| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agencies expiration date of their certificate of compliance is 3/4/25. The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/4/24 to 1/4/25, and the self- assessment was completed 1/30/25. This exceeds the requirement. Per the Regulatory Compliance Guide (RCG) there is no grace period for this regulation. | 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.
| This reg. is important to measure the record of compliance with the chapter
When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 |
03/06/2025
| Implemented |
| 6400.64(e) | There was a white trash can located in the basement that was approximately 23 inches high, and did not have a lid on it at the time of the inspection. Agency staff did remove the trash can during the inspection. | Trash receptacles over 18 inches high shall have lids. | It is important to have a lid over trash can to prevent pest and other insects.
There was a trash bin in the basement over 18-inces that did not have lid at the time of the inspection. Staff emptied the trash that morning and replaced the trash bag but forgot to put the lid over the can. Instead, they have it placed behind the stairs wall. |
03/06/2025
| Implemented |
| 6400.67(a) | One of the blinds located on the kitchen door was cracked in two places on the end of the blind. The bathroom door had paint peeling/chipping off the back of it, and an area that was missing paint on it that was approximately 2 ½ inches wide and 1 inch long. | Floors, walls, ceilings and other surfaces shall be in good repair. | The home is to be in good repair, as the safety and wellbeing of the individual is important. At the time of the inspection, the bathroom door had a spot of paint peeling at the back of the door. Maintenance missed the spot. |
03/11/2025
| Implemented |
| 6400.143(a) | On2/14/25, Individual #1 had a podiatry appointment and it noted on the form "Individual #1 refused to go to the appointment he said he did not have to leave the house." There was no documentation that the staff trained Individual #1 on the importance of routine medial care. The agency does have a section on their medical form that does state "if the individual chose not to attend the appointment. Staff needs to encourage individual about the importance of the appointment. Did staff encourage individual to attend Yes____ N0__this section was left blank on the form. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Medical appointments are essential to the health and well-being for the individual we support. On 2/14/25, the individual has an appointment that he refused. However, staff are supposed to encourage and educate the individual on the importance of medical appointments. They did not educate the individual. The individual may sometimes refuse an appointment; however, staff usually encourage him and in more cases he will go. Staff did not document his case note to indicate their effort. |
03/14/2025
| Implemented |
| 6400.144 | Individual #1 had an appointment on 1/26/24 at Eastern Pennsylvania Gastroentoology and Liver specialist and it noted a next appointment in 6 months no appointment. There is no record of this appointment occurring. When the Licensing Representative (LR) inquired about the appointment for Individual #1 the agency reported he was not able to be seen within the 6 months period, and It was rescheduled for May 8,2025 due to not having availability. There was no record or documentation as to why Individual #1 was unable to be seen for their appointment in the recommended 6 month timeframe. | 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.
| It is important to follow all recommendations of a physician.
The individual Gastro recommended him for a follow-up appointment in 6 months but was not seen. He was not able to be seen within the 6-month period. Due to the lapse in the doctor¿s schedule. |
03/05/2025
| Implemented |
| 6400.181(a) | 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. Individual #1 had an annual assessment completed on 1/5/24 and their next one wasn't completed until 2/12/25. This exceeds the requirement. | 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. | Initial assessment is important for the individual¿s team to understand and know how to support the individual. During the inspection, the initial assessment was not done within the required time. The program specialist did the initial assessment within the 60 days period and then annually; however, the SC did not schedule the ISP in the 90 days¿ time frame. Therefore, the PS changed the date to reflect the ISP review date. |
03/12/2025
| Implemented |
| 6400.165(c) | A prescription medication shall be administered as prescribed. Individual #1 is prescribed Pulmicort 90 MCG Flexhale, Inhale 1 puff my mouth 2x/day at 8am-8pm. The pharmacy label on the medication had a 12/9/24 fill date and the box states 60 meter dosage. The medication container in the box remained approximately ¼ of the way full of the medication. There was another box of the Pulmicort 90 MCG Flexhale in with Individual #1's medication, and the pharmacy label on this medication had a 2/7/25 fill date. The medication container in the box remained approximately full. The medication is documented as being administered as prescribed on the Medication Administration Record. | A prescription medication shall be administered as prescribed. | This regulation is important for individual health and safe. At the time of inspection, it was discovered that the individual Pulmicprt 90 MCG Flexhale was not administered as directed. The medication was not administered correctly by staff, the puff was not fully inhaled. All staff were retained on how to administer the medication on 3/13/25 and documentation is sent. |
03/13/2025
| Implemented |
| 6400.181(f) | 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 #1's Individual Support Plan (ISP) meeting was held on 2/19/25 and Individual #1's assessment was sent to the team on 2/18/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Providing Assessment within 30 days is important for the individual¿s team to understand and know if there have been any changes to the individual well-being and growth. During the inspection, the assessment was not sent to the SC within the required time before the individual ISP update. The program specialist sent the assessment late due to the inconsistency of the individual ISP updates every year. Different SC are on board every year and changing the date of the Review. |
03/13/2025
| Implemented |