| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #2's most recent individual plan from 9/15/23 states that effective as of their admission date, Individual #2 is authorized for supplemental habilitation at a 2:1 (staff-to-individual ratio) to assist transitioning into residential services due to a history of behaviors. Individual #2's 2:1 staffing ratio will be reviewed in 90 days or on 12/13/23. During the on-site renewal inspection conducted on 9/21/23, CEO #4 and another Direct Support Professional were the only two staff observed to be present with Individual #1. When CEO #4 left the home to continue the renewal inspection with the Department at 12:00 PM, despite the Department representative advising them that they should not be leaving Individual with only one staff per the ISP. Individual #2 was left in the care of one Direct Support Professional until a second staff arrived at 12:27 PM. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | CEO #4 created an incident report in EIM reporting the incident that caused individual #2 to stay with one staff from 12:12pm to 12:27pm which was due to an injury caused by individual #2 on one of the staff members forcing him to leave as soon as CEO #4 arrived. CEO #4 called for a replacement before leaving but replacement arrived 12 minutes later. |
09/25/2023
| Implemented |
| 6400.21(a) | Direct Support Professional #2's date-of-hire is 9/12//23. Documentation that an application for a Pennsylvania criminal history record check had been submitted to the State Police was absent from their record. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The HR Supervisor did the background check for staff #2 on 9/20/2023. The initial background check on file for staff #2 was done on 1/29/2021 because staff #2 used to work for the Homecare business. |
09/23/2023
| Implemented |
| 6400.64(a) | On 9/21/23, ten dead bees were observed on the floor in the living area located on the top floor of the home at 10:10 AM. | Clean and sanitary conditions shall be maintained in the home. | The dead insects were removed on 9/21/2023. |
09/21/2023
| Implemented |
| 6400.64(e) | On 9/21/23, two trash receptacles located outside in the back of the home at the bottom of the stairs and measuring approximately 28 inches in height were observed without lids at 11:10 AM. | Trash receptacles over 18 inches high shall have lids. | The containers seen were not used as trash containers. All containers used for trash were kept in front of the home and were covered. |
09/21/2023
| Not Implemented |
| 6400.72(b) | On 9/21/23, the window in the bathtub area of the bathroom on the top floor of the home was stuck in an open position, was unable to be closed, and was covered with plastic at 10:45 AM. | Screens, windows and doors shall be in good repair. | The window was broken by individual #1 on 9/4/2023. We contacted a handy man on 9/5/2023, who installed temporary coverage on the window. The handyman obtained a proforma invoice from Boulevard Glass & Metal company, Pittsburgh on 9/5/2023. Because it is a specialized window, the supplier has placed an order and is expecting the materials to get the glass window repaired by October 31, 2023. |
10/11/2023
| Not Implemented |
| 6400.80(b) | On 9/21/23, unmaintained vegetation that included bushes with sharp jaggers was observed overgrowing onto the side steps outside of the home at 11:15 AM. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The vegetation was trimmed on 9/22/2023. |
10/11/2023
| Implemented |
| 6400.110(e) | On 9/21/23, the smoke detectors of this 3-floor home were found to be not interconnected at 11:40 AM. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Interconnected smoke detectors were purchased from Home Depot and installed on 10/11/2023. |
10/11/2023
| Not Implemented |
| 6400.113(a) | Individual #1, date of admission 8/9/23, did not receive fire safety training. Individual #2, date of admission 9/15/23, did not receive fire safety training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The CEO registered for the Fire Safety Train the Trainer course on 10/12/2023. Fire Safety Training for staff and individual #1 is scheduled on 10/20/2023. |
10/20/2023
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination completed on 5/27/23, did not include a record of their immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The Program Specialist obtained documentation on immunization of Individual # 1 on 9/22/2023. See attachment. |
10/10/2023
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 8/9/23, did not have tuberculosis testing of any kind demonstrating negative results. | 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 obtained documentation on Tuberculin test result of Individual #1 on 9/22/2023. See attachment. |
10/10/2023
| Implemented |
| 6400.151(a) | Direct Support Professional #2, date-of-hire 9/12//23, did not have a physical examination completed. CEO #4, who regularly has direct contact with individuals, had a physical examination last completed on 1/29/21. | 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. | On September 25, 2023, Direct Support Professional #2 provided a physical dated 9/12/2023. CEO #4 has set up an appointment with PCP for a physical on 10/16/2023. |
