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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(d) | Individual #1 is prescribed Ibuprofen 800mg, "Take 1 tablet by mouth every 8 hours if needed to relieve pain, reduce fever, and decrease inflammation. On 3/18/2026 at 10:37 AM the following medication was identified for Individual #1: over the counter bottle Ibuprofen 200mg tablets, with instructions "Adults and children 12 years and older: Take 1 tablet every 4 to 6 hours while symptoms persist. If pain or fever does not respond to 1 tablet, 2 tablets may be used. Do not exceed 6 tablets in 24 hours, unless directed by a doctor. | The directions of the prescriber shall be followed. | PROVIDER'S PLAN OF CORRECTION
iHomeCare Solutions acknowledges the violation that the directions of the prescriber were not followed for Individual #1 under 55 Pa. Code Chapter 6400.
Individual #1 is prescribed Ibuprofen 800mg, "Take 1 tablet by mouth every 8 hours as needed." On 3/18/2026 at 10:37 AM, an over-the-counter bottle of Ibuprofen 200mg with different directions was present in the medication area. The OTC medication had been provided by the individual's parent and placed with prescribed medications, creating the potential for administration not in accordance with the prescriber's order.
Immediate Corrective Actions Taken
The OTC Ibuprofen 200mg bottle was immediately removed from the medication area
The prescriber's order was verified against the MAR and medication supply
The correct medication and dosage were confirmed and maintained
A full medication review was conducted for Individual #1
A house-wide medication audit was completed to ensure all medications align with prescriber orders
Staff were re-educated immediately that medications from any source (including family) cannot be used unless they match the prescriber's order
The incident was documented and reported per agency policy
Root Cause Identified
The violation occurred due to the presence of an over-the-counter medication provided by a family member that was not verified against the prescriber's order prior to being placed with active medications, resulting in a risk of administration not following prescribed directions.
Responsible Person(s):
Weekly Oversight: House Lead
Monthly Oversight: Residential Manager
Final Oversight: Operations Management |
05/11/2026
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Peg 3350 powder 17gm, "Take 17gm by mouth daily for constipation. On 3/18/2026 Individual #1's March 2026 medication administration record documented the medication was missed on 3/04/2026 because the agency did not have the medication. [Repeat violation 4/29/25, et. al.] | Medication errors include the following: Failure to administer a medication. | PROVIDER'S PLAN OF CORRECTION
iHomeCare Solutions acknowledges the violation that Individual #1's prescribed medication PEG 3350 powder 17gm was not administered on 3/04/2026 due to the medication not being located at the time of administration.
The agency recognizes that although the medication was present in the home, it was not identified by staff, resulting in a missed dose.
Immediate Corrective Actions Taken
The medication PEG 3350 was confirmed to be present in the home within the backup medication supply
It was identified that medications are distributed at the end of each month, and a new batch had already been delivered and stored in the backup location
Staff were immediately retrained on the location of both primary and backup medication storage areas
Medication storage areas were reviewed and organized to ensure accessibility and consistency
The MAR was reviewed and verified to ensure accurate documentation of the missed dose
The incident was documented and reported in accordance with agency policy
Root Cause Identified
The violation occurred due to staff not thoroughly checking both primary and backup medication storage locations, despite the medication being available in the home.
