | Individual #1's most recent physical exam completed on 10/16/2025 states that they have a biPAP machine. Individual #1's hospital documentation from November 2025 states that they have a cPAP machine and Individual #1 has reported use of it. Staff providing direct care for Individual #1 do not possess training for positive airway pressure -- CPAP and BPAP use, including application of mask, operation of the device, and cleaning and maintenance of the equipment. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Faithful Homes house manager personnel will review all homes that are not staffed with LPN's for accessory equipment such as a CPAP or BPAP. This will be completed by August 30, 2026. Additionally, the program specialist will review the same houses ISP's to ensure we have all the equipment listed in the ISP by August 30, 2026. If any equipment is identified a training on the use of the equipment will be implemented by September 4, 2026. This training will be will be implemented by the house manager and the house manager will collect attendance records from the DSP staff. The house manager and the DSP staff will also be required to sign an acknowledgement that they understand how to use the equipment properly and when to use the equipment. |
09/04/2026
| Accepted |
| 6400.185(5) | Individual #1's current assessment dated 12/22/2025 does not contain any information regarding the risk to the Individual's health by their refusal to utilize their prescribed biPAP machine. Individual #1's most recent physical exam dated 10/16/2025 states that they have a habit of refusing to wear their biPAP, but they are a higher risk for CO2 retention and hypercapnic respiratory failure. | The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. | The root cause is that the service coordinator was not aware that individual used this machine and that it would be coming with him when he relocated to Faithful homes and was not in the ISP. The second root cause, is when staff saw the machine, the program specialist did not review the ISP to ensure it was included in the ISP for review and training with correct procedure.
If an individual is refusing to use medical equipment per the Doctors orders and / or the ISP, Faithful Homes will utilize a Behavior Specialist to determine the root cause of the refusal. It may be possible that a trigger can be identified and overcome thru Behavior supports or educational supports and information may also assist in the individuals decision to use the medical equipment. Behavioral supports can develop a plan and the frequency of BS visits to overcome the refusal. If the individual refuses BS, Faithful Homes will document the refusal of BS as well as the refusal of the medical equipment. |
09/04/2026
| Accepted |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Square and rectangular areas on the wall were unpainted behind the living room sofa. | Floors, walls, ceilings and other surfaces shall be in good repair. | Associate director alerted maintenance to repaint section of the wall immediately on 1/7/26. Entire wall was repainted by Maintenance on 1/7/2026. Immediately:
1. All homes will be inspected by staff at house on 3/7/26 for all items listed in 67 (a)
2. That staff will send a confirming text to Compliance by 5pm that this action item has been completed
3. This text and picture will be stored in FH Share Drive for documentation
4. Any items will be input into the ICare Manager system for maintenance review and maintenance will schedule repair
Quality Improvement and on-going compliance:
1. The root cause is the hard wear and tear on the houses and the frequency of inspections
2. A new robust checklist will be utilized to document maintenance items. The checklist will be utilized by house manager for completion and signature and any repair items will be uploaded into the ICare Manager system. This will be done weekly beginning 3/9/2026 and continue for a period of 52 weeks. At 52 weeks a review will be done by Compliance to determine if this has been effective and whether this process should be continued.
3. Additionally, the frequency of the physical site tool will be increased from quarterly to every other month beginning April 2026. This also includes documentation of maintenance items. The site tool will be completed by key leaders of Faithful Homes. This could include: Compliance, Associate Director, Program Specialist, Operations Manager, Strategic Development and Compliance and Director.
4. Training on the weekly checklist and Physical site tool will be mandatory for all Operations managers by Compliance and will be completed by 3/7/2026. Additionally, mandatory training will be done by the Operations managers to the house managers. A signature will be required on training sheet to verify training was completed.
5. Weekly, the checklist will be forwarded to operation manager for signature and then provided to compliance for scanning to the share drive and documentation.