10/10/2023
| Not Implemented |
| 6400.151(c)(2) | CEO #4, who regularly has direct contact with individuals, had a tuberculin skin test via Mantoux method last read with negative results on 2/1/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | CEO #4 has set up an appointment with PCP for a physical on 10/16/2023 including tuberculin skin test. |
10/20/2023
| Not Implemented |
| 6400.151(c)(3) | Program Specialist #1's physical examination completed on 5/10/23, did not include a signed statement that indicating they are free of communicable diseases. Direct Support Professional #3's physical examination completed on 8/4/23, did not include a signed statement that indicating they are free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Program Specialist was notified on 9/22/2023 to specifically request PCP to indicate and sign on physical ¿free of communicable diseases¿. |
10/10/2023
| Not Implemented |
| 6400.44(c)(3) | Verification that Program Specialist #1 had 4 years of work experience working directly with individuals with an intellectual disability or autism prior to their date-of-hire of 1/29/21 was not provided. | A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism. | Program Specialist #1 is a Registered Nurse, has an associate degree and currently has 6 years of work experience working directly with individuals with an intellectual disability or autism. Solidarity will provide Degree and Resume that was reviewed as part of the licensure process. |
10/14/2023
| Implemented |
| 6400.46(b) | Program Specialist #1, date-of-hire is 1/29/21, has not been trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Direct Service Worker #2, date-of-hire 9/12/23, has not been training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The CEO registered for the Fire Safety Train the Trainer course on 10/12/2023. Fire Safety Training for staff and individual #1 is scheduled on 10/20/2023. |
10/20/2023
| Implemented |
| 6400.46(c) | Direct Support Professional #2. date-of-hire 9/12/23, did not have orientation training in first aid techniques prior to 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. | Direct support Professional #2 has a CPR Certificate dated 1/3/2023 that was obtained prior to hiring. This will be presented as an attachment. |
10/14/2023
| Implemented |
| 6400.46(d) | Program Specialist #1 was trained in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 7/9/21, receiving a 2-year certification and has not received any training since. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program Specialist provided CPR completed on 5/6/2023. Attached. |
09/23/2023
| Implemented |
| 6400.52(c)(5) | Program Specialist #1's 2022 calendar training year did not include completion of the following required content: the safe and appropriate use of behavior supports. | 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. | Program Specialist #1 was notified by CEO on 10/6/2023 to complete annual training on the appropriate use of behavior Supports. |
12/31/2023
| Implemented |
| 6400.52(c)(6) | Program Specialist #1's 2022 calendar training year did not include completion of the following required content: implementation of the individual plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Program Specialist #1 was notified by CEO on 10/6/2023 to complete annual training on the implementation of the individual support plan. |
12/31/2023
| Implemented |
| 6400.162(a) | Direct Support Professional #3, date-of-hire 8/7/22, did not complete their initial medication administration practicum and have been passing medications. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Direct support Professional #3 completed the initial Medication Administration online training and 4 observations prior to administering medications. CEO #4 who is ODP Medication Administration Trainer contacted ODP Medication Administration Help desk on 10/9/2023 for clarification. Response will be submitted as an attachment. |
10/09/2023
| Implemented |
| 6400.166(a)(7) | On 9/21/23, the medication label on Individual #1's prescribed Polyethylene Glycol Powder 3350 NF was found to read as follows: Take 17 GM (one packet) mixed with liquids then take by mouth daily as needed for constipation. Individual #1's September 2023 Medication Administration Record listed the prescribed medication as follows: Polyethylene Glycol 3330 G -- Mix 17 G in 8 ounces of water/juice. Drink by mouth once daily as needed for constipation. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Medication Administration Trainer corrected the MAR on 10/11/2023 to reflect the exact instructions on the medication label. |
10/11/2023
| Not Implemented |
