| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's financial record had a balance of $1.15 on 11/8/24. There was a deposit of $200. There were 4 purchases on that day totaling $83.15. It was recorded as a total of $83.35. In addition, it was recorded that the balance after the deposit and debits for the day was $116.65, but the correct balance was $118. The incorrect recording of the transactions and balances made the financial log incorrect moving forward. | 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. | The home keeps up-to-date financial and property records for each individual. Sisters and Brothers Keepers has a plan to manage the individual's finances that aligns with ODP's regulations. All staff are trained on the policy for Managing Individual Finances before they work independently with the individuals. Staff will count money on the locked box and document at the change of shifts. The House Supervisor is trained and responsible for ensuring the procedure is followed. If there is a discrepancy, it must be corrected immediately, staff retrained and documented. The policy was reviewed on 7/7/2025. On 7/15/2025 all staff were retrained to follow the procedure and protocol to ensure that ODP regulations are followed. |
07/15/2025
| Implemented |
| 6400.112(e) | A sleep drill was completed 11/23/24 and not again until 6/27/25, which is outside of the six-month time frame that a sleep drill must be completed. | A fire drill shall be held during sleeping hours at least every 6 months. | House supervisor and were retrained on the fire safety policy, with a special emphasis on sleep drills to be done during sleeping hours at least every 6 months. Policy reviewed on 7/7/2025. Staff retrained on 7/15/2025. |
07/15/2025
| Implemented |
| 6400.181(a) | Individual #1's date of admission was 7/22/24 and their new admission assessment was not completed until 9/23/24, which is outside of the 60-day time frame. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | SBK acknowledges that the individual's assessment was not completed within the required 60 calendar days of admission as specified under 55 PA Code § 6400.181(a). To ensure ongoing compliance with this regulation, SBK has developed and implemented the following corrective plan:
Sisters and Brothers Keepers has a plan to ensure all initial assessments are completed within 30 - 50days of admission. This was put in place on 7/10/2025 |
07/10/2025
| Implemented |
| 6400.165(g) | (Repeat from 3/10/25 inspection) For Individual #1, the 9/4/24, 12/4/24, 1/16/25, and 4/9/25 quarterly psychiatric medication review forms did not identify the reason for prescribing the medication. | 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. | Sisters and Brothers Keepers revised the Quarterly, the psychological review appointment form on 7/7/2025. In compliance 6400.165(g) of the Pennsylvania Code, the new form that will be taken to quarterly psychiatric appointments for the doctor who prescribes any medication to treat a symptom of a psychiatric illness. The following must be documented on the psychiatric medication administration form; review by a licensed physician at least every 3 months, name of the medication(s), reason for prescribing the medication, need to continue or discontinue the medication, the necessary dosage and frequency the medication is taken. |
07/07/2025
| Implemented |
| 6400.166(a)(1) | For individual #1, the July 2024 and September 2024 medication records did not identify the individual's name. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | Sisters and Brothers has reviewed /revised the policy for Medication Administration on 7/3/2025. The policy states:
A medication administration record (MAR) must be kept for everyone for whom a medication is administered.
a) The MAR must contain the following:
1. Name of the individual.
2. Name of the prescriber.
3. Drug allergies.
4. Name of medication.
5. Strength of medication.
6. Dosage form.
7. Dose of medication.
8. Route of administration.
9. Frequency of administration.
10. Administration times.
11. Diagnosis or purpose for the medication, including the pro re nata (PRN)
12. Date and time of medication administration.
13. Name and initials of person administering the medication.
14. Duration of treatment, if applicable.
15. Special precautions, if applicable.
16. Side effects of the medication, if applicable. |
07/03/2025
| Implemented |
| 6400.166(a)(2) | For individual #1, the July 2024 and September 2024 medication records did not identify the name of the prescriber. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Sisters and Brothers reviewed /revised the policy for Medication Administration on 7/3/2025. The policy states:
A medication administration record (MAR) must be kept for everyone for whom a medication is administered.
a) The MAR must contain the following:
1. Name of the individual.
2. Name of the prescriber.
3. Drug allergies.
4. Name of medication.
5. Strength of medication.
6. Dosage form.
7. Dose of medication.
8. Route of administration.
9. Frequency of administration.
10. Administration times.
11. Diagnosis or purpose for the medication, including the pro re nata (PRN)
12. Date and time of medication administration.
13. Name and initials of person administering the medication.
14. Duration of treatment, if applicable.
15. Special precautions, if applicable.
16. Side effects of the medication, if applicable. A medication administration record (MAR) must be kept for everyone for whom a medication is administered. |
07/03/2025
| Implemented |
| 6400.166(a)(3) | For individual #1, the July 2024 and September 2024 medication records did not identify the drug allergies for the individual. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | Sisters and Brothers reviewed /revised the policy for Medication Administration on 7/3/2025. The policy states:
A medication administration record (MAR) must be kept for everyone for whom a medication is administered.
a) The MAR must contain the following:
1. Name of the individual.
2. Name of the prescriber.
3. Drug allergies.
4. Name of medication.
5. Strength of medication.
6. Dosage form.
7. Dose of medication.
8. Route of administration.
9. Frequency of administration.
10. Administration times.
11. Diagnosis or purpose for the medication, including the pro re nata (PRN)
12. Date and time of medication administration.
13. Name and initials of person administering the medication.
14. Duration of treatment, if applicable.
15. Special precautions, if applicable.
16. Side effects of the medication, if applicable. A medication administration record (MAR) must be kept for everyone for whom a medication is administered. |
07/03/2025
| Implemented |
| 6400.183(a)(3) | There was not a direct care staff person present for the Annual ISP review on 3/12/25 for individual #1. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | Sisters and Brothers Keepers (SBK) implemented a New Annual ISP Review Meeting Form on 7/11/2025 with a reminder that the Individual plan will be developed by an interdisciplinary team including, the individual, persons designated by the individual, the individual¿s direct care staff persons, the program specialist, the supports coordinator, the program specialist for the individual¿s day program if applicable and any specialists working with the individual such as health care, behavior management, speech, occupational, and physical therapy as appropriate for the individual |
07/11/2025
| Implemented |
| 6400.183(b) | There were not three members present for the Annual ISP review on 3/12/25 for individual #1. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | Sisters and Brothers Keepers (SBK) implemented a New Annual ISP Review Meeting Form on 7/11/2025 with a reminder that the Individual plan will be developed by an interdisciplinary team including, the individual, persons designated by the individual, the individual¿s direct care staff persons, the program specialist, the supports coordinator, the program specialist for the individual¿s day program if applicable and any specialists working with the individual such as health care, behavior management, speech, occupational, and physical therapy as appropriate for the individual. |
07/11/2025
| Implemented |