Responsible Person(s):
Weekly Oversight: House Lead
Monthly Oversight: Residential Manager
Final Oversight: Program Specialist |
05/11/2026
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 2/17/2026, documents "Staff remove {Individual #1] from triggers in the environment & any items that {the Individual] could utilize to harm [themselves]." On 3/17/2026 Chief Executive Officer #1 stated this is not current and staff are not restricting the individual by removing items they could harm themselves with, nor removing triggers in the environment. Individual #1's assessment completed 1/20/2026 documents the individual can avoid heat sources. Individual #1's individual support plan, last updated 2/17/2026, documents, [The individual] understands dangers around heat sources & electrical outlets. [The individual] can be easily distracted and may benefit from occasional reminders to use caution around heat sources or other potentially dangerous items. Individual #1 has put their hand on the stove to see if it was hot. Individual #1 is physically capable of moving away from heat sources but requires close monitoring when around said appliances. Individual #1's assessment completed 1/20/2026 documents the individual can safely use and avoid poisonous materials. Individual #1's individual support plan, last updated 2/27/2026, documents [Individual #1] does not have a history of ingesting cleaning or poisonous products. [The individual] can use these products safely." Individual #1's restrictive procedure plan, last updated 10/07/2025 documents they have a history of ingesting cleaning or poisonous products. Individual #1's assessment completed 1/20/2026 documents that they need visual supervision in the home and that they must be supervised at all times at home, simply meaning staff is always on the premises. Individual #1 also requires sleepover staff at night in case of an emergency. Individual #1's restrictive procedure plan, last updated 10/07/2025, documents the individual requires arms' length supervision in the home, except in the bedroom and the bathroom, and that Individual #1 requires auditory supervision while they are in their bedroom and in the bathroom. [Repeat violation 4/29/25, et. al.] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | PROVIDER'S PLAN OF CORRECTION
iHomeCare Solutions acknowledges the violation that Individual #1's Individual Support Plan (ISP), Assessment, and Restrictive Procedure Plan (RPP) contained inconsistent, outdated, and conflicting information regarding supervision level, safety needs, and restrictive interventions.
The agency recognizes that documentation did not accurately reflect the individual's current needs, abilities, and level of supervision, and included language that was no longer in practice.
Immediate Corrective Actions Taken
The ISP, Assessment, and Restrictive Procedure Plan were reviewed in full for accuracy and consistency
Outdated and conflicting information was removed or corrected to reflect the individual's current needs and actual level of supervision
The ISP was updated to align with the current assessment and team recommendations
The Restrictive Procedure Plan was reviewed and discontinued, as appropriate, to reflect current practices
All documentation was aligned to ensure consistency across ISP, Assessment, and RPP
Staff were informed of the correct supervision level and expectations for Individual #1
Root Cause Identified
The violation occurred due to a failure to update all related documents simultaneously, resulting in inconsistencies between the ISP, Assessment, and Restrictive Procedure Plan, and documentation that did not reflect current practice.
Responsible Person(s):
Primary: Program Specialist
Oversight: CEO/Program Specialist |
05/11/2026
| Implemented |
| 6400.195(c)(1) | Individual #1 has a restrictive procedure plan, last updated 10/07/2025, which documents, "[The individual] requires protective use of force, if individual displays physical aggression, self-injurious behaviors, or property destruction they should remain at home until they are safe and calm. If Individual #1 engages in behavior while in CLA vehicle or in community, they should be returned home as soon as possible. Phone is set-up to remove access to social media." On 3/18/2026 Direct Service Worker (DSW) #1 confirmed the agency is not following the Individual #1's restrictive procedure plan, last updated 10/07/2025. DSW #1 states the staff attempt to give individual verbal redirection when they try using the internet, but that the phone itself is not set-up to have social media removed. On 3/18/2026 there were no picture frames in the home with the glass removed, and Individual #1 had a glass mirror in their bedroom. Direct Service Worker #1 confirmed staff do not need to follow the protective use of force because the individual is not displaying the behaviors identified in the restrictive procedure plan. | The behavior support component of the individual plan shall include: The specific behavior to be addressed. | PROVIDER'S PLAN OF CORRECTION
iHomeCare Solutions acknowledges the violation that Individual #1's Restrictive Procedure Plan (RPP) dated 10/07/2025 was not being followed and did not reflect the individual's current needs or practices under 55 Pa. Code Chapter 6400.
