Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256641 Unannounced Monitoring 12/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 is prescribed medication, Clonidine. Doctor's orders regarding the administration of this medication are that prior to administering Clonidine, Individual #1's blood pressure it to be taken utilizing their blood pressure cuff. If the first number is less than 90 and the second number is less than 60, hold the dose of Clonidine. Clonidine is to be administered 3 times a day (8:00am, 2:00pm, and 8:00pm), therefore blood pressure should also be taken 3 times a day. In the month of November 2024, there were 13 occurrences where blood pressure was not recorded and there is no documentation of why it was not recorded. Examples of dates and times not recorded are: 11/11/24 at 2:00pm, 11/16/24 at 2:00pm, 11/17/24 at 8:00am, 11/27 -- 11/29/24 at 8:00pm, and more.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. The Medical Coordinator will be responsible for ensuring the immediate correction and ongoing monitoring of blood pressure prior to administering medications requiring the checking of blood pressure. To address this, staff will be trained on the correct procedure for taking blood pressure and documenting the results by 1/20/2025. A new blood pressure vital check was created and implemented. This form will be used by staff to record the blood pressure reading. This oversight highlights the need for clear and accessible documentation procedures to ensure that blood pressure is consistently monitored and recorded as required by the doctors orders. The absence of these documents led to non-compliance with the prescribed protocol for Clonidine administration. 01/20/2025 Implemented
6400.163(d)Upon entry into the home on 12/3/2024, Individual #1's medications were in an unlocked box sitting on the kitchen counter.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Upon entry into the home on 12/3/2024, it was observed that Individual #1s medications were stored in an unlocked box on the kitchen counter, which does not comply with proper medication storage procedures. The use of an unlocked box for storing Individual #1's medications may have resulted from either a momentary lapse in attention or a misunderstanding of the established protocol for medication storage. To immediately correct this issue, the medication was secured in a locked self-locking box and relocated to a locked office within the home. Staff were immediately educated on the importance of medications remaining locked at all times, and the procedure for medication storage was reinforced. 01/20/2025 Implemented
SIN-00241869 Unannounced Monitoring 03/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There was a golf ball size amount of lint in the lint trap at the time of the inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.Preventing hazards and maintaining the safety of the individuals and staff members is very important to the Management Team at QLS. One of the biggest challenges is getting staff members to identify and report hazards and maintain cleanliness to the extent that is required by regulation, which is the root cause of this violation. We employee a diverse group of employees that come from many different walks of life and what are acceptable conditions to one could be viewed as unacceptable by another. All dryers in the homes have been equipped with magnetic clips. The lint traps are to be clear of all lint and attached to the magnetic clip when the dryer is not in use. 05/10/2024 Implemented
SIN-00239311 Renewal 02/21/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was dried yellow substance on the floor in the upstairs bathroom which appeared to be urine.Clean and sanitary conditions shall be maintained in the home. 1. A plan to fix the immediate problem a. WHO: QLS Field Managers b. WHAT: Homes will be clean and sanitary c. WHEN and HOW: By April 5th QLS will have two field managers hired and scheduled to inspect each of the homes in their entirety at least once a week. 04/05/2024 Accepted
6400.82(f)During the 2/21/24 inspection, there was no soap in the bathroom upstairs. Staff stated the individual dumps the soap if in the bathroom, there was no hand soap in the house for the Individual to use. The toilet paper was no available for Individual #1 to use. The toilet paper is kept in a drawer out of reach if on the toilet.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. 1. A plan to fix the immediate problem a. WHO: QLS Field Managers and Staff b. WHAT: Homes will be clean and sanitary c. WHEN and HOW: By April 5th QLS will have two field managers hired and scheduled to inspect each of the homes in their entirety at least once a week. Checklists will be implemented for bathrooms. 04/05/2024 Accepted
