| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The microwave, located in the kitchen, was dried splattered food covering the interior walls. The microwave was also black on the top inside and appeared to have been on fire. The stairs leading to the second floor of the home were covered with dirt and debris. Individual #1's mattress was covered with various stains, was grayish brown in color and has wearing on the fabric. Individual #1's bedroom had a very pungent odor. | Clean and sanitary conditions shall be maintained in the home. | Serenity care staff will ensure that homes remain clean and in sanitary conditions. Serenity care staff will complete daily cleaning logs documenting the completion of daily mandatory cleaning shift responsibilities. Serenity care staff will deep clean homes weekly to ensure they are in regulatory compliance with Chapter 6400.64(a) . |
07/15/2023
| Implemented |
| 6400.64(b) | The second floor hallway was observed with spider's webs and spiders in the corners at the top of the stairs. | There may not be evidence of infestation of insects or rodents in the home. | Serenity Care staff will ensure that homes are in clean and sanitary conditions shall be maintained in the home at all times. Serenity care staff will complete daily cleaning logs for all chores that are completed daily. Serenity care staff will deep clean homes weekly to ensure that the homes meet sanitary conditions. Serenity Care staff will ensure the homes are swept and dusted and clean any infestation of insects or rodents in the home. |
07/15/2023
| Implemented |
| 6400.64(f) | Trash to include an empty kitchen garbage bag and cigarette butts were found scattered on the patio located at the back of the home. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Serenity Care Program Director will ensure that there are closed receptacles placed on the outside of the homes to ensure grounds are free from any garbage and cigarette butts.
All staff of Serenity Care will be serviced and trained on the implemented policies regarding the disposal of trash and cigarette butts in closed trash receptacles
. |
07/15/2023
| Implemented |
| 6400.67(a) | Individual #1's bedroom walls were covered with writing. The writing included threats toward staff and other individuals, accusations of staff abuse, and descriptions of incident reports spanning from March 2023 to May 2023. | Floors, walls, ceilings and other surfaces shall be in good repair. | Serenity Care maintenance designee will ensure that all floors, walls, ceilings, and other surfaces are repaired including the basement, and are in compliance according to 55 PA Code Chapter 6400.67 (a)
Serenity Care CEO will initiate an internal investigation regarding the allegations that were made by the individual. |
07/25/2023
| Implemented |
| 6400.67(b) | Shopping bags and grocery boxes were thrown and piled at the bottom of the basement stairs causing a potential slipping or tripping hazard. Wooden boards with rusty nails protruding from them were being stored under the basement stairs creating a potential safety hazard. The basement floor surrounding the dryer was covered with spilled powdered laundry detergent creating a potential slipping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Serenity Care maintenance designee will ensure that all floors, walls, ceilings, and other surfaces shall be free of hazardous conditions.
Serenity Care CEO has implemented an electronic work order system to ensure that work order requests are documented and submitted to the maintenance designee, Within 24 hours of the issue being discovered. |
07/15/2023
| Implemented |
| 6400.72(a) | The dining room window contains an air conditioning unit. The unit is not properly fitted into the window with gaps on either side of the unit and no screen is in the window to prevent from infestation. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Serenity Care maintenance designee will inspect all windows containing an air conditioning unit, ensure the units are properly fitted into the window with gaps, and ensure that screens are properly installed in the window to prevent infestation.
All staff of Serenity Care will be serviced and trained on the implemented policies regarding reporting maintenance issues within 24 hours of discovering the problem in the home to ensure that concerns are addressed to ensure homes meet the standards outlined in the 6400 Regulations to prevent any future violations from re-occurring. |
07/25/2023
| Implemented |
| 6400.80(a) | The front steps leading to the porch of the home had multiple steps that are crumbling with lose concrete and uneven stair treads creating a potential tripping hazard. The concrete patio in the rear of the home is covered in moss creating a potential slipping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Serenity Care maintenance designee will ensure that outside walkways shall be free of obstructions and other hazardous conditions including crumbling loose concrete or uneven stair treads creating a potential tripping hazard.
Serenity Care maintenance designee will ensure outside of the building and the yard or grounds shall be well maintained, in good repair, and free from unsafe conditions. |
08/30/2023
| Implemented |
| 6400.80(b) | An old, broken door was laying in the back yard creating a potential hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Serenity Care Maintenance designee will ensure that any broken or hazardous furniture is removed from the outside of the building and the yard or grounds and that the grounds are well maintained, free from unsafe conditions.
All staff of Serenity Care will be serviced and trained on the implemented policies regarding reporting maintenance issues within 24 hours of discovering the problem in the home to ensure that issues are addressed to ensure homes meet the standards outlined in the 6400 Regulations to prevent any future violations from re-occurring. |
07/15/2023
| Implemented |
| 6400.81(i) | Individual #1's bedroom has two windows and neither had window coverings to provide privacy. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | The Program Director will ensure that all bedrooms have appropriate coverings for the windows and ensure that individuals are provided with privacy. |
07/25/2023
| Implemented |
| 6400.81(k)(3) | Individual #1's bed did not have sheets or pillow cases. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | Serenity Care staff will ensure that each individual bedroom has adequate bedding, including pillows, linens, and blankets appropriate for the season.
Serenity Care staff will ensure that all linen is washed weekly and/or as needed to ensure that they are clean and in compliance with the 55 PA Code Chapter 6400 regulations.
Serenity Care Program Director will ensure that the home has extra linen in the homes for appropriate seasons. |
07/15/2023
| Implemented |
| 6400.82(f) | No toilet paper was present in the 2nd floor full bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Serenity Care Staff will ensure that each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels, and trash receptacles.
Serenity Care Program Director will ensure that the homes are stocked with the necessary items to ensure compliance with 55 PA Code Chapter 6400.82(f). |
07/15/2023
| Implemented |
| 6400.110(a) | the home did not have a smoke detector present on the second floor. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Serenity Care maintenance designee will ensure that all homes have a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
The Program Director will ensure that any non-operable automatic smoke detectors are submitted to electronic work order system to ensure that work order requests are documented and submitted to the maintenance designee, Within 24 hours of the issue being discovered. |
07/15/2023
| Implemented |
| 6400.111(e) | The fire extinguisher on the second floor of the home was locked in the staff office and was not accessible to the individual in case of a fire. | A fire extinguisher shall be accessible to staff persons and individuals. | The Program Director and or Maintenance Designee will ensure that the fire extinguishers in the homes are easily accessible to the staff persons and individuals.
The Program Director will ensure that any visible issues with fire extinguishers in the homes are submitted to the electronic work order system to ensure that work order requests are documented and submitted to the maintenance designee, Within 24 hours of the issue being discovered.
Serenity Care staff persons and individuals shall be in-serviced as to the locations of the fire extinguishers in the homes. |
07/25/2023
| Implemented |
| 6400.171 | An open bag of Lays potato chips was found on the floor of the living room next to the couch. The bag was not closed or sealed to prevent from contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Serenity Care staff will ensure that all food shall be protected from contamination and properly sealed. Serenity Staff will ensure that homes are cleaned daily and any unused food is properly stored and dated or discarded. |
07/15/2023
| Implemented |
| 6400.214(b) | While completing an on-site review of individual #1's records, the most recent assessment was not kept at the residential home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Serenity Care Program Director will ensure a file for each individual at each home. This file will contain each individual's most recent annual physical, annual assessment, and ISP. This book will keep locked in each home's respective office area. |
07/15/2023
| Implemented |
| 6400.18(b)(2) | While completing a medication audit for individual #1 on-site on 6/16/2023 at 1:30PM, it was discovered and reported to the agency Program Specialist that the following medications were not administered on 6/7/2023 at 8:00AM: Vitamin D 1000 units; Loratadine 10mg tablet. The incident report for this medication error was not entered into EIM within 72 hours. The incident had not been entered into EIM as of 6/27/2023 at 11:15am. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Serenity Care Program Director will ensure that all medication errors are entered into EIM within 72 hours through the Department's information management system.
Serenity Care certified assigned nurse will complete weekly audits to ensure all MARS are in compliance and that there are no non-reported medication errors. |
07/15/2023
| Implemented |
| 6400.165(c) | On 6/7/2023, the following medications were not administered to Individual #1 at 8:00AM Vitamin D 1000 units; Loratadine 10mg tablet. These medications were still present in the pillow pack for that day and time. | A prescription medication shall be administered as prescribed. | Serenity Care will ensure that A medication record shall be kept for each individual for whom a prescription medication is administered. Serenity Care staff will ensure that individual prescription medications are administered as prescribed.
The Program Director will ensure that there are medications still present in the pillow packs that should have been administered. |
07/15/2023
| Implemented |
| 6400.165(g) | Individual #1's most recent psychiatric medication review was completed on 2/14/2023. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Serenity Care CEO, Program Director, agency nurse, and any other leadership designee will ensure that if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
07/15/2023
| Implemented |
| 6400.166(a)(13) | The June 2023 Medication Administration Record did not contain the initials of the staff that administered the following medications to individual #1: Olanzapine 15mg tab on 6/2/2023 at 6:00PM, 6/3/2023 at 6:00PM, 6/6/2023 at 6:00PM, 6/7/2023 at 6:00PM, 6/10/2023 at 6:00PM, 6/11/2023 at 6:00PM, 6/12/2023 at 6:00PM, 6/13/2023 at 6:00PM, 6/14/2023 at 6:00PM; Omeprazole 20mg tab on 6/2/2023 at 6:00PM, 6/3/2023 at 6:00PM, 6/6/2023 at 6:00PM, 6/7/2023 at 6:00PM, 6/10/2023 at 6:00PM, 6/11/2023 at 6:00PM, 6/12/2023 at 6:00PM, 6/13/2023 at 6:00PM, 6/14/2023 at 6:00PM; Vitamin D 1000 unit on 6/6/2023 at 8:00AM, 6/8/2023 at 8:00AM, 6/11/2023 at 8:00AM, 6/12/2023 at 8:00AM, 6/13/2023 at 8:00AM, 6/14/2023 at 8:00AM, 6/15/2023 at 8:00AM, 6/16/2023 at 8:00AM; Loratadine 10 mg tab on 6/6/2023 at 8:00AM, 6/8/2023 at 8:00AM, 6/11/2023 at 8:00AM, 6/12/2023 at 8:00AM, 6/13/2023 at 8:00AM, 6/14/2023 at 8:00AM, 6/15/2023 at 8:00AM, 6/16/2023 at 8:00AM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the name and initials of the person administering the medication.
Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the name and initials of the person administering the medication.
The designated site nurse will immediately report concerns to the CEO and other leadership designees. |
07/15/2023
| Implemented |