Inspection IDReason for InspectionInspection DateInspection Status 
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