SIN-00236938 Monitoring - Reported Incident 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the 01/03/24 inspection, there was an accumulation of lint in the lint trap of the clothes dryer in the mudroom that was the size of two softballs. The clothes dryer was not actively being used at the time of the inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.1. A plan to fix the immediate problem a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring that all floors, walls, ceilings and other surfaces are free of hazards. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.80(a)At the time of the 01/03/24 inspection, there was a baseball sized hole in the concrete deck where it attaches to the driveway that is large enough for an Individual's foot to become stuck in. Outside walkways shall be free from ice, snow, obstructions and other hazards. 1. A plan to fix the immediate problem. a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring that walkways are free of hazards. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.80(b)At the time of the 01/03/24 inspection, there were discarded cigarette butts in the front, side, and rear yard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.1. A plan to fix the immediate problem. a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.144At the time of inspection, Pro Re Nata (PRN) medications were not available in the home for Individual #1.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. 1. A plan to fix the immediate problem. a. WHO: QLS Management and Staff b. WHAT: QLS Management will ensure that all PRN medications are always available in the home to the individuals. QLS staff will audit and report PRN medication needs. c. WHEN and HOW: Effective 2/1/2024 all PRN medications will be audited by staff members in the homes weekly and reported back to the Medical Coordinator by Tuesdays at noon of any medications that are low, or close to expiration. 02/02/2024 Not Implemented
6400.214(a)At the time of the 01/03/24 inspection, the current Annual Assessment and ISP for Individual #1 was not at the home.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.1. A plan to fix the immediate problem. a. WHO: QLS Management b. WHAT: QLS Management will ensure that the staff have access to the most recent assessment, physical, ISP, Behavior Support Plan and any other pertinent information specific to the individual being served c. WHEN and HOW: QLS Program Specialist, Medical Coordinator and Behavior Specialist will ensure that all records are kept in digital and paper form in the homes for the staff by 2/1/2024. 02/05/2024 Implemented
6400.186At the time of the 01/03/24 inspection, there was no document in the home to track the calorie intake of Individual #1. Individual #1 most recent Individual Support Plan (ISP) states that Individual #1 is not to consume more than 1800 calories per day.The home shall implement the individual plan, including revisions.1. A plan to fix the immediate problem. a. WHO: QLS Management and Staff b. WHAT: QLS Program Specialist will ensure that all revisions to the individual plan are made available for staff immediately via the online database and update the individual binder within the home. QLS Program Specialists will monitor that all plans are being implemented. QLS Staff will review any revisions and sign off that they have read and understand them as well as begin implementing the changes. c. WHEN and HOW: QLS Medical Coordinator will ensure all homes have received training on any and all medically related restrictions, recommendations, practices for each individual. QLS Behavior Specialist will ensure that staff are trained on all behavioral support plans, restrictions, non-restrictive environmental adaptations. QLS Program Specialists will ensure that all staff are trained on the individual plans and are implementing them by conducting weekly audits of documentation in the homes. QLS management will be conducting weekly house inspections to ensure compliance with this regulation. 02/02/2024 Not Implemented
SIN-00195753 Renewal 11/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)A golf ball size of lint was left in the laundry dyer machine's lint trap. Floors, walls, ceilings and other surfaces shall be free of hazards.A plan to fix the immediate problem a. WHO: QLS management and staff b. WHAT: QLS management and QLS staff will be responsible in ensuring that all homes are free from hazards monthly c. WHEN and HOW: On 12/30/21 the attached memo was sent out to all QLS Inc., management and staff on the additional checklist that will be completed monthly. 01/07/2022 Implemented
6400.77(b)No antiseptic in first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A plan to fix the immediate problem a. WHO: QLS management will be responsible in ensuring that all homes have all items needed in their first aid kits monthly. b. WHAT: All first aid kits will include the following: antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. c. WHEN and HOW: On 12/30/21 the attached memo was sent out to all QLS Inc., management on the additional checklist that will be completed monthly. 01/07/2022 Implemented
6400.82(f)There was no toilet paper in the upstairs or downstairs bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. . A plan to fix the immediate problem a. WHO: QLS management b. WHAT: QLS management will be responsible in ensuring that all homes have all regulatory items needed in the bathroom monthly. c. WHEN and HOW On 12/30/21 a memo was distributed to QLS management, and the entire team will be trained on the role they play in this additional house check no later than 1/7/2022. 01/07/2022 Implemented
