| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On or around May 15, 2025, Individual #1 was subjected to physical abuse perpetrated by staff members of Kels LLC, including Staff #1 and #3, both identified as the agency's Chief Executive Officers. A video recording of the incident depicts five adults surrounding Individual #1, who was lying on the sidewalk while holding onto Staff #2's sweatshirt hood string. The recording shows Staff #1, Staff #2, and Staff #3 engaging in acts of physical abuse against Individual #1. Specifically, they are observed stepping on Individual #1, pulling Individual #1's hair, striking Individual #1 in the head, and placing Individual #1 in a choke hold position to take Individual #1 to the ground. Furthermore, Individual #2 was subjected to the abuse of Individual #1 by proximity. The abuse captured in the video constitutes the intentional infliction of harm by multiple staff, including the agency's Chief Executive Officer. This conduct not only demonstrates a direct violation of the individual's right to be free from abuse but also reflects a systemic breakdown in the provider's responsibility to establish and enforce a culture of safety, accountability, and dignified treatment. The involvement of executive leadership further magnifies the severity of the violation, evidencing a pervasive disregard for regulatory requirements and fundamental protections owed to individuals in 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. | Staff will be trained on Non-Violent crisis prevention on techniques by an outside agency to try and deescalate behaviors that the individuals may present. If that doesn't work and the individual gets violent staff will call the police for assistance. |
09/03/2025
| Not Accepted |
| 6400.43(b)(1) | Staff #4 was hired with a criminal history, and their policy for review of offenses for staff #4 was not documented. Staff #1,2,3 did not follow their abuse policy that states; KELS LLC will not tolerate abuse in any form. Any staff member, contractor, or volunteer who commits abuse will be subject to immediate removal from contact with individuals, disciplinary action up to and including termination, and referral to law enforcement, Protective Services, and DHS Licensing. when on or around May 15, 2025, Individual #1 was subjected to physical abuse perpetrated by staff members of Kels LLC, including Staff #1 and #3, both identified as the agency's Chief Executive Officers. A video recording of the incident depicts five adults surrounding Individual #1, who was lying on the sidewalk while holding onto Staff #2's sweatshirt hood string. The recording shows Staff #1, Staff #2, and Staff #3 engaging in acts of physical abuse against Individual #1. Specifically, they are observed stepping on Individual #1, pulling Individual #1's hair, striking Individual #1 in the head, and placing Individual #1 in a choke hold position to take Individual #1 to the ground. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Human resources will ensure that upon hire that all staff who have offenses will be documented in their file and request 2 references letters. All staff who is alleged of committing abuse on any individual will be immediately taken off the schedule and will have no contact with the individual. Pending the outcome of the investigation the staff may face disciplinary action that may include termination. |
09/03/2025
| Not Accepted |
| 6400.43(b)(3) | In May 2025, a video recording documented staff of Kels LLC, including both Chief Executive Officers, physically abusing Individual #1. The video shows the CEOs actively participating in the abuse or failing to take action to intervene or protect the individual from others' abuse. The video recording shows agency staff members stepping on Individual #1, pulling his/her hair, striking him/her in the head, and placing him/her in a choke hold. Instead of safeguarding the individual from abuse and ensuring the health and safety of Individual #1, they directly inflicted harm and created unsafe conditions, demonstrating a complete disregard for Individual #1's safety. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | The Chief executive officers should always protect all individuals that are in their care at all times and use the de-escalation techniques that are taught by the behavior specialist, if those techniques are not working, they will call 911 for assistance. The Chief executive officers will wait for the assistance of the police. |
09/03/2025
| Not Accepted |
| 6400.18(a)(4) | On or around May 15, 2025, Individual #1 was subjected to physical abuse perpetrated by staff members of Kels LLC , including Staff #1 and Staff #3, both identified as the agency's Chief Executive Officers. The incident of physical abuse was reported to the Department through the EIM system on August 27, 2025. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| All incidents will be entered by the CEO within 24hrs of the incident and all staff included in the allegations will be taken off the schedule. |
09/03/2025
| Not Accepted |
| 6400.18(f) | Individual #2 was subjected to the abuse of Individual #1 by proximity. Following the incident, staff members involved in the abuse continued to have access to Individual #1, Individual #2, and other individuals in Kels LLC's care. The provider failed to take immediate action to restrict the abusive staff or otherwise implement protective measures, placing all individuals at ongoing risk of further harm. | 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. | All implicated staff were removed from operational authority with no contact with the individuals and a protection staffing plan was activated to ensure there was no interruptions in care. Individual #2 was received medical and behavioral treatment following the incident |
09/03/2025
| Not Accepted |
| 6400.18(g) | Kels LLC failed to initiate an investigation within 24 hours of the abuse depicted above. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | The CEO will enter all incidents in the 24hr time frame and initiate an investigation if its required. |
