| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.11 | As of 2/27/2025, the agency did not have a room and board contract for Individual #1, date of admission 3/30/2020. | The requirements specified in Chapter 20 (relating to licensure or approval of
facilities and agencies) shall be met. | Individual Rights ¿ 55 PA Code Chapter 6400.11
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission along with room and board contract and annually thereafter. Staff will receive training on residents' rights by April 15, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
| 6400.21(a) | Direct Service Worker #1, date of hire 12/2/2024, had a Pennsylvania criminal history record check on 2/25/25. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Criminal Background Checks ¿ 55 PA Code Chapter 6400.21(a)
All new employees will undergo a Pennsylvania criminal history record check within five days of hire. A tracking system will be implemented to monitor compliance, and HR staff will receive refresher training on background check policies by April 10, 2025.
Corrective Actions:
¿ HR is sending off all potential new hire criminal records check to PA and waiting until a clear criminal background check is done before they are scheduled for orientation.
¿ HR created a tracking document to track all new hire documentation, training and certifications.
¿ HR and Training is auditing all new hire folds to ensure compliance. |
05/30/2025
| Not Implemented |
| 6400.63(a) | On 2/26/25 at 1:28PM, the hot water temperature at the kitchen sink measured 134 degrees Fahrenheit. [Repeated violation -- 10/7/24 and 1/23/25] | 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. | Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
Daily water temperature checks in bathrooms and kitchen
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.64(a) | On 2/26/25 at 1:59PM, Individual #1's bedroom contained a broken dresser. In the bottom dresser obstructing the drawer from being opened, there was a tall kitchen bag containing discarded items including five 52-ounce orange juice containers filled with a dark brown liquid, with dark thick particles floating inside. These containers exuded an extremely fetid odor. | Clean and sanitary conditions shall be maintained in the home. | Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.67(a) | On 2/26/25 at 2:08PM, the center flooring, in the sitting room of the home, was chipped with circular marks and impressions encompassing a triangular-shaped area that measured six inches by six inches by six inches. [Repeated Violation -- 10/7/24] | Floors, walls, ceilings and other surfaces shall be in good repair. | Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.67(b) | On 2/26/25 at 2:02PM, the drain near the laundry area in the basement of the home did not have a cover posing a tripping hazard. At 2:03PM, an enclosed toilet in the basement had three broken pieces of drop ceiling tile that were coated in a black substance that appeared to be mold and/or mild. [Repeated Violation -- 10/7/24] | Floors, walls, ceilings and other surfaces shall be free of hazards. | Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.70 | On 2/26/25 at 1:23PM, the only telephone in the home did not have an outside line. [Repeated Violation -- 10/7/24] | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.72(b) | On 2/26/25 at 2:00PM, the screen in the window above Individual #1's bedroom had a tear on the left side measuring approximately four inches by two and a half inches and a tear on the right side measuring approximately four inches and one inch. [Repeated Violation -- 7/23/24 et al, 10/7/24, and 11/21/24] | Screens, windows and doors shall be in good repair. | Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.76(a) | On 2/26/25 at 1:58PM, the dresser in Individual #1's bedroom had three drawers that were askew, missing the bottom section and unable to be fully closed. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Environmental Safety & Sanitation ¿ 55 PA Code Chapters 6400.63(a), 6400.64(a), 6400.67(a), 6400.67(b), 6400.70, 6400.72(b), 6400.76(a)
Corrective Actions:
¿ Air quality and carbon monoxide detectors is being inspected, and non-functioning units will be discarded replaced by March 30, 2025.
¿ Sanitation protocols is being reinforced with weekly cleaning schedules and monthly inspections to maintain a safe environment.
¿ Repairs to damaged walls, flooring, and furniture will be completed by April 15, 2025, and maintenance staff will perform monthly inspections.
¿ Telephone accessibility will be ensured by installing a functioning phone in a common area by March 25, 2025.
