Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286183 Renewal 04/01/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1 requires assistance with making purchases on his own behalf. Per documentation in the individual's financial record, the provider utilized the individual's funds to purchase personal cleansing wipes for Individual #1 on the following occasions: Sam's Club on 03/29/2026 ($65.22), Walmart on 10/15/2025 ($66.52), Walmart on 06/27/2025 ($17.85), and Dollar Tree on 03/26/2025 ($15.00). In addition, the provider utilized the individual's funds to purchase both personal cleansing wipes and shampoo for Individual #1 at Target on 09/18/2025 ($34.21). All of these items are personal care items that should be covered under the individual's Room & Board payments to the provider. As such, the total amount of $198.80 of Individual #1's funds were not used for the individual's benefit when the provider assisted the individual in making the noted purchases.Individual funds and property shall be used for the individual's benefit. The above-mentioned receipts were reviewed by LHSS Quality and Compliance Manager. During review, it was determined that the following items/amounts were purchased using Individual #1's funds: -$65.22 on wipes at Sam's Club on 03/29/26 -$25.38 on wipes at Walmart on 10/15/25 (not $66.52) -$34.21 on wipes and shampoo at Target on 09/18/25 -$06.87 on wipes at Walmart (remaining money was spent on socks which are not included in R&B) -$15.00 on wipes at Dollar Tree on 03/26/25 Total for these receipts would be $146.68 owed to Individual #1. However: -an additional receipt for $16.99 on wipes at Redner's on 01/06/26 was found Complete total is $163.67. LHSS reimbursed Individual $163.67 on 04/21/26. 04/22/2026 Implemented
6400.71At the time of inspection, there were no emergency telephone numbers on or by the telephone located in the home's kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The telephone related to this citation did not have emergency numbers on or by it as part of a restrictive plan for Individual #1's housemate. Housemate frequently made false reports to local EMS and the plan had been created at the request of representatives from the local fire and police departments who attended a team meeting for the housemate in August of 2025. LHSS program manager removed this phone from the home on 04/14/26. It was no longer necessary as Individual #1's housemate was discharged from LHSS on that date. 04/14/2026 Implemented
6400.77(b)At the time of inspection, there was no tape located within the home's first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. On 04/02/26, LHSS operations director visited all LHSS CLAs where he removed all first aid kits with missing items and replaced them with kits which contained all required items. 04/22/2026 Implemented
6400.110(e)This home has three full stories, including a basement, first floor, and second floor. At the time of inspection, although all three smoke detectors within the home were independently operable, they were not all interconnected. The smoke detectors on the second floor and in the basement were interconnected with each other; however, the smoke detector on the first floor would not sound when the other two were set off nor would the other two sound when the first floor smoke detector was set off.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. LHSS operations director replaced the smoke detectors in the home with ones which are interconnected on 04/17/26. 04/22/2026 Implemented
6400.144Per Individual #1's April 2026 Medication Administration Record (MAR), this individual was prescribed Mucus Relief Tab 600MG ER ("Take 2 Tablets (1200MG) by mouth twice a day"). This medication could not be located on site during the physical site inspection. As this prescribed medication was unavailable to the individual, the provider failed to arrange pharmaceutical services for the individual.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The current script for this medication did not have any refills. LHSS program manager has communicated with Individual #1's PCP several times (03/25, 04/01, 04/06, 04/21) in an attempt to obtain either a refill or a discontinue order but neither LHSS nor Individual #1's pharmacy have received anything. Program manager will continue to follow-up with the PCP (with slightly increased, but still reasonable, frequency) to resolve this issue as soon as possible. 04/22/2026 Implemented
6400.181(e)(10)Individual #1's most recent Individual Assessment was dated 10/26/2025. The provider maintained a Lifetime Medical History (LMH) in the Individual Record as a separate document, ostensibly to accompany the assessment. The two most recent iterations of this LMH were dated 11/21/2024 and 03/05/2026. As neither of these LMH documents had a date matching the date of the Individual Assessment, the 10/26/2025 Individual Assessment did not include a LMH, which is a required component of the assessment.The assessment must include the following information: A lifetime medical history. LHSS has hired a new program specialist who will be starting on 04/27/26. They will ensure that assessments for each individual served include the LMH. 04/27/2026 Implemented