Evidence of Completion
1. All documentation will be uploaded to the share drive for inspection
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. Associate director immediately corrected missing trash can on 1/7/26 prior to individual moving into the home. Trash can was placed in bathroom. House managers will complete quarterly licensing tools and self site for things missing. POC will be completed for each item. House managers will be retrained on how to complete licensing tools and self sit by 2/2/26 01/23/2026 Accepted |
01/23/2026
| Implemented |
| 6400.72(b) | The bottom track was missing for Individual #1's bedroom sliding closet door. | Screens, windows and doors shall be in good repair. | Associate director alerted Maintenance to concern immediately on 1/7/26. Maintenance replaced track immediately on 1/7/26. |
01/23/2026
| Implemented |
| 6400.81(k)(6) | A mirror was not present in Individual #2's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Associate director immediately directed staff to return mirror to Individual #2s room. Individual #2 requested isp change to include not having a mirror. ISP was updated by Supports coordinator to include preference to not have a mirror in individual #2 room. |
01/23/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1 is not safe around poisonous materials. At the time of the 2/2/22 inspection, there was a bottle of Palmolive dish detergent and a bottle of Method hand soap by the kitchen sink and various bottles of powder and lotions in a caddy beside the bathroom sink. These products are required to be locked in this home when not actively in use. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1) Plan to Fix the Immediate Problem
a. WHO: House Manager took all products not in use and placed them in the Cleaning Supply Closet after inspection was completed.
b. WHAT: All cleaning supplies/bathroom supplies that are considered poisonous materials were placed back into the cleaning supply closet. |
02/18/2022
| Implemented |
| 6400.141(c)(4) | Individual #1's 5/26/20 and 5/25/21 annual physicals indicate that the physician was "unable to perform" hearing and vision exams. There are no records maintained that Individual #1 has had a completed hearing or vision exam. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 1) Plan to Fix the Immediate Problem
a. WHO: Operations Manager will schedule both a hearing exam (ENT) and vision exam (Optometrist) for the individual to have these exams completed.
b. WHAT: These appointments will ensure that individual has an up to date hearing and vision exam. |
04/06/2022
| Implemented |
| 6400.141(c)(6) | Individual #1 had a tuberculin test on 8/19/19 and not again until 12/29/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | 1) Plan to Fix the Immediate Problem
a. WHO: Program Specialist caught error prior to licensing but still was overdue by 4 months. Tuberculin test was completed/read on 12/29/2021.
b. WHAT: Program Specialist corrected non-compliance by getting Tuberculin test completed for individual on 12/29/21.
c. WHEN/HOW: Tuberculin test was completed on 12/29/2021. |
02/08/2022
| Implemented |
| 6400.165(c) | Individual #1 has a PRN prescription for acetaminophen that is to be administered, "every 4 hours as needed for pain." On 9/2/21 and 9/3/21, this medication was administered for the reason of "running nose." | A prescription medication shall be administered as prescribed. | 1) Plan to Fix the Immediate Problem
a. All medication administration records were reviewed on 2/9/2022 to ensure no other errors in administration occurred throughout agency in relation to regulation 165(c). No other issues found at this time. |
02/18/2022
| Implemented |
| 6400.166(a)(11) | There is no diagnosis or purpose listed on Individual #1's Medication Administration Record for the following medications: clobazam, vimpat, and omeprazole. | 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. | 1) Plan to Fix the Immediate Problem
a. Contacted providers and received updated orders instructing on diagnoses/purposes completed on 2/14/2022. |
02/18/2022
| Implemented |
| 6400.167(a)(1) | The following medications were not administered to Individual #1 at 8pm on 7/25/21: topiramate, divalproex, vimpat, clobazam, melatonin.
Individual #1 did not receive their 8am dose of clobazam on 11/20/21 and their 8pm dose of clobazam on 11/21/21.
Individual #1 did not receive their 12am dose of divalproex on 11/26/21. | Medication errors include the following: Failure to administer a medication. | 1) Plan to Fix the Immediate Problem
a. All medication errors were reviewed and ensured they were reported. |
02/18/2022
| Implemented |
| 6400.167(b) | There is no documentation maintained that the failure to administer Individual #1's 8pm medications on 7/25/21 was reported as a medication error. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | 1) Plan to Fix the Immediate Problem
a. This medication error was reported on the EIM system on 2/2/2022 after it was identified as an error by the Executive Director. |
02/18/2022
| Implemented |
| 6400.167(c) | The failure to administer Individual #1's 8pm medications on 7/25/21 was not reported as an incident in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | 1) Plan to Fix the Immediate Problem
a. Incident reported onto the EIM system on 2/2/2022 by Executive Director. |
02/18/2022
| Implemented |
| 6400.181(f) | Individual #1's 2020 ISP meeting was conducted on 12/4/20. Their assessment was not sent to the plan team until 11/6/20. Individual #1's 2021 ISP meeting was conducted on 12/3/21. Their assessment was not sent to the plan team until 11/5/21. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 1) Plan to Fix the Immediate Problem
a. Reviewed all other assessments to ensure compliance with other assessments within Faithful Homes. |
02/18/2022
| Implemented |
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