Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251959 Renewal 09/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance expires on 12/28/24. The home completed the self-assessment on 06/06/24. The self-assessment was not completed 3 to 6 months prior to the expiration of the certificate of compliance.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Abound Health will utilize the correct Licensing approved Licensing Inspection Instrument (LII) and completed the LII for all Residential Sites by October 31, 2024. 10/31/2024 Implemented
6400.15(b)The agency completed the Department's self-assessment (last modified in June of 2018), which does not contain all Chapter 6400 regulations promulgated on October 5, 2019.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Abound Health will utilize the correct Licensing approved Licensing Inspection Instrument containing all Chapter 6400 regulations promulgated on October 2, 2019, and will complete the LII for all Residential Sites by October 31, 2024. 10/31/2024 Implemented
6400.46(c)Program Specialist #2, date of hire 08/19/24, was not trained in first aid techniques before working with individuals.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.Program Specialist #2 was trained on CPR/First Aid on 9/30/2024. 10/04/2024 Implemented
6400.51(b)(1)Chief Executive Officer #1, date of hire 05/19/24, did not complete "The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships" during the agency's orientation training.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Executive Director will complete the application of Person-Centered Practices, Community Integration, Individual Choice, and supporting individuals to develop and maintain relationships by 10/31/2024. 10/31/2024 Implemented
6400.51(b)(4)Chief Executive Officer #1, date of hire 05/19/24, did not complete "Recognizing and reporting incidents" during the agency's orientation training.The orientation must encompass the following areas: recognizing and reporting incidents.Executive Director will complete Recognizing and Reporting Incidents by 10/31/2024. 10/31/2024 Implemented
6400.52(c)(1)Program Specialist #3, date of hire 01/27/21, did not complete did not complete "The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program Specialist #3 will complete the application of Person-Centered Practices, Community Integration, Individual Choice, and supporting individuals to develop and maintain relationships by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(2)Program Specialist #3, date of hire 01/27/21, did not complete "The prevention, detection and reporting of abuse, suspected abuse, and alleged abuse" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.: Program Specialist #3 will complete the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(3)Program Specialist #3, date of hire 01/27/21, did not complete "Individual rights" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Program Specialist #3 will complete Individual Rights 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(4)Program Specialist #3, date of hire 01/27/21, did not complete "Recognizing and reporting incidents" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Program Specialist #3 will complete Recognizing and Reporting Incidents by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
SIN-00232587 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1, date of hire 1/13/23, had a physical examination completed 1/16/23. Direct Service Worker #2 had physical examinations completed 8/4/21 and then again 9/20/23. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Direct Service Worker #1 did have a physical exam on 1/13/23, the doctor did not sign the physical until 1/16/23 when Training coordinator asked for it to sent over via fax. Training Coordinator will utilize a new system called on target to keep certification dates up to date. This will assist with knowing when all staff physicals and Mantoux dates are up for renewal. A letter will be sent to the staff 6 months and 3 months prior to date. The system will be able to send a direct message through on target to the staff with this information. The system is still being impemanted and certifications are being entered by Training Coordinator. 10/30/2023 Implemented
6400.151(c)(2)Direct Service Worker #2 had Tuberculin skin testing by Mantoux method completed 8/2/21 and then again 9/22/23. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Training Coordinator will utilize a new system called on target to keep certification dates up to date. This will assist with knowing when all staff physicals and Mantoux dates are up for renewal. A letter will be sent to the staff 6 months and 3 months prior to date. The system will be able to send a direct message through on target to the staff with this information. The system is still being impemanted and certifications are being entered by Training Coordinator. 11/30/2023 Implemented