Immediate Corrective Actions Taken
The Restrictive Procedure Plan was immediately reviewed and discontinued as it was no longer clinically appropriate or reflective of current practice
The ISP and Assessment were reviewed and updated to reflect current supports, including the use of least restrictive interventions (e.g., verbal redirection)
iHomeCare Solutions has initiated the process of securing a new Behavioral Support Provider
A new Restrictive Procedure Plan will be developed and implemented only if clinically necessary
Staff were informed of current expectations and supervision/support strategies
Root Cause Identified
The violation occurred due to failure to discontinue the RPP when the individual's behaviors and needs changed, resulting in outdated documentation that was not reflective of current practice.
Responsible Person(s):
Primary: Program Specialist
Oversight: CEO/Program Specialist |
05/11/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 4/30/2025 at 10:13AM, the hot water temperature measured 131.9°F at the sink in the kitchen 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 120F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:13 AM, the hot water temperature at the kitchen sink in the home measured 131.9°F, exceeding the regulatory limit of 120°F. This posed a significant risk of burns to individuals and violated safety requirements. The issue occurred because the water heater was set too high and there was no system in place to routinely monitor hot water temperatures.
What specific change was made to fix the problem:
On May 2, 2025, the Facility Compliance Manager adjusted the water heater to its lowest safe setting. A follow-up measurement confirmed the water temperature at the kitchen sink was reduced to 112°F, safely below the 120°F threshold. The water heater was labeled with the approved setting and access was restricted to authorized personnel only.
Who made the change and when:
The Facility Compliance Manager completed the adjustment and verified the corrected temperature on May 2, 2025.
How was the issue corrected:
The water temperature is now within compliant range. The heater is labeled and locked to prevent unauthorized adjustments, and a monitoring system has been implemented. |
05/02/2025
| Implemented |
| 6400.68(b) | On 4/30/2025 at 10:55AM, the hot water temperature measured 128.1°F at the bathtub in the only bathroom in the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:55 AM, the hot water temperature at the bathtub in the home¿s only bathroom measured 128.1°F, exceeding the maximum allowable limit of 120°F as outlined in § 6400.68(b). This posed a significant scalding risk to the individuals residing in the home. The violation occurred due to the water heater being set too high, coupled with the absence of a consistent monitoring system to verify water temperature at point-of-use locations.
What specific change was made to fix the problem:
On May 2, 2025, the Facility Compliance Manager adjusted the water heater to its lowest effective setting. A calibrated thermometer was used to re-check the temperature at the bathtub, confirming a new safe range of 110°F¿112°F. The water heater was labeled with the approved setting and secured to restrict unauthorized access.
Who made the change and when:
The Facility Compliance Manager performed the adjustment and verified the new temperature reading on May 2, 2025.
How was the issue corrected:
The water temperature at the bathtub is now compliant and safe. The adjustment was logged, and the water heater was marked with a compliance label. Staff were informed of the correction and reminded of heat risk awareness protocols. |
05/02/2025
| Implemented |
| 6400.70 | On 4/30/2025 at 10:30AM, the cellular telephone provided by the home was on the end table next to the couch in the living room of the home and was not fully charged and required a passcode to operate; therefore, not easily accessible to Individual #1. There is no landline telephone service in the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:30 AM, the home only had a cellular phone, which was found on an end table in the living room. The phone was not fully charged and required a passcode to operate. This made it inaccessible to Individual #1, violating § 6400.70, which requires an operable, non-coin-operated telephone with an outside line that is easily accessible to individuals and staff. There was no landline telephone service in place at the time of the inspection.
What specific change was made to fix the problem:
On May 1, 2025, a landline telephone with an outside line was installed in the living room of the home. The phone is plugged in, operable at all times, and does not require a passcode. Emergency phone numbers for the police, fire department, hospital, ambulance, and poison control were printed and clearly posted both on the base of the phone and on a label on the back of the handset for quick reference.
Who made the change and when:
The Facility Compliance Manager installed and verified the operability of the landline phone on May 1, 2025.