¿ Windows and doors are being inspected, and necessary repairs will be completed by April 21, 2025. |
05/30/2025
| Not Implemented |
| 6400.77(b) | On 2/26/25 at 1:25PM, the first aid kit did not contain medical tape. [Repeated Violation -- 10/7/24] | 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. | Emergency Preparedness ¿ 55 PA Code Chapters 6400.77(b), 6400.114(b)
All individuals will receive fire safety training upon admission and annually thereafter. This training will include evacuation procedures, designated meeting places, and smoking safety protocols. Training records will be maintained for compliance verification. All staff will follow there pocedures during the monthly fire drills.
Corrective Actions:
¿ Staff was trained on Fire Safety March 7, 2025.
¿ First aid kits will be audited and restocked monthly by Leads, with missing items replaced by April 15, 2025.
¿ The emergency evacuation plan will be reviewed and updated, ensuring compliance with fire safety standards. Staff will undergo fire safety training by April 15, 2025
¿
¿ All new staff will be trained on Fire Safety.
¿ All Fire Safety training documentation is being viewed and updated daily to ensure all staff is compliant. |
05/30/2025
| Implemented |
| 6400.114(b) | On 2/26/25 at 1:33PM, in the vacant room of the second floor of the home there was a plastic container in one of the dresser drawers filled with ashes and 8 partially smoked rolled cigars. The homes smoking policy reads, "it is the policy of On-Site Companionship Services, Inc that smoking inside a facility is strictly prohibited. Staff or visitors are to properly dispose of all cigarette butts in a receptacle with a lid.". At 1:57PM, a strong smell of a skunky tobacco smoke was exuded upon opening the door to Individual #1's bedroom. At 1:58PM, a metal tobacco grinder that said elevated life on top, a container of Verano THC infused troches which contain a medication label with prescribed name ripped off, and a 3.5g bag of Justice League Cannabis Flower was found on Individual #1's dresser. [Repeated Violation -- 7/23/24 et al, and 10/7/24] | Written smoking safety procedures shall be followed. | Emergency Preparedness ¿ 55 PA Code Chapters 6400.77(b), 6400.114(b)
All individuals will receive fire safety training upon admission and annually thereafter. This training will include evacuation procedures, designated meeting places, and smoking safety protocols. Training records will be maintained for compliance verification. All staff will follow there pocedures during the monthly fire drills.
Corrective Actions:
¿ Staff was trained on Fire Safety March 7, 2025.
¿ First aid kits will be audited and restocked monthly by Leads, with missing items replaced by April 15, 2025.
¿ The emergency evacuation plan will be reviewed and updated, ensuring compliance with fire safety standards. Staff will undergo fire safety training by April 15, 2025
¿
¿ All new staff will be trained on Fire Safety.
¿ All Fire Safety training documentation is being viewed and updated daily to ensure all staff is compliant. |
05/30/2025
| Not Implemented |
| 6400.141(c)(10) | Individual #1's physical examination dated 7/17/2024 did not address communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Medical Compliance ¿ 55 PA Code Chapters 6400.141(c)(10), 6400.141(c)(14), 6400.151(a), 6400.151(c)(2)
A tracking system will be implemented to ensure that all staff receive physical examinations before employment and every two years thereafter. The HR department will develop and update the tracking document. HR will conduct monthly audits to ensure compliance.
Corrective Actions:
¿ All annual physicals for residents and staff will be scheduled and tracked using an electronic system tracked by Program Specialist and overseen by HR to ensure completion and compliance.
¿ Hearing and vision screenings for residents will be conducted and documented.
¿ TB testing for employees will be completed before employment and every two years thereafter, with a compliance audit scheduled for April 21, 2025..
¿ Program Specialist and HR created tracking document to track and alert upcoming expired physical examinations within 6 months and 3 months of expiration.
