| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 11:06AM on 1/23/2025, the hot water temperature measured 125.2°F at the sink in the bathroom in the basement of the home. At 11:10AM on 1/23/2025, the hot water temperature measured 123.2°F at the sink in the ensuite bathroom in Individual #1's bedroom. At 11:46AM on 1/23/2025, the hot water temperature measured 131.5°F at the sink in the bathroom on the first floor of the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Our Maintenance person, sub-contractor, installed water heater regulators to all the sinks and shower areas that were in violation of exceeding 120 degrees Fahrenheit to heat temperatures between 108 to 115 degrees. A Paid Invoice with the completed installation of heat regulators to all the homes was issued on 21 February 2025. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to each home quarterly throughout the year to ensure that the water heat regulators are working properly with compliant code 6400.63(a). The training/consolation form was signed and dated by the contractor on 21 February 2025. In addition, the Site Operations Managers were given a training/counseling session by the CFO in the steps of overseeing their Direct Support Staff of daily checking the water temperatures. The counseling/training form was signed and dated 24 February 2025. The steps consist of DSS performing daily temperature checks throughout the house. If the water temperature is over 120 degrees, the staff are trained to check the water heater to see if it¿s on the lowest level, report it to their supervisor. Still not in compliance, the supervisor will contact the sub-contractor for assistance to ensure that we become compliant, immediately. |
02/21/2025
| Implemented |
| 6400.65 | At 11:13AM on 1/23/2025, the mechanical ventilation fan in the ceiling of the bathroom was coated in a thick layer of dust. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Our Maintenance person, sub-contractor, cleaned the ceiling mechanical ventilation fan from dust debris in the bathroom on 1 February 2025. (please SEE picture) In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 along with a signed agreement for the duties of going to the Andrea home quarterly throughout the year to ensure that the ceiling mechanical ventilation fan will be free from dust debris in the bathroom. An Invoice was issued by the contractor on 21 February 2025 that showed the work was completed and to ensure that the ceiling mechanical ventilation fan is free of dust and working properly with compliant code 6400.65. |
02/21/2025
| Implemented |
| 6400.80(a) | At 10:06AM on 1/23/2025, part of the deck and exterior stairs the back exit of the home were covered in several inches of snow and ice. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The walkway was cleared on 24 January 2025 by a Direct Support Staff. The Site Operation Managers were given a counseling session to make sure that the duties would be performed by the DSS to clear the snow away the walkways. The signed agreement was signed on 24 February 2025 by all Site Operations Managers. For Major snowstorms over three inches, there was a counseling session given to our land-care sub-contractor. to clear the driveways for all of the Homes. The agreement was signed on 24 February 2025. |
02/24/2025
| Implemented |
| 6400.104 | The provider agency sent a letter to the local fire department on 10/30/2020, advising that there are two individuals that need assistance with evacuating in the event of a fire. The letter did not include the exact locations of the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The provider agency sent a letter to the local fire department on October 30, 2020 advising that there are two individuals that need assistance with evacuating in the event of a fire. This letter did not include the exact location of the individual's bedroom and was changed on February 4, 2025 to reflect the location of the individual's bedrooms Per 55 Code Chapter 6400.104. Site Operations Manager has revised all other homes letters to the local fire department to reflect the individual¿s room locations. This letter has been sent to the fire department in the areas that the homes are located. |
02/25/2025
| Implemented |
| 6400.112(c) | The written fire drill record for the fire drill conducted on 7/10/2024, does not include the time of the fire drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The written fire drill record for the fire drill conducted on 7/10/2024 has been corrected and the time has been added to the fire drill record on 2/5/2025 and all other fire drills for the home have been reviewed to make sure it was completed in its entirety Per 55 Code Chapter 6400.122(c). |
02/25/2025
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination on 11/25/2022 and then again on 1/23/2024. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 had a physical examination on November 25, 2022, and then again on January 23, 2024 the site operations manager, received a letter from the doctor stating that the appointment had to be changed due to the physician, not being in the office for that day. The site operations manager had placed documentation in individual #1¿s file to reflect the physician canceling the appointment and scheduled the next available time so that individual one could have an annual physical per 55 code chapter 6400.141 (a). |
02/25/2025
