| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 11/25/24, was not conducted either within 3-6 months of the current license's expiration date of 2/22/2025 or within 6-9 months following the last annual inspection by the Department completed 12/20/23. [Repeated Violation-12/19/23, et al] | 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.
| A compliance calendar has been implemented to ensure timely completion of the annual self-assessment. Management was trained regarding the requirements for completing and documenting the annual self-assessment. |
02/27/2025
| Implemented |
| 6400.21(d) | Direct Support Professional #2's date-of-hire is 11/20/24. An application for a Pennsylvania criminal history record check was requested on 11/20/24. However, this Pennsylvania criminal history record check indicates the "request is still pending for control." Therefore, the agency did not provide documentation of the final report. | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| The criminal history check for the staff member in question came back with a final report and no disqualifying results were found. The hiring process was revised to ensure that no staff begin employment without documented completion of a criminal history check. Human Resources staff were retrained reguarding the requirements for criminal history checks and documentation prior to the start of employment. |
02/27/2025
| Not Implemented |
| 6400.22(a) | The agency's written policy on individual funds and property did not specify how individuals will be counseled regarding the use of funds and property. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | Management revised the policy on individual funds and had the individual sign the new copy. |
02/27/2025
| Implemented |
| 6400.64(e) | On 12/6/24 at 11:41 AM, a trash receptacle that measured approximately 24 feet in height was located in the kitchen of the home and did not contain a lid. | Trash receptacles over 18 inches high shall have lids. | Management purchased a new trash can for the home with a lid. |
02/27/2025
| Not Implemented |
| 6400.66 | On 12/6/24 at 10:11 AM, the rear egress of the home did not contain a light or a nearby sufficient lighting source. At 11:36 AM, the front egress of the home did not contain a light or a nearby sufficient lighting source. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Management repaired the light fixture in the stairway leading to the second floor of the home. |
02/27/2025
| Not Implemented |
| 6400.67(b) | On 12/6/24 at 11:57 AM, the dryer lint trap filter was covered in a thick coating of lint, dust, and particles. Additionally, the dryer's air-duct exhaust pipe was disconnected from the wall. [Repeated Violation-12/19/23, et al] | Floors, walls, ceilings and other surfaces shall be free of hazards. | Management contacted the contracted maintenance provider to repair the lint trap. Staff was retrained on the responsibility of keeping the home free of hazards. The Program Specialist posted a sign stating the lint trap is to be cleaned after every use. |
02/27/2025
| Not Implemented |
| 6400.72(a) | On 12/6/24 at 12:04 PM, Individual #1's bedroom windows did not contain any screens. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Management replaced the screens. |
02/27/2025
| Not Implemented |
| 6400.74 | On 12/6/24 at 11:37 AM, the exterior wooden set of stairs leading from the front porch to the lower level of the property were missing a nonskid surface on the following steps in descending order: the first step; the second step; the fifth step; and the seventh step. | Interior stairs and outside steps shall have a nonskid surface.
| Management replaced the nonskid surface on the stairs. |
02/27/2025
| Not Implemented |
| 6400.76(a) | On 12/6/24 at 12:03 PM, Individual #1's bedroom closet door was broken and leaning up against the wall. At 12:04 PM, the air-duct wall vent cover in Individual #1's bedroom was detached approximately one inch from the wall. At 12:16 PM, the basement airduct vent cover was detached approximately one-half inches from the ceiling. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Furniture and equipment shall be nonhazardous, clean and sturdy. | Management contacted the HVAC provider to assess for the status of the furnace and to complete any neccessary repairs. |
02/27/2025
| Not Implemented |
| 6400.80(a) | On 12/6/24 at 11:42 AM, the rear deck and attached steps leading from the kitchen egress of the home were snow- covered and had not been shoveled or salted. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Management shoveled and salted the back porch and stairs. |
02/27/2025
| Implemented |
| 6400.101 | On 12/6/24 at 11:56 AM, the door leading from the basement of the home to the attached garage was equipped with a key lock facing the garage side and a turn lock on the basement side. The attached garage does not have a swing door to be used as an alternate egress causing a potential entrapment risk. [Repeated Violation-12/19/23, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Management contacted the contracted maintenance provider in order to remove the slide locks on the doors. Management received retraining on unobstructed throughways. |
02/27/2025
| Not Implemented |
| 6400.104 | The local fire department notification letter dated 2/16/24, for this home indicates that Individual #1 requires physical assistance to evacuate in the event of an actual fire but does not include a description or diagram of the exact location of their bedroom. | 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.