¿ Program Specialist and HR are reviewing all staff and clients to ensure physical examinations are in compliance. |
05/30/2025
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 7/17/2024 did not address medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical Compliance ¿ 55 PA Code Chapters 6400.141(c)(10), 6400.141(c)(14), 6400.151(a), 6400.151(c)(2)
A tracking system will be implemented to ensure that all staff receive physical examinations before employment and every two years thereafter. The HR department will develop and update the tracking document. HR will conduct monthly audits to ensure compliance.
Corrective Actions:
¿ All annual physicals for residents and staff will be scheduled and tracked using an electronic system tracked by Program Specialist and overseen by HR to ensure completion and compliance.
¿ Hearing and vision screenings for residents will be conducted and documented.
¿ TB testing for employees will be completed before employment and every two years thereafter, with a compliance audit scheduled for April 21, 2025..
¿ Program Specialist and HR created tracking document to track and alert upcoming expired physical examinations within 6 months and 3 months of expiration.
¿ Program Specialist and HR are reviewing all staff and clients to ensure physical examinations are in compliance. |
05/30/2025
| Not Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire of 12/2/2024, had physical examination completed on 12/10/24. | 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. | Medical Compliance ¿ 55 PA Code Chapters 6400.141(c)(10), 6400.141(c)(14), 6400.151(a), 6400.151(c)(2)
A tracking system will be implemented to ensure that all staff receive physical examinations before employment and every two years thereafter. The HR department will develop and update the tracking document. HR will conduct monthly audits to ensure compliance.
Corrective Actions:
¿ All annual physicals for residents and staff will be scheduled and tracked using an electronic system tracked by Program Specialist and overseen by HR to ensure completion and compliance.
¿ Hearing and vision screenings for residents will be conducted and documented.
¿ TB testing for employees will be completed before employment and every two years thereafter, with a compliance audit scheduled for April 21, 2025..
¿ Program Specialist and HR created tracking document to track and alert upcoming expired physical examinations within 6 months and 3 months of expiration.
¿ Program Specialist and HR are reviewing all staff and clients to ensure physical examinations are in compliance. |
05/30/2025
| Not Implemented |
| 6400.151(c)(2) | Direct Service Worker #1, date of hire 12/2/2024, had a tuberculin skin testing on 12/12/24. | 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. | Medical Compliance ¿ 55 PA Code Chapters 6400.141(c)(10), 6400.141(c)(14), 6400.151(a), 6400.151(c)(2)
A tracking system will be implemented to ensure that all staff receive physical examinations before employment and every two years thereafter. The HR department will develop and update the tracking document. HR will conduct monthly audits to ensure compliance.
Corrective Actions:
¿ All annual physicals for residents and staff will be scheduled and tracked using an electronic system tracked by Program Specialist and overseen by HR to ensure completion and compliance.
¿ Hearing and vision screenings for residents will be conducted and documented.
¿ TB testing for employees will be completed before employment and every two years thereafter, with a compliance audit scheduled for April 21, 2025..
¿ Program Specialist and HR created tracking document to track and alert upcoming expired physical examinations within 6 months and 3 months of expiration.
¿ Program Specialist and HR are reviewing all staff and clients to ensure physical examinations are in compliance. |
05/30/2025
| Implemented |
| 6400.181(d) | Individual #1's assessement, completed 5/15/2024 was not signed by Program Specialist #2. | The program specialist shall sign and date the assessment. | Resident Assessments & Plans ¿ 55 PA Code Chapters 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.182(c), 6400.183(c)
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.181(e)(10) | Individual #1's most recent assessment dated 5/15/24 did not include a lifetime medical history. This section indicated the lifetime medical history was attached; however, it was not attached. [Repeated violation: 7/23/2024 et al] | The assessment must include the following information: A lifetime medical history. | Resident Assessments & Plans ¿ 55 PA Code Chapters 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.182(c), 6400.183(c)
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.181(e)(11) | Individual #1's assessment 5/15/24 did not include a copy of the individual's psychological evaluation. This section indicated the Psychological Evaluation was attached; however, it was not attached. [Repeated violation: 7/23/2024 et al] | The assessment must include the following information: Psychological evaluations, if applicable. | Resident Assessments & Plans ¿ 55 PA Code Chapters 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.182(c), 6400.183(c)
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.216(a) | On 2/26/25 at 1:24PM, a stack of medical records for Individual #1 to include psychiatric medication reviews from 3/1/22 and 10/4/22 were unlocked and accessible atop the kitchen counter. The individual and staff were not at home. [Repeated Violation -- 10/7/24] | An individual's records shall be kept locked when unattended.
