| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.21(b) | On 9/26/23 the agency provided a letter to the department indicating that the home was closed. The agency moved Individual #1 into the home on 7/1/24. The agency failed to submit an application to license the home prior to moving the individual into the home. | The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued. | Serenitycare will ensure that all legal entities are submitted and a certificate of compliance before a facility or agency can start operating if it is subject to licensure. |
10/14/2024
| Implemented |
| 6400.22(e)(3) | The agency is Individual #1's representative payee. Individual #1's individual support plan last updated 5/29/24, stated "[they] understand the purpose and concept of money; however, support is needed to budget, pay expenses, and save money." However, Individual #1's financial ledgers from July and August 2024 display purchases of greater than $15, for which the agency did not provide receipts. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Serenitycare will implement 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 to ensure compliance of 55 PA Code Chapter 6400.22(e)(3). |
10/14/2024
| Implemented |
| 6400.76(a) | On 9/18/24 at 12:46 PM, both doors of the vanity cabinet located in the home's only bathroom located on the upper level was observed without knobs or handles. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Serenity care staff will replace any broken or hazardous furniture with non-hazardous furniture. The Program Manager will ensure this site is well maintained according to 55 PA Code Chapter 640076(a) and that all furniture remains clean and sturdy. |
10/14/2024
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's current assessment completed on 3/8/24, did not address their level of performance and progress in the acquisition of financial functional skills regarding the following criteria: identifying monetary values, making purchases, receiving correct change, and budgeting, etc. Individual #1's 3/8/24 assessment stated the following for this skill domain: "Individual #1's assets must remain under $2,000 to remain eligible for the waiver. Individual #1's representative payee is Serenity Care which will ensure [they] remain under $2,000." | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | The Program Manager will ensure complaince that initial assessments are completed either within one year prior to admission or within 60 days after admission. These assessments must evaluate adaptive behavior and skill levels. Following the initial assessment, annual assessments will be conducted every year. Serenitycare will ensure that all assessments address the individual¿s functional strengths, needs, preferences, likes, dislikes, interests, and current level of performance. |
10/14/2024
| Implemented |
| 6400.181(e)(6) | Individual#1's 3/8/24 assessment did not address their ability to use poisonous materials and cleaners. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The Program Manager will ensure complaince that initial assessments are completed either within one year prior to admission or within 60 days after admission. These assessments must evaluate adaptive behavior and skill levels. Following the initial assessment, annual assessments will be conducted every year. Serenitycare will ensure that all assessments address the individual¿s functional strengths, needs, preferences, likes, dislikes, interests, and current level of performance. Including The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. |
10/14/2024
| Implemented |
| 6400.181(e)(7) | Individual#1's 3/8/24 assessment did not address their ability to sense and quickly move away from heat sources which exceed 120 degrees Fahrenheit and are not insulated. Individual #1's 3/8/24 assessment stated the following for this skill domain: "Individual #1 will intentionally set a fire; therefore, [they] should be nowhere near any sort of fire starters." | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The Program Manager will ensure complaince that initial assessments are completed either within one year prior to admission or within 60 days after admission. These assessments must evaluate adaptive behavior and skill levels. Following the initial assessment, annual assessments will be conducted every year. Serenitycare will ensure that all assessments address the individual¿s functional strengths, needs, preferences, likes, dislikes, interests, and current level of performance. Including an individual's knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources that exceed 120° F and are not insulated. |
10/14/2024
| Implemented |
| 6400.181(e)(10) | Individual #1's 3/8/24 assessment did not include a complete lifetime medical history and included only the following elements: their diagnoses, their corrective lenses, and a past hip surgery. | The assessment must include the following information: A lifetime medical history. | The program Manager will ensure complaince that initial assessments are completed either within one year before admission or within 60 days after admission. These assessments must evaluate adaptive behavior and skill levels. Following the initial assessment, annual assessments will be conducted every year. Serenitycare will ensure that all assessments address the individual functional strengths, needs, preferences, likes, dislikes, interests, and current level of performance. |
10/14/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's content of records did not include a current, dated photograph. | Each individual's record must include the following information: Personal information, including: (vi) A current, dated photograph. | The program manager will ensure that individual's records include their personal information, such as their name, sex, birthdate, admission date, Social Security number and a current, dated photo. |
10/14/2024
| Implemented |