09/03/2025
| Not Accepted |
| 6400.24 | Violations of 55 Pa Code 6400. 16, 32c, 32d, 18a4, 18f, 18g, also constitute violations of 55 Pa. Code Chapter 6100. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The CEO will ensure that the agency is operating in accordance with the Pa 6400and Pa 6100 regulations at all times. |
09/03/2025
| Not Accepted |
| 6400.32(c) | On or around May 15, 2025, Individual #1 was subjected to physical abuse perpetrated by staff members of Kels LLC, including Staff #1 and #3, both identified as the agency's Chief Executive Officers. A video recording of the incident depicts five adults surrounding Individual #1, who was lying on the sidewalk while holding onto Staff #2's sweatshirt hood string. The recording shows Staff #1, Staff #2, and Staff #3 engaging in acts of physical abuse against Individual #1. Specifically, they are observed stepping on Individual #1, pulling Individual #1's hair, striking Individual #1 in the head, and placing Individual #1 in a choke hold position to take Individual #1 to the ground. Furthermore, Individual #2 was subjected to the abuse of Individual #1 by proximity. The abuse captured in the video constitutes the intentional infliction of harm by multiple staff, including the agency's Chief Executive Officer. This conduct not only demonstrates a direct violation of the individual's right to be free from abuse but also reflects a systemic breakdown in the provider's responsibility to establish and enforce a culture of safety, accountability, and dignified treatment. The involvement of executive leadership further magnifies the severity of the violation, evidencing a pervasive disregard for regulatory requirements and fundamental protections owed to individuals in care. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | All staff will be retrained on the rights of the individual. |
09/03/2025
| Not Accepted |
| 6400.32(d) | On or around May 15, 2025, Individual #1 was subjected to physical abuse perpetrated by staff members of Kels LLC, including Staff #1 and #3, both identified as the agency's Chief Executive Officers. A video recording of the incident depicts five adults surrounding Individual #1, who was lying on the sidewalk while holding onto Staff #2's sweatshirt hood string. The recording shows Staff #1, Staff #2, and Staff #3 engaging in acts of physical abuse against Individual #1. Specifically, they are observed stepping on Individual #1, pulling Individual #1's hair, striking Individual #1 in the head, and placing Individual #1 in a choke hold position to take Individual #1 to the ground. Furthermore, Individual #2 was subjected to the abuse of Individual #1 by proximity. The abuse captured in the video constitutes the intentional infliction of harm by multiple staff, including the agency's Chief Executive Officer. This conduct not only demonstrates a direct violation of the individual's right to be free from abuse but also reflects a systemic breakdown in the provider's responsibility to establish and enforce a culture of safety, accountability, and dignified treatment. The involvement of executive leadership further magnifies the severity of the violation, evidencing a pervasive disregard for regulatory requirements and fundamental protections owed to individuals in care. | An individual shall be treated with dignity and respect. | All Staff will be retrained on the rights of the individuals to ensure that each individual is being treated with respect and dignity. |
09/03/2025
| Not Accepted |
| 6400.195(a) | Individual #1's record contained an outdated behavior support plan, dated 2/1/24, from a previous service provider and was the only plan in the file for staff to reference. Outdated support plans may contain inaccurate information which misinforms staff when supporting the individuals' behavioral health needs and could jeopardize the individual's safety. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The Program specialist will ensure that the behavior support plan is updated annually and when changes are made. Staff will be trained on the BSP by the behavior specialist at orientation and annually. |
09/03/2025
| Not Accepted |
| 6400.195(b) | Individual #1's behavior support plan has a restrictive component, which include MANDT Walking with and accompanying, avoidance redirection and releases and there was no documentation in the record of a human rights team, or a review by a human rights team. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | The Program specialist will work with the Behavior Specialist to ensure that all restrictive plans are reviewed by the Human rights team every 3-6 months, and all documentation will be readily available in the participants service book at the individual's home. |
09/03/2025
| Not Accepted |
| 6400.196(a) | Licensing was not provided with training for staff on individual #1's behavior support plan. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Program specialist will ensure that all staff with be trained at orientation and annually on the individuals behavior support plan and documentation of training will be kept in the individuals service book at the home. |
09/03/2025
| Not Accepted |
| 6400.208(a) | On or around May 15, 2025, Individual #1 was subjected to physical abuse by staff members of Kels LLC, including Staff #1 and Staff #3, both identified as the agency's Chief Executive Officers. A video recording shows Staff #1, Staff #2, and Staff #3 engaging in acts of physical aggression against Individual #1. Specifically, the video depicts Staff #3 placing Individual #1 in a choke hold position to force Individual #1 to the ground. The use of a choke hold, a prohibited restrictive procedure, creates an immediate risk of serious harm. | A physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others. | Staff will not Use any physical restraints on any individuals staff will use de-escalation techniques provided in the behavior support plan created by the behavior specialist. |
09/03/2025
| Not Accepted |