| Confidentiality & Record-Keeping ¿ 55 PA Code Chapter 6400.216(a)
All confidential records will be securely stored in a locked file cabinet with restricted access to authorized personnel only. An audit of current records will be conducted, and staff will be retrained on confidentiality policies by April 15, 2025.
Corrective Actions:
¿ All client confidential files are locked in the HR office and House Office.
¿ We ordered locked file cabinets to house all client folders with strict access to all confidential documents.
¿ HR and Program Specialist can access the files to update and correct.
¿ HR and Program Specialist will audit files weekly to ensure compliance. |
05/30/2025
| Not Implemented |
| 6400.46(c) | Direct Service Worker #1, date of hire of 12/2/2024 did not complete initial first aid training until 2/25/25. | 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. | Training & Documentation ¿ 55 PA Code Chapters 6400.46(c), 6400.50(a)
Corrective Actions:
¿ Staff is undergoing mandatory first aid and CPR training before working with residents.
¿ All training sessions, certificates, and attendance records is being documented and stored in personnel files for auditing.
¿ A training coordinator is ensuring ongoing compliance with state-mandated training requirements are being practiced, updated and documented.
¿ HR and Program Specialist developed a training and documentation tracking system that tracks and documents all current and outstanding trainings. |
05/30/2025
| Not Implemented |
| 6400.50(a) | Direct Service Worker #1 with a date of hire of 12/2/2024 fire safety training record did not include the training source and content. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Training & Documentation ¿ 55 PA Code Chapters 6400.46(c), 6400.50(a)
Corrective Actions:
¿ Staff is undergoing mandatory first aid and CPR training before working with residents.
¿ All training sessions, certificates, and attendance records is being documented and stored in personnel files for auditing.
¿ A training coordinator is ensuring ongoing compliance with state-mandated training requirements are being practiced, updated and documented.
¿ HR and Program Specialist developed a training and documentation tracking system that tracks and documents all current and outstanding trainings. |
05/30/2025
| Not Implemented |
| 6400.163(d) | On 2/26/25 at 1:47PM, 22 blister packs of medication prescribed for Individual #1 were unlocked and accessible in an unlock "tackle" box in a closet which did not have a door in the hallway on the second floor of the home. [Repeated Violation -- 7/23/24 et al, and 10/7/24] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Medication Management ¿ 55 PA Code Chapters 6400.163(d), 6400.165(g)
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Monthly medication audits is being conducted to ensure proper documentation of medication administration.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file. |
05/30/2025
| Not Implemented |
| 6400.165(g) | As of 2/27/2025, the most recent psychiatric medication review for individual #1 was 5/24/2024. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Medication Management ¿ 55 PA Code Chapters 6400.163(d), 6400.165(g)
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Monthly medication audits is being conducted to ensure proper documentation of medication administration.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file. |
05/30/2025
| Not Implemented |
| 6400.182(c) | The individual support plan last updated 12/13/2024 for individual #1 states he needs verbal prompts to evacuate during a fire. The assessment dated 5/15/2024 states he can evacuate independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Resident Assessments & Plans ¿ 55 PA Code Chapters 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.182(c), 6400.183(c)
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.183(c) | There was no list of persons who participated in the individual plan meeting held on 6/24/2024 for individual #1. | The list of persons who participated in the individual plan meeting shall be kept. | Resident Assessments & Plans ¿ 55 PA Code Chapters 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.182(c), 6400.183(c)
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |