Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00273688 Renewal 09/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 9/11/25 at 10:36 AM several poisonous materials were unlocked and accessible in the home. In the first-floor laundry room were Dreft laundry pods, Shout Triple Acting Stain remover and Oxi Clean odor and stain remover that were unlocked and accessible. On 9/11/25 at 10:37 AM 6 containers of Dreft laundry pods, 3 containers Oxi Clean odor and stain remover, 2 gallons of Clorox Bleach, 6 containers of Clorox Disinfecting Wipes were in the basement that were unlocked and accessible. Individual #1 is not assessed to be safe around poisonous material.Poisonous materials shall be kept locked or made inaccessible to individuals. All Poisonous materials have been locked. 10/31/2025 Implemented
6400.101On 9/11/25 at 10:49 a "hook and eye" locking mechanism was discovered on a door leading to the storage area of the basement. This was the only door leading into the storage area. When engaged the looking mechanism causes an obstructed egress and potential entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Lock was removed. 10/30/2025 Implemented
6400.112(d)On 4/15/25 at 6:00 PM a fire drill was conducted with an evacuation time of 5 minutes and 37 seconds, exceeding the required 2 1/2 minute evacuation time. On 6/18/25 at 6:00PM a fire drill was conducted with an evacuation time of 2 minutes and 57 seconds, exceeding the required 2 1/2 minute evacuation time. On 6/20/25 at 3:00AM a fire drill was conducted with an evacuation time of 3 minutes and 37 seconds, exceeding the required 2 1/2 minute evacuation time. On 6/24/25 at 2:30PM a fire drill was conducted with an evacuation time of 6 minutes and 41 seconds, exceeding the required 2 1/2 minute evacuation time. On 6/26/25 at 10PM a fire drill was conducted with an evacuation time of 3 minutes and 22 seconds, exceeding the required 2 1/2 minute evacuation time. On 7/19/25 at 12:30AM a fire drill was conducted with an evacuation time of 4 minutes and 11 seconds, exceeding the required 2 1/2 minute evacuation time. The homes does not have an extended evacuation time designated in writing by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Practice Fire Drills will no longer be documented on Fire Drill Form. 10/30/2025 Implemented
6400.151(a)Direct Services Worker #3 had a physical examination completed on 4/3/23, and then again on 4/22/25. This exceeds the every 2-year requirement. 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. All staff physicals are uploaded in On Target Clinical and an expiration date is set to ensure DSPs have enough time to schedule a Physical Exam. Personal Record Specialist sends an email to the Program Specialist along with the DSP alerting them that their physical is due in a month. The DSP is responsible for scheduling their own Physical date, Program Specialist will follow up with the DSP to ensure a timely date was secured. A message will be sent out in Teams to remind all DSPs that physicals do not have a grace period as a reminder for when they are scheduling. 10/30/2025 Implemented
6400.181(a)Individual #1 had an annual assessment completed on 2/14/24, and then again on 5/1/25. This exceeds the annual requirement. 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. Annual Assessments are uploaded into OTC and have an expiration date set for month prior to due date. Program specialists print a report each month alerting them of coming Assessment dates, this gives them enough time to gather all necessary information to include in the Assessment Tool. The initial program specialist over this case resigned and left assessments not completed. When new Program Specialist took over Assessments were reviewed and completed for outstanding dates. 10/30/2025 Implemented
6400.181(e)(12)Individual #1's assessment dated 5/1/25 did not have any recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Recommendations for specific training, programming and services has been added to the Assessment Tool. 10/30/2025 Implemented
6400.34(a)Individual #1 was informed and explained rights on 12/5/23, and then again on 12/6/24. This exceeds the annual requirement.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.All individual rights are listed in a consent packet that is set to expire in On target a month before due date. There is an option to send this electronically to individual/guardians/families to review and sign off on. Program Specialist will run a report in OTC each month to ensure any upcoming Consent packets including the Individual Rights is reviewed and signed with the individual/guardian/families in a timely manner. 10/30/2025 Implemented
6400.163(a)On 9/11/25 Individual #1's medication, Oxcarbazepine 300mg, was not in its original labeled container and this prescription medication was not labeled with a label issued by a pharmacy.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.A new pharmacy label was sent and applied to the medication. 10/31/2025 Implemented
6400.166(b)On 9/3/25 at 8am Direct Services Worker #1 did not record the administration of medications in individual #1's Medication Administration Record for the following medications: Baclofen 20 MG, Clonazepam 0.5MG, Levocarnitine 330mg, Oxcarbazepine 300mg and Valproic Acid 250mg. On 9/1/25 at 8pm Direct Services Worker #2 did not record the administration of medications in individual #1's Medication Administration Record for the following medications: Baclofen 20 MG, Clonazepam 0.5MG, Levocarnitine 330mg, Oxcarbazepine 300mg and Valproic Acid 250mg.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All EMAR's have been checked to ensure that all administered medication are recorded correctly on the MAR. 10/31/2025 Implemented
SIN-00251961 Renewal 09/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance expires on 12/28/24. The home completed the self-assessment on 06/14/24. The self-assessment was not completed 3 to 6 months prior to the expiration of the certificate of compliance.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. Abound Health will utilize the correct Licensing approved Licensing Inspection Instrument (LII) and completed the LII for all Residential Sites by October 31, 2024. 10/31/2024 Implemented
