| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 12:47PM, the outside and inside of the refrigerator/freezer, in the attached garage of the home, had a multitude of areas of brown and black discoloration that appeared to be mold and/or mildew. | Clean and sanitary conditions shall be maintained in the home. | Immediate Cleaning: On May 5, 2025, the refrigerator/freezer was thoroughly cleaned and disinfected using EPA-registered mold/mildew cleaners. All visible discoloration was removed. Refrigerator was also removed from the site.
Appliance Inspection: Maintenance staff inspected the refrigerator/freezer to ensure proper operation and to identify and resolve any moisture or drainage issues contributing to mold growth.
Disposal of Compromised Items: Any expired or improperly stored food items were discarded. Shelves and bins were sanitized.
Staff Notification: All staff were notified of the immediate cleaning and reminded of sanitation standards for all household appliances. |
06/11/2025
| Not Implemented |
| 6400.64(e) | At 12:46PM, the two trash receptacles, measuring 32 inches and 38 inches containing loose and garbage bags of discarded items in the attached garage of the home, did not have lids. [Repeated Violation - 2/25/25, et al] | Trash receptacles over 18 inches high shall have lids. | Plan of Correction:
Immediate Remediation: On May 6, 2025, both trash receptacles were fitted with secure, tight-fitting lids to prevent exposure to waste and maintain sanitation.
Waste Removal: All loose trash was bagged and properly disposed of. The garage area was cleaned and disinfected to eliminate odors and possible contamination.
Staff Notification: All staff were informed that all trash receptacles must remain covered at all times to comply with health and safety regulations. |
06/11/2025
| Not Implemented |
| 6400.64(f) | At 11:05AM, the outside uncovered trash receptacle in the driveway of the home contained discarded items including dry leaves, a black garbage bag, a bottle of Arizona green tea, and an empty pack of Newport cigarettes. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Plan of Correction:
Immediate Cleaning: On May 5, 2025, all contents were removed from the uncovered trash receptacle in the driveway. The area was cleaned and debris was properly disposed of.
Cover Installed: A secure, weather-resistant lid was installed on the outdoor trash receptacle to ensure waste remains contained and is not exposed to the elements.
Staff Notification: Staff were reminded that all exterior trash receptacles must be covered at all times in accordance with sanitation and safety standards. |
06/11/2025
| Not Implemented |
| 6400.82(e) | At 12:44PM, the shower in the basement bathroom did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | Plan of Correction:
Immediate Action: On May 4, 2025, a nonslip shower mat was placed in the basement bathroom shower to reduce the risk of slips and falls.
Surface Inspection: The shower floor was inspected for any damage or slickness. No structural concerns were noted beyond the absence of a nonslip surface.
Staff Notification: Staff were informed of the requirement to ensure all showers and tubs have nonslip surfaces or mats at all times. |
06/11/2025
| Not Implemented |
| 6400.105 | At 12:48AM, the dryer vent had an inordinate accumulation of dryer lint. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Plan of Correction:
Immediate Cleaning: On May 7, 2025, the dryer vent was thoroughly cleaned by maintenance staff to remove all accumulated lint.
System Inspection: The dryer and venting system were inspected to ensure proper airflow and safe operation. No mechanical issues were found.
Staff Notification: Staff were notified of the safety hazard and reminded of the importance of routine lint removal and vent maintenance. |
06/11/2025
| Not Implemented |
| 6400.171 | At 11:09AM, an unsealed partially covered hot dog was in the refrigerator in the kitchen of the home. At 12:41PM, a partially used unsealed box of dry spaghetti was in a cupboard in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Plan of Correction:
Immediate Removal: On May 3, 2025, the unsealed hot dog and unsealed box of spaghetti were discarded to prevent potential contamination.
Kitchen Inspection: A full inspection of the refrigerator and cupboards was conducted to ensure no other improperly stored food items were present.
Staff Notification: Staff were immediately reminded of proper food storage practices, including sealing all opened items to ensure food safety and compliance. |
06/11/2025
| Not Implemented |
| 6400.216(a) | At 11:19AM, Individual #1's current Individual Plan and personal information sheet was unlocked and unattended in a binder on a table in the living room of the home. [Repeated Violation - 2/25/25, et al] | An individual's records shall be kept locked when unattended.
| Plan of Correction:
Immediate Action: On May 4, 2025 , the binder containing Individual #1¿s plan and personal information was immediately secured in a locked storage area.
Staff Notification: All staff were reminded that all individual records containing personal and confidential information must be locked when not in active use.
Reinforcement of Privacy Practices: The Program Specialist met with staff to review the importance of confidentiality and compliance with HIPAA and 55 PA Code Chapter 6400.216(a). |
06/11/2025
| Not Implemented |
| 6400.163(a) | Lantus Solostar 100 Unit/ml prescribed to Individual #1 was not being stored in the original labeled container with the label issued by the 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. | Plan of Correction:
Immediate Correction: On May 3, 2025, the improperly stored Lantus Solostar pen was removed and replaced with a properly labeled pen in the original pharmacy-issued container.
Pharmacy Coordination: The pharmacy was contacted to verify the prescription and ensure all future refills are provided in clearly labeled containers per regulation.
Staff Notification: All staff were immediately reminded that all medications must be stored in their original, pharmacy-labeled containers without exception. |
06/11/2025
| Not Implemented |
| 6400.163(d) | At 11:16AM, Individual #1's medications were unlocked and accessible in the medication box with a disengaged keypad lock on the desk in the unlocked staff office. Individual #2's medications were unlocked and accessible in the medication box with the disengaged combination padlock in the closet with a disengaged key padlock in the unlocked staff office. In addition, at 1:00PM, a loose Quetiapine 50mg tablet prescribed to Individual #1 was on a shelf of the desk in the staff office. [Repeated Violation - 2/25/25, et al] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Plan of Correction:
Immediate Securing of Medications: On May 2, 2025, all medications were immediately secured in locked containers with functioning locks, and the staff office was secured. All non-functioning or disengaged locks were replaced.
Loose Medication Disposal: The loose Quetiapine tablet was disposed of per agency medication disposal policy. A full medication count and reconciliation were completed to ensure all doses were accounted for.
Staff Accountability: All staff were informed of the severity of the violation and the requirement that medications be secured at all times per regulation and not commingled with any other consumer's medications. |
06/11/2025
| Not Implemented |
| 6400.163(f) | At 11:08AM, Lantus Solostar Inj 100/ml and Insulin Lispro 100 Unit/ml pen prescribed to Individual #1 were kept in a "lock box" in the refrigerator in the kitchen of the home; however, the locking mechanism was disengaged. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | Plan of Correction:
Immediate Securing: On May 3, 2025, the insulin pens were immediately removed and secured in a properly functioning lock box with the locking mechanism engaged inside the refrigerator.
Lock Box Replacement: The defective lock box was replaced with a fully functional, tamper-proof model to ensure ongoing secure storage of refrigerated medications.
Staff Notification: All staff were informed of the requirement that refrigerated medications must be stored in a locked and secure container at all times. |
06/11/2025
| Not Implemented |
| 6400.166(b) | Lantus Solostar 100 Unit/ml, Metformin HCL 500mg and Quetiapine Tab 50 mg and 200mg prescribed to Individual #1 at bedtime were not initialed as administered at the 10:00PM on 4/25/25 and 4/27/25. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Plan of Correction:
Immediate Review: On May 4, 2025, the MAR for 4/25/25 and 4/27/25 was reviewed. Staff involved confirmed the medications were administered but failed to initial the record. A late entry was documented per policy, noting the reason for the omission.
Staff Counseling: The staff responsible were counseled individually on the importance of real-time documentation and the regulatory requirement to initial the MAR immediately after medication administration. |
06/11/2025
| Not Implemented |
| 6400.167(a)(1) | Lantus Solostar 100 Unit/ml., inject 44 units under the skin daily at bedtime prescribed to Individual #1 was not administered at 10:00PM on 4/20/25, the corresponding comment read "Never took Lantus medication No medication." | Medication errors include the following: Failure to administer a medication. | Plan of Correction:
Immediate Investigation: On May 3, 2025, the Program Supervisor investigated the incident. It was confirmed that Lantus was not available in the home at the time of administration on 4/20/25 due to a delay in medication refilling.
Medication Refilled: The Lantus Solostar pen was obtained on May 4, 2025 and properly stored. Medication administration resumed as prescribed.
Incident Documentation: A medication error report was completed and reviewed. The error was logged and submitted per agency policy.
Staff Counseling: Staff responsible were counseled on the requirement to report low or missing medication supplies immediately and ensure timely refills. |
06/11/2025
| Not Implemented |