| Management sent a formal written notification to the local fire department, including the home's address and a detailed floor plan indicating the exact locations of bedrooms for the individual requiring evacuation assistance. Staff were trained on the importance of maintaining current evacuation information and the proceedure for updating the fire department. |
02/27/2025
| Implemented |
| 6400.110(a) | On 12/6/24 at 12:13 PM, the basement level of the home did not contain a smoke detector. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Management installed a smoke detector in the basement of the home. |
02/27/2025
| Not Implemented |
| 6400.113(a) | Individual #1's date-of-admission to the home is 8/12/24, and they were not instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Management reviewed the fire safety policy with the individual and had them sign off on it. |
02/27/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's date-of-admission is 8/12/24. However, Individual #1's content of records revealed that they did not have vision and hearing screenings or examinations completed within 12 months prior to admission. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Management was retrained on the elements of proper individual physical documentation requirements. |
02/27/2025
| Not Implemented |
| 6400.141(c)(13) | Individual #1 has a physical examination completed on 10/27/23 that did not address allergies or contradicted medications. | The physical examination shall include: Allergies or contraindicated medications. | Management was retrained on the elements of an individual's physical exam documentation. |
02/27/2025
| Not Implemented |
| 6400.151(a) | Program Specialist #1's date-of-hire is 7/31/23, but they did not have a physical examination completed until 8/2/23. | 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. | Management requested a copy of Program Specialist #3's physical. |
02/27/2025
| Not Implemented |
| 6400.181(a) | Individual #1's date-of-admission is 8/12/24. Individual #1's content of records indicated that they have not had an assessment completed. | 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. | Management located the individual's assessment and placed it in their file. |
02/27/2025
| Implemented |
| 6400.20(b) | The agency did not review and analyze incidents as well as conduct and document a trend analysis at least every three months since the Department's last annual renewal inspection. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | Management was retrained on the proper procedure for maintaining and reviewing incidents. |
02/27/2025
| Implemented |
| 6400.51(b)(1) | Program Specialist #1's date-of-hire is 7/31/23. Their orientation training conducted on 8/8/23, included training in the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships. This training was completed by "self-reading" the material. Direct Support Professional #2's date-of-hire is 11/20/24. Their orientation training conducted on 11/21/24, included training in the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships. This training was completed by "self-reading" the material. | 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. | Management implemented a revised checklist to ensure all new hires complete orientstion training, including person-centered practices, prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.51(b)(2) | Program Specialist #1's date-of-hire is 7/31/23. Their orientation training conducted on 8/8/23, included training on the prevention, detection, reporting of abuse, suspected abuse, and alleged abuse. This training was completed by "self-reading" the material. Direct Support Professional #2's date-of-hire is 11/20/24. Their orientation training conducted on 11/21/24, included training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse. This training was completed by "self-reading" the material. | The orientation 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. | Management implemented a revised checklist to ensure all new hires complete orientation training, including The Prevention, Detection and Reporting of Abuse, Suspected Abuse, and Alleged Abuse, prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.51(b)(3) | Program Specialist #1's date-of-hire is 7/31/23. Their orientation training conducted on 8/8/23, included training on individual rights. This training was completed by "self-reading" the material. Direct Support Professional #2's date-of-hire is 11/20/24. Their orientation training conducted on 11/21/24, included training on individual rights. This training was completed by "self-reading" the material. | The orientation must encompass the following areas: Individual rights. | Management implemented a revised checklist to ensure all new hires complete orientation training, including Individual Rights, prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.51(b)(4) | Program Specialist #1's date-of-hire is 7/31/23. Their orientation training conducted on 8/8/23, included training on recognizing and reporting incidents. This training was completed by "self-reading" the material. Direct Support Professional #2's date-of-hire is 11/20/24. Their orientation training conducted on 11/21/24, included training on recognizing and reporting incidents. This training was completed by "self-reading" the material. | The orientation must encompass the following areas: recognizing and reporting incidents. | Management implemented a revised checklist to ensure all new hires complete orientation training, including recognizing and reporting incidents training. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.162(b)(1) | Direct Support Professional #2 was trained in medication administration by Program Director/ Chief Executive Officer Designee #3 on 11/27/24. Program Director/ Chief Executive Officer #3's medication administration trainer certification expired on 9/29/24. On 12/6/24 at 11:43 AM, it was discovered that Direct Support Professional #2 administered the following medications to Individual #1 on 12/2/24 at 8:00 AM: Diphenhydram Cap 25mg, Lithium Carb Tab 450mg ER; Paroxetine Tab 25mg ER; Hydroxyz Pam Cap 25mg, Simethicone Chw 125mg; Nyamyc Pow 100000, Paliperidone Tab ER 6mg; Clindamycin Lot 1%; and Clonazepam Tab 0.5mg. Direct Support Professional #2 also administered Vitamin D Cap 50000 Units on 12/2/24 and 12/5/24 at 12:00 PM. | A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications. | The Director was recertified in Medication Training. Management was retrained on medication administration and medication training record policies. |
02/27/2025
| Not Implemented |
| 6400.165(g) | Individual #1's date-of-admission is 8/12/24, and they are prescribed medication to treat symptoms of a psychiatric illness. However, Individual #1's content of records revealed that they have not had any medication reviews completed by a licensed physician. | 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. | Management requested the records of the individual's quarterly medication review and ensured they are placed in the individual's residential binder. Management was retrained on the proper documentation and importance of a quarterly medication review. |
02/27/2025
| Not Implemented |
| 6400.166(a)(4) | On 12/6/24 at 11:51 AM, Individual #1's the December 2024 Medication Administration Record documented the name of the following prescribed medication as "Simethicone Chw 125 mg." However, the name listed on this medication's pharmacy label read, "Gas Relief Chw." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |