| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.21(b) | The Agency commenced operation of this Community Home for Individuals with an Intellectual Disability or Autism on November 20, 2023, prior to the submission of an application and approval from the Department. | The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued. | Victory Health Inc received this violation due to an emergency move that was not approved by ODP nor was it relayed through all the proper channels in regards to the individuals team. |
12/23/2023
| Implemented |
| 6400.66 | There is not a source of outside light at the exit from the basement on the side of the home. [Repeat Violation, 12/22/2022, 4/20/2023] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| We received this violation due to lack of enough light in rear of home. We had our maintenance man install an exterior light outside the door |
01/04/2023
| Implemented |
| 6400.70 | At 2:38PM, the telephone in the home was not connected to an outside line. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| We received this violation due to emergency Victory Health cell phone was not onsite during time post move in. We had the telecommunications company scheduled to connect the phone on 11/25/23 |
01/04/2023
| Implemented |
| 6400.80(b) | At 2:26PM, a quarter inch thick layer of moss was on the outside concrete steps between the exit from the basement to the side of the home posing slipping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | We received this violation due to moss growing on certain cement steps on the exterior steps. We hired an pressure washer to clean the steps. |
01/05/2023
| Implemented |
| 6400.101 | At 2:28PM, the inside of the exit door, from the basement of the home, has four "hook and eye" locks and a slide locking mechanism posing an obstructed egress. [Repeat Violation, 12/22/2022, 6/29/2023] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| We received this violation due to scheduling of contractor to remove locks was not done in a timely manner. We had our maintenance man remove the latches from the door on 11/23/2023 |
01/05/2023
| Implemented |
| 6400.107 | At 2:20PM, a portable space heater was in the closet in the staff office. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| We received this violation because the home owner was supposed to pickup space heater from home before move in. They failed on picking it up. The space heater was removed from the home by Victory Health and taken to external site where the home owner can arrange pickup. |
01/04/2023
| Implemented |
| 6400.193(a) | The knives and scissors are locked in the closet of the staff office. Individual #1 does not have a restrictive procedure plan. | A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. | What actions were taken to resolve issue. We received this violation due to the fact individual ISP did not specify locking up of poisons, knives, and scissors. All knives scissors and poisons were removed from the staff closet. |
01/05/2023
| Not Implemented |