6400.46(d)Documentation regarding Direct Service Worker #2 training in first aid, Heimlich techniques and cardio-pulmonary resuscitation was not provided. Therefore, compliance could not be measured.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.The On target system will have all information related to staff certifications entered into it including CPR/First Aid/Heimlich information for each staff. It will send a reminder for the renewal date 6 months then 3 months prior to renewal date. Staff will not be able to be scheduled or work directly with a client if this certification is not completed by the renewal date and the staff will be suspended until it is completed. DSW #2 did receive CPR Training on 9-29-23. 11/30/2023 Implemented
SIN-00213175 Renewal 10/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination compelted on 6-2-21, and then again on 6-27-22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Program specialist will create a spreadsheet with all scheduled current physical dates, as well as renewal due dates to ensure a timely exam and for 2022-2023 to meet compliance. Program Specialist will call 6 months prior to annual date to schedule renewal physical date to ensure it is compliant. Once scheduled Program Specialist place the renewal date on the company calendar. 12/26/2022 Implemented
6400.141(c)(6)Individual #1 had a Tuberculin skin test completed on 2-14-20, and then again on 6-29-22.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. Mantoux date and renewal date will be listed on a spreadsheet created by Program Specialist along with all current physical dates with renewal dates to ensure compliance. Once scheduled Program Specialist place the renewal date on the company calendar. 12/26/2022 Implemented
6400.32(r)The agency has not provided Individual #1 the right to lock Individual #1's bedroom door. The agency has not provided Individual #2 the right to lock Individual #2's bedroom door.An individual has the right to lock the individual's bedroom door.Individual #1 signed a declination form on 10/14/2022 declining a locking mechanism on their bedroom door. Individual #2's Legal guardian signed a declination form on 10/14/2022 declining a locking mechanism on their bedroom door. 10/14/2022 Implemented
6400.181(f)The program specialist provided Individual #1's annual assessment, completed on 3-17-22 to the plan team members on 3-17-22 for an annual individual plan meeting on 3-10-22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Individual's Assessment Date needs to be pushed back to ensure Assessment is sent to Program Specialist 30 days prior to ISP Date. Individuals new assessment date will be 1/31/2023 to ensure that the Assessment is sent by 2/10/2023 to the Program Specialist which is 30 days prior to his ISP meeting date of 3/10/2023. Spreadsheet of Individuals assessment dates will be updated to meet these requirements. 10/28/2022 Implemented
SIN-00196455 Renewal 11/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(b)Direct Service Worker #2, date of hire 10/29/13, completed annual fire safety training on 06/24/21 but did not have fire safety training in 2020.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program Specialist will check Fire Safety qualifications of all DSP's working in the home and place the due date on the calendar to alert the Program Specialist that it is due. A reminder will be sent to the DSP at least a week in advance so they are aware that it is due and will not be missed. 12/03/2021 Implemented
6400.52(c)(2)CEO #1's Annual Training did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse for the annual training year dated 7/1/2020 through 6/30/2021.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.CEO did complete the necessary training, it was done past the 6/30/21 deadline. Training qualifications are checked quarterly by the Office Manager and reminders are sent out to remind staff what training needs completed. 12/03/2021 Implemented
6400.52(c)(3)CEO #1's Annual Training did not encompass Individual Rights for the annual training year dated 7/1/2020 through 6/30/2021.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.CEO did complete the necessary training; it was done past the 6/30/21 deadline. Training qualifications are checked quarterly by the Office Manager and reminders are sent out to remind staff what training needs completed. 12/03/2021 Implemented
SIN-00180975 Renewal 12/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1, date of hire 7/28/20, had initial physical examination completed on 12/09/20. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. As soon as PHS noticed that DSP #1 did not have a Physical, one was immediately scheduled and completed on 12/9/2020 at 8:45a by Corporate Health who PHS uses to complete DSP's Physical's and Mantoux's. Residential Director is responsible for reviewing and ensuring Physical qualifications are met and kept up to date. A spread sheet is utilized for this process along with calendar reminders. [Prior to hire and at least quarterly for 1 year, the CEO or designee shall audit new staff persons' physical examinations and aforementioned tracking system to ensure all staff person have physical examinations completed, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 12/30/20)] 12/09/2020 Implemented