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination on 7/24/2023 and then again on 12/10/2024. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual # 1 had a dental exam on 7/24/2023 and then again on 12/10/2024. Site Operations Manager has scheduled Individual #1¿s next appointment so that Individual #1 is complaint with all dental appointments and receiving the right care Per 55 Code Chapter 6400.142(a) |
02/25/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 2/4/2024, does not include the preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #1¿s current assessment, completed on 2/4/2024 did not include the preference of the Individuals . Individual #1¿s current Skill Assessment was changed by the Program Specialist 2/4/2025 to reflect Individual #1¿s disability, including functional and non-medical limitations per 55 PA Code Chapter 6400.181(e)(1). |
02/25/2025
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment, completed 2/4/2024, does not include documentation of the individual's disability including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #1¿s current assessment, completed on 2/4/2024 did not include the preference of the Individuals . Individual #1¿s current Skill Assessment was changed by the Program Specialist 2/4/2025 to reflect Individual #1¿s disability, including functional and non-medical limitations per 55 PA Code Chapter 6400.181(e)(1). |
02/25/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 2/4/2024, does not include lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual #1¿s current assessment, completed on 2/4/2024 did not include Individual #1¿s Lifetime Medical History. Individual #1¿s current Skill Assessment was changed by the Program Specialist 2/4/2025 to reflect Individual #1¿s Lifetime Medica; History per 55 PA Code Chapter 6400.181(e)(10). |
02/25/2025
| Implemented |
| 6400.163(a) | At 11:07AM on 1/23/2025, Individual #1's prescribed medication, Clindamycin Phosphate Topical Lotion, was on the windowsill in the ensuite bathroom in Individual #1's bedroom. The original labeled box was not present in the home. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | On 1/23/2025 during Inspection the Site Operations Manager removed prescribed medications Clindamycin gel 1% phosphate topical lotion, that was left in the ensuite bathroom in individual #1¿s bedroom. All other prescribed topical creams and prescribed face washes were removed from the room Per 55 Code Chapter 6400.163 (a). |
02/25/2025
| Implemented |
| 6400.163(d) | At 11:07AM on 1/23/2025, Individual #1's prescribed medication, Clindamycin Phosphate Topical Lotion, was on the windowsill in the ensuite bathroom in Individual #1's bedroom. At 11:11AM on 1/23/2025, Individual #1's prescribed medication, Clindamycin Gel 1%, was on a dresser in Individual #1's bedroom. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 1/23/2025 during Inspection the Site Operations Manager removed prescribed medications Clindamycin phosphate topical lotion, that was left in the ensuite bathroom in individual #1¿s bedroom and also on the dresser of Individual #1¿s bedroom. All other prescribed topical creams and prescribed face washes were removed from the room Per 55 Code Chapter 6400.163 (d). |
02/25/2025
| Implemented |
| 6400.163(g) | At 11:24AM on 1/23/2025, a tablet of Individual #1's prescribed medication, Topamax, was on the bottom of the 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. | On 1/23/2025 during Inspection a tablet of Individual #1¿s prescribed medication Topamax was on the bottom of the medication box. The Site Operations Manager disposed of the medication immediately due to it not being stored in an organized manner under he proper conditions of sanitation, temperature, moisture, and light and in accordance with the manufacturer¿s instructions Per 55 Code Chapter 6400.163 (g). The Site Operations Manager checked all medications at each home to ensure that all medication was stored correctly. |
02/25/2025
| Implemented |
| 6400.163(h) | At 11:07AM on 1/23/2025, Individual #1's prescribed medication, Clindamycin Phosphate Topical Lotion, was on the window sill in the ensuite bathroom in Individual #1's bedroom. This medication expired in 01/2022. At 11:11AM on 1/23/2025, Individual #1's prescribed medication, Clindamycin Gel 1%, was on a dresser in Individual #1's bedroom. This medication expired in 4/2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 1/23/2025 during Inspection the Site Operations Manager removed prescribed medications Clindamycin phosphate topical lotion, that was left in the ensuite bathroom in individual #1¿s bedroom and Clindamycin Gel1% was in the dresser, medication expired 4/2024. All other prescribed topical creams and prescribed face washes were removed from the room by the Site Operations Manager Per 55 Code Chapter 6400.163 (h). |
02/25/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 2/4/2024, states that Individual #1 needs gestural cues to safely use poisons. Individual #1's Service Plan reads, "[Individual #1] knows how to handle poisonous substances and sharp objects. No supervision is needed in this area. [Individual #1] is not at risk of ingesting poisonous materials." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1¿s assessment completed on 2/4/2024, states that Individual #1 needs gestural cues to safely use poisons. Individual #1¿s SP reads knows how to handle poisonous substances and sharp objects. No supervision is needed in this area. 55 PA Code Chapter 6400.182(c). Program Specialist has updated Skill Assessment information on the new form to reflect Individuals ability to handle poisonous substances and sharp objects. No supervision is needed in this area. |
02/25/2025
| Implemented |