| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. At the time of the inspection, located on the left corner of the kitchen counter near the sink was a square plastic rubber maid container with a small plate flipped upside down on top of it. Inside the contained it was filled approximately ¾ of the way with ¼ sized cubed eggplant. The eggplant pieces were turning brown, and the bottom of the container which had approximately 1/8 of the container filled with a dark brown liquid. The container was not properly sealed for food storage. | Clean and sanitary conditions shall be maintained in the home. | The attending staff were reminded of proper food handling practices and storage. |
09/01/2025
| Implemented |
| 6400.112(a) | Individual #1 moved into the home "on respite" on 02/25/2025 per the provider. A letter to the local fire department was present in the individual record for this date (02/25/2025), stating that the individual was "residing at" the location and providing a diagram showing the location of the individual's bedroom. This suggests that Individual #1 was a resident of the home during February 2025. A fire drill was not conducted for this location until 03/14/2025. No fire drill was held for the month of February 2025 despite the individual residing in the home for 3 days that month. | An unannounced fire drill shall be held at least once a month. | The House Manager will ensure that all individuals, whether respite or permanent, will participate in a monthly fire drill. |
09/01/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's 9/30/24 physical examination did not include a vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Specialist will ask for a new physical that will be done on our Agency¿s physical form. If another Agency¿s physical is used, the Program Specialist will ensure that the physical form meets the required licensing regulations. The Individual is scheduled for an annual physical on 09.12.25. |
09/01/2025
| Implemented |
| 6400.141(c)(6) | Individual #1's date of admission is 2/24/25 and their negative Mantoux was completed on 9/11/23, which was not completed 1 year prior to their date of admission. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Program Specialist will inspect Tuberculin skin testing by Mantoux method¿s dates and ensure that they are no more than a year old at intake. |
09/09/2025
| Implemented |
| 6400.165(a) | During the inspection, a bottle of over-the-counter medication (OTC) Ibuprofen 200 mg tablets were located on the shelf in the cabinet in the kitchen where other medications are stored. The agency staff stated that the Ibuprofen did not belong to Individual #1 and was not prescribed in writing by an authorized prescriber. The following OTC medications and /or treatments were found hanging on the shelf attached to Individual #1's closet door: Benadryl Extra Strength Itch Stopping Gel-Diphendramine HCL @5 Topical Analgesic, Extra Strength Benadryl Topical Analgesic/Skin Protectant Itch Cooling Spray, Tinactin Antifungal liguid Spray, CVS Health Advanced Healing Ointment Skin Protectant, CareAll Ant-Itch Cream-Dipenhydramine HCL2%, Xinc Acetate.1%, Cerave Healing ointment, Neutrogena Beach Defense Sunscreen Spray, and Neosporin First aid foaming liquid. Per the Office of Developmental Programs (ODP) 55 PA Code Chapter 6400 Regulatory Compliance Guide (RCG), "···For purposes of applying these regulations, 'prescription medications' includes over the counter (OTC) medications, vitamins, and complementary and alternative medications (CAM)." The aforementioned prescription medications were not prescribed in writing by an authorized prescriber. The agency would want to ensure Individual #1 can take the medications and that they're not contradictive of their other medications. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The former Program Specialist reached out to individual #1¿s mother on 08.28.25 and spoke to her about the over the counter (OTC) medications. Individual #1¿s mother reported to the residence on 08.29.25 and removed the OTC. Also, a team meeting was held 09.10.25 so a decision can be made and recorded in the ISP as it relates to OTC. |
09/09/2025
| Implemented |
| 6400.186 | Per Individual #1's Individual Support Plan (ISP) they are not assesses as being self-medicating---the ISP's "Know & Do" section states that, "Individual #1 does not have the skills needed to be able to self-medicate she does not understand why she takes each medication. During the inspection, The following OTC medications and /or treatments were found hanging on the shelf attached to Individual #1's closet door: Benadryl Extra Strength Itch Stopping Gel-Diphendramine HCL 5 Topical Analgesic, Extra Strength Benadryl Topical Analgesic/Skin Protectant Itch Cooling Spray, Tinactin Antifungal liguid Spray, CVS Health Advanced Healing Ointment Skin Protectant, CareAll Ant-Itch Cream-Dipenhydramine HCL2%, Xinc Acetate.1%, Cerave Healing ointment, Neutrogena Beach Defense Sunscreen Spray, and Neosporin First aid foaming liquid. The agency staff were unaware the Individual #1 had the above medication in her room. The agency is not implementing Individual ISP. | The home shall implement the individual plan, including revisions. | A team meeting was conducted on 09.11.25 and it was determined that the individual's PCP should offer a written standing order for the OTC to include but not limited to sunscreen etc., and those items will be kept in a locked cabinet with her other medications. The individual will see their PCP on 09.12.25 for an annual physical. |
09/09/2025
| Implemented |