How was the issue corrected:
The cell phone was removed from the home to eliminate confusion and noncompliant practices. The landline was tested and confirmed to provide immediate access to emergency services and outgoing communication. |
05/23/2025
| Implemented |
| 6400.71 | On 4/30/2025 at 10:30AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the the cellular telephone in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:30 AM, the only telephone in the home was a cellular phone, and it did not have the required emergency phone numbers (police, fire department, hospital, ambulance, and poison control) posted on or near it. This violated § 6400.71, which mandates that these numbers must be visibly posted on or by the telephone to ensure access in case of emergency. The oversight occurred due to reliance on a personal-use cell phone, which is not compliant with 6400 standards.
What specific change was made to fix the problem:
On May 1, 2025, a landline telephone was installed in the living room of the home. A list of emergency numbers¿including the nearest hospital, local police and fire departments, ambulance service, and poison control center¿was printed in large, legible font and posted directly on the wall above the phone and also taped to the back of the phone handset.
Who made the change and when:
The Facility Compliance Manager installed the phone and posted the emergency numbers on May 1, 2025.
How was the issue corrected:
The non-compliant cell phone was removed, and a compliant landline with posted emergency numbers is now in place and accessible to all staff and individuals. |
05/23/2025
| Implemented |
| 6400.77(b) | On 4/30/2025 at 10:23AM, the home's first aid kit did not contain a thermometer. | 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. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, at 10:23 AM, the home¿s first aid kit did not contain a thermometer, as required by § 6400.77(b). This occurred due to lack of a standardized contents checklist and inconsistent restocking procedures following use or inspection.
What specific change was made to fix the problem:
On May 1, 2025, a new standardized first aid kit was delivered and placed in the home. All required items were verified, including:
Thermometer
First aid manual
Antiseptic
Adhesive bandages (assorted sizes)
Sterile gauze pads
Tape
Scissors
Tweezers
(Syrup of Ipecac if applicable, based on individual profiles)
Who made the change and when:
The Facility Compliance Manager distributed and verified contents of the new first aid kits in all homes on May 1, 2025.
How was the issue corrected:
The thermometer and manual were added, and the full contents were cross-checked against a standardized list. The complete kit is now stored in a designated, clearly labeled area in the home. |
05/16/2025
| Implemented |
| 6400.77(c) | On 4/30/2025 at 10:23AM, a first aid manual was not kept with the the home's first aid kit. | A first aid manual shall be kept with the first aid kit. | Provider¿s Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 10:23 AM, the home¿s first aid kit was found without a first aid manual, which is a violation of § 6400.77(c). This occurred due to incomplete restocking during a previous kit replacement and the omission was not identified during routine checks.
Corrective Action Taken:
On May 1, 2025, the home was issued a new, fully stocked first aid kit, which included the required first aid manual.
The Facility Compliance Manager confirmed the manual was included and placed directly inside the kit for accessibility.
All other homes were reviewed and provided with updated first aid kits to ensure compliance. |
05/02/2025
| Implemented |
| 6400.104 | The letter to the local fire department, dated 3/31/2025, did not include exact locations of the bedrooms of the individuals who need assistance evacuating in the event of an actual fire. | 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.
| Provider¿s Plan of Correction
What Happened / Why It Happened:
The letter sent to the local fire department on March 31, 2025, did not include the exact bedroom locations of individuals who require assistance evacuating in the event of a fire, which is a violation of § 6400.104.
This occurred due to the use of an outdated template that lacked the required specificity and had not been updated to reflect current regulatory expectations.
Corrective Action Taken:
On May 1, 2025, a new letter template was created to include:
The full address of the home
The number of individuals residing in the home
A list of any individuals who require evacuation assistance
The exact bedroom location of each individual requiring assistance
Updated letters were completed and sent to the local fire department for each licensed home.
Copies of the letters were filed both at the home and the administrative office. |
05/02/2025
| Implemented |
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