6400.32(m)Individual #1's mail was left out on the inside of front door. Center for Ankle and Foot; Department of Human Services, Cambria County Assistance Office (August 5th, 2021); Social Security Administration; and Magellan Health. This mail was unopened and never given to individual.An individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses.. A plan to fix the immediate problem a. WHO: QLS management b. WHAT: QLS management will be responsible for ensuring that all individuals that are temporarily relocated to a different home are receiving their mail if delivered to their temporarily vacant home. c. WHEN and HOW: On 1/4/2022 the attached memo was sent out to all QLS Inc., management regarding the additional checklist that will be completed monthly. 01/07/2022 Implemented
SIN-00117511 Renewal 08/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Large hole in wood paneling behind Individual #1's bedroom door.Floors, walls, ceilings and other surfaces shall be in good repair. Quality Life Services, Inc is committed to providing the individuals that they support with a setting that represents a home like environment. During the inspection, it was noticed that there was an impact between the individual¿s bedroom door and the wall behind the bedroom door causing a hole in the wall. This hole is in violation of regulation 6400.67(a) and was repaired on August 21, 2017. A photograph of the repaired wall is Attachment #5. This issue was reported by the staff member on duty when the need for repair was noticed, but the repair couldn¿t be addressed by the maintenance department immediately as they were working on a project of higher priority. Quality Life Services, Inc. has a Policy and Procedure for Maintenance Request Reporting and Job Completion which prioritizes how maintenance issues are addressed. The policy was followed by all persons involved and the unresolved issue was just a matter of timing. Please see Attachment #6 for current Policy and Procedure being utilized by the Corporation. Furthermore, effective November 6, 2017, Quality Life Services, Inc. will be employing a Field Manager in which her job duties will include unannounced inspections of each residential location multiple times a month. She will be provided a checklist of regulatory items that need to be checked during her announced inspection and this will be one of the items she will be ensuring compliance with. 11/06/2017 Implemented
6400.216(a)Individual #1's records were unlocked on kitchen counter. An individual's records shall be kept locked when unattended. As the individual¿s privacy and HIPPA compliance are very important to everyone that we provide supports to it is very important that all individual records are kept locked when unattended as specified in regulation 6400.216(a). Upon the licensers exiting meeting on August 18, 2018 the homes in which regulation was cited for was contacted by their Program Specialist and informed that the records needed to be locked up immediately. Attachment #4 is an agency wide memo that was sent out on August 21, 2017, reminding staff that all individual records and staff note books need to be kept in the designated locked area (cabinet or staff office, depending on the residential location) when bookwork isn¿t being completed and/or reviewed. On October 11, 2017, the Policy & Procedure for Storing Individual Records was updated to reflect the record storing procedures for the residential setting (Attachment #3). This updated policy will be reviewed with all corporate employees at one of the mandatory employee meetings being held on October 18th and 19th. All employees will sign the meeting Agenda acknowledging the information to be reviewed during the meeting session. Furthermore, effective November 6, 2017, Quality Life Services, Inc. will be employing a Field Manager in which her job duties will include unannounced inspections of each residential location multiple times a month. She will be provided a checklist of regulatory items that need to be checked during her announced inspection and this will be one of the items. 11/06/2017 Implemented
SIN-00063442 Renewal 04/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff #1 did not complete the medication administration course before passing medications. Staff #1 only completed 1 of the 2 observations needed. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Provider¿s program that is used to track annual training has been updated to reflect the need for 2 observations. All employee files have been corrected as they have received the correct number of observations since Citation was noted. Please refer to Attachment #1 and #2. 04/17/2014 Implemented
SIN-00267212 Unannounced Monitoring 06/05/2025 Compliant - Finalized
SIN-00264305 Unannounced Monitoring 04/10/2025 Compliant - Finalized
SIN-00218812 Renewal 02/06/2023 Compliant - Finalized
SIN-00161746 Renewal 10/23/2019 Compliant - Finalized
SIN-00076075 Renewal 03/17/2015 Compliant - Finalized
SIN-00046058 Renewal 04/09/2013 Compliant - Finalized