6400.15(b)The agency completed the Department's self-assessment (last modified in June of 2018), which does not contain all Chapter 6400 regulations promulgated on October 5, 2019.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Abound Health will utilize the correct Licensing approved Licensing Inspection Instrument containing all Chapter 6400 regulations promulgated on October 2, 2019, and will complete the LII for all Residential Sites by October 31, 2024. 10/31/2024 Implemented
6400.46(c)Direct Support Professional #3, date of hire 05/31/24, was not trained in first aid techniques before working with individuals.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.DSP #3 will be trained on First Aid and CPR by 10/31/2024. 10/31/2024 Implemented
6400.51(b)(1)Direct Support Professional #3, date of hire 05/31/24, did not complete "The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships" during the agency's orientation training.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.The DSP # 3 will complete the application of Person-Centered Practices, Community Integration, Individual Choice, and supporting individuals to develop and maintain relationships by 10/31/2024. 10/31/2024 Implemented
6400.52(c)(1)Direct Support Professional #1, date of hire 11/23/22, did not complete did not complete "The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships" during the agency's annual training year, dated 7/1/23 to 6/30/24. Direct Support Professional #2, date of hire 11/29/22, did not complete did not complete "The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.DSP #1 will complete the application of Person-Centered Practices, Community Integration, Individual Choice, and supporting individuals to develop and maintain relationships by 10/31/2024 for training year 23-24. DSP #2 will complete Person Centered Practices, Community Integration, Individual Choice, and supporting individuals to develop and maintain relationships by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(2)Direct Support Professional #1, date of hire 11/23/22, did not complete did not complete "The prevention, detection and reporting of abuse, suspected abuse, and alleged abuse" during the agency's annual training year, dated 7/1/23 to 6/30/24. Direct Support Professional #2, date of hire 11/29/22, did not complete did not complete "The prevention, detection and reporting of abuse, suspected abuse, and alleged abuse" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) 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.DSP #1 will complete the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse by 10/31/2024 for training year 23-24. DSP #2 will complete Person Centered Practices, Community Integration, Individual Choice, and supporting individuals to develop and maintain relationships by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(3)Direct Support Professional #1, date of hire 11/23/22, did not complete did not complete "Individual rights" during the agency's annual training year, dated 7/1/23 to 6/30/24. Direct Support Professional #2, date of hire 11/29/22, did not complete did not complete "Individual rights" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.DSP #1 will complete Individual Rights 10/31/2024 for training year 23-24. DSP #2 will complete Individual Rights by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(4)Direct Support Professional #1, date of hire 11/23/22, did not complete did not complete "Recognizing and reporting incidents" during the agency's annual training year, dated 7/1/23 to 6/30/24. Direct Support Professional #2, date of hire 11/29/22, did not complete did not complete "Recognizing and reporting incidents" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.DSP #1 will complete Recognizing and Reporting Incidents by 10/31/2024 for training year 23-24. DSP #2 will complete Recognizing and Reporting Incidents by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.52(c)(5)Direct Support Professional #1, date of hire 11/23/22, did not complete did not complete "The safe and appropriate use of behavior supports" during the agency's annual training year, dated 7/1/23 to 6/30/24. Direct Support Professional #2, date of hire 11/29/22, did not complete did not complete "The safe and appropriate use of behavior supports" during the agency's annual training year, dated 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.DSP #1 will complete Safe and appropriate use of behavior supports by 10/31/2024 for training year 23-24. DSP #2 will complete Safe and appropriate use of behavior supports by 10/31/2024 for training year 23-24. 10/31/2024 Implemented
6400.169(a)Direct Support Professional #1, date of hire 11/23/22, completed the Department-approved medication course on 11/23/22; However, Direct Support Professional #1's certification to administer medications expired on 11/23/23. Direct Support Professional #1 continued to administer medications to individuals without a current Department-approved certification to administer medications from 11/23/23 until 09/16/24.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).DSP #1 was requalified to pass medications as of 9/16/2024. 10/31/2024 Implemented
SIN-00232589 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #2, date of admission 1/19/23, had a Tuberculin skin testing by Mantoux method completed 9/11/23.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. Individual Transitioned from Polk Center and was supposed to have this completed prior to discharge into PHS Residential Program. Once PS and Program Director reviewed medical information it was noted that it was not given on immunization record and appointment was made to receive a Mantoux as soon as appointment could be made. 10/30/2023 Implemented
6400.141(c)(13)Individual #2's 3/27/23 physical examination did not include allergies or contraindicated medications. This section was left blank.The physical examination shall include: Allergies or contraindicated medications.Program specialists are responsible for ensuring the physical is filled out completely by Physician. The Director of Nursing will review Physical once completed to ensure all information is complete and will reach out to appropriate PCP if needed to add/complete physical. 11/30/2023 Implemented
6400.181(a)Individual #1, date of admission 12/30/22, had an initial assessment completed 3/22/23. 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. PS will complete assessment within 60 calendar days of admission. This will be docuemnted on a spreadsheet to keep track of assessment dates annually for individuals. PS will be responsibe for this. 11/30/2023 Implemented