| 6400.166(a)(8) | Individual #2 is prescribed the following medications: Lithium Orotate Gummy 2.5 MG -- Take two gummies in the afternoon; Gaba 500 MG Capsule---Take capsule once a day in the PM; and L-Theanine 200 MG Chewable---Take once a day in the PM. On 9/21/23, their September 2023 Medication Administration Record do not include the route of administration for these medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The Medication Administration Trainer corrected the MAR on 10/11/2023 to reflect the route as indicated on the medication label. |
10/11/2023
| Not Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed the following medication: Abilify Meintena 400 MG Injection---Inject 400 MG into a muscle every 4 weeks. On 9/21/23, their September 2023 Medication Administration Record did not include the diagnosis or purpose of this medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Medication Administration Trainer corrected the MAR on 10/11/2023 to reflect the diagnosis as indicated in the Doctor¿s instructions. |
10/11/2023
| Not Implemented |
| 6400.166(b) | Individual #1 had the following prescribed medications administered on 9/21/2023 at 9:00 AM but were not initialed as having been given on their September 2023 Medication Administration Record: Hydroxyzine Pamoate 50 MG Capsule; Divalproex Sodium 250 MG DR Tablet; and Guanfacine 1 MG Tablet. Individual #1 is prescribed the following medications: Divalproex Sodium 250 MG DR Tablet -- Take 1 tablet by mouth in the morning and two tablets by mouth at night---and Guanfacine 1 MG Tablet -- Take 1 tablet by mouth two times a day. During the on-site renewal inspection conducted on 9/21/23, Individual #1's August 2023 Medication Administration Record was observed from 8/10/23 to 8/31/23 with a third row of staffs' initials listed underneath the two AM and PM administration time rows for both of the aforementioned medications. This third row of staff's initials did not include an administration time, and the two above medications are both prescribed to be given twice daily. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | he Medication Administration Trainer organized a training on 10/11/2023 to discuss issues relating to medication Administration including the need to ensure that all information to be included in the Medication Administration Record (MAR) as prescribed in 6400.166 are completed. |
10/11/2023
| Not Implemented |
| 6400.166(d) | Individual #2's September 2023 Medication Administration Record and corresponding physician's orders indicate that they are prescribed the following medication: Vitamin C 2,000 MG --Dispense 1 tablet of vitamin C orally daily as needed for cold symptoms. On 9/21/23, the actual medication observed at the home was Vitamin C 1000 MG. | The directions of the prescriber shall be followed. | The Program Specialist contacted individual #2¿s mother on 9/28/2023 who instructed Staff to administer 2 tablets, equivalent to the 2000 MG in the Doctor¿s instructions. The next appointment with Individual #2¿s new PCP is 10/30/2023 to review his medications and correct the prescription. |
10/11/2023
| Implemented |
| 6400.186 | Individual #1's most recent individual plan from 9/6/23, states that they are not safe around knives and sharps due to historical threats of self-harm. On 9/21/23, a razor blade was found at 10:15 AM resting on the windowsill in the living area on the top floor of the home. | The home shall implement the individual plan, including revisions. | The blade found on one of the windows on the top floor of the building was immediately removed on 9/21/2023. |
10/11/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include their religious affiliation. Individual #2's records did not include their religious affiliation. | Each individual's record must include the following information: Personal information, including: (iv) Religious affiliation. | Individuals #1 & #2¿s records were updated on 9/23/2023 to include religious affiliation. |
10/10/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include their next of kin. Individual #2's record did not include their next of kin. | Each individual's record must include the following information: Personal information, including: (v) Next of kin. | Individuals #1 & #2¿s records were updated on 9/23/2023 to include Next of kin. |
10/10/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include their race, height, weight, hair color, eye color, and identifying marks. Individual #2's record did not include their race, height, weight, hair color, eye color, and identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) Their race, height, weight, hair color, eye color, and identifying marks. | Individuals #1 & #2¿s records were updated on 9/23/2023 to include race, height, weight, color of hair, color of eyes and identifying marks. |
10/10/2023
| Not Implemented |
| 6400.213(1)(i) | Individual #1's record did not address their primary language of communication. Individual #2's record did not address their primary language of communication. | Each individual's record must include the following information: Personal information, including: (iii) Primary means of communication. | Individuals #1 & #2¿s records were updated on 9/23/2023 to include language of communication |
10/10/2023
| Implemented |