6400.163(h)The following medication was found in the home and prescribed for Individual #1: Fluticasone Propionate 50mcg Nasal Spray with instructions to "Instill 2 sprays in each nostril for seven days." Per the pharmacy label, this medication was dispensed to the individual on 01/02/2026 and was not entered onto the individual's April 2026 Medication Administration Record (MAR). This medication was not discarded or destroyed after the seven days of administration specified on the prescription elapsed.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.This medication was removed from the home and destroyed in a safe manner on 04/02/26 by LHSS program manager. 04/22/2026 Implemented
6400.165(c)Per Individual #1's April 2026 Medication Administration Record (MAR), this individual was prescribed Mucus Relief Tab 600MG ER ("Take 2 Tablets (1200MG) by mouth twice a day"). This medication was not on site during the physical site inspection. Staff did not initial the MAR for the 04/01/2026 administration time. An empty blister-pack for this medication was located in the staff office; each individual empty blister on the pack was dated with a date of administration. Per the dates on this blister-pack, the last administration of this medication occurred at 8:00pm on 03/28/2026. The evidence showed that Individual #1 was not administered this medication as prescribed between 03/29/2026 at 8:00am and 04/01/2026 at 8:00am. Per Individual #1's April 2026 MAR, this individual was prescribed Risperidone Tab 1mg ("Take 2 tablets (2mg) daily in the afternoon (4pm) (DX: Autistic Disorder)"). This medication's 4pm blister-pack had a blister dated 03/31/2026 that was partially popped out with one pill observed to be inside of the blister. The evidence showed that Individual #1 was administered only one 1mg tablet (1mg) on 03/31/2026 instead of the two 1mg tablets (2mg) prescribed. Because the individual received the wrong dose at this administration time, this medication was not administered to the individual as prescribed.A prescription medication shall be administered as prescribed.The current script for Individual #1's Mucus Relief medication did not have any refills and the last tab was taken on 03/29/26 at 8PM. LHSS program manager has communicated with Individual #1's PCP several times (03/25, 04/01, 04/06, 04/21) in an attempt to obtain either a refill or a discontinue order but neither LHSS nor Individual #1's pharmacy have received anything. Program manager will continue to follow-up with the PCP (with slightly increased, but still reasonable, frequency) to resolve this issue as soon as possible. The staff who administered Individual #1's 4PM Risperidone participated in a "refresher" med admin training on 04/17/26. 04/22/2026 Implemented
6400.165(f)Per psychotropic medication review forms dating back to 02/24/2025, Individual #1 had been prescribed medications to treat the symptoms of a psychiatric illness. The only Behavioral Support Plan (BSP) located in Individual #1's Individual Record was dated 09/16/2025. Although this individual was prescribed a medication to treat the symptoms of a psychiatric illness between 02/24/2025 and 09/16/2025, there was no BSP or protocol to address this individual's social, emotional, or environmental in place for the individual during that time frame as required.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.LHSS has hired a new program specialist who will be starting on 04/27/26. They will ensure that any individuals served by LHSS who take psychotropic medications but do not have a BSP have a written protocol to address their social, emotional, and environmental needs. 04/27/2026 Implemented
6400.166(a)(8)Per Individual #1's April 2026 Medication Administration Record (MAR), this individual was prescribed Pro re Nata (PRN) Hemorrhoidal Ointment for hemorrhoids. The MAR contained two different sets of administration instructions for this medication: 1) "Apply topically around the anus up to 4 times a day as needed for hemorrhoids (pain, burning, irritation)" and 2) "Insert 1 application into rectum 4 times a day as needed for hemorrhoids." The pharmacy label on the medication matched the second set of instructions. The route of administration for this medication was unclear based on the MAR entries, as one suggested a topical application and one suggested a rectal application.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The topical administration instructions were removed from the MAR on 04/17/26. 04/22/2026 Implemented
6400.166(a)(11)Per Individual #1's April 2026 Medication Administration Record (MAR), this individual was prescribed Mucus Relief Tab 600MG ER ("Take 2 Tablets (1200MG) by mouth twice a day"). The entry for this medication on the MAR did not contain a diagnosis or purpose for the 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 current script for Individual #1's Mucus Relief medication did not have any refills and the last tab was taken on 03/29/26 at 8PM. LHSS program manager has communicated with Individual #1's PCP several times (03/25, 04/01, 04/06, 04/21) in an attempt to obtain either a refill or a discontinue order but neither LHSS nor Individual #1's pharmacy have received anything. Program manager will continue to follow-up with the PCP (with slightly increased, but still reasonable, frequency) to resolve this issue as soon as possible. If the medication is refilled instead of discontinued, LHSS program manager will ensure that the diagnosis is included in the new order. 04/22/2026 Implemented
SIN-00269887 Renewal 07/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(g)Sleep drills are documented as occurring on 2/6/25 at 12:30am and 8/6/24 at 12:30am. All fire drills shall be held at different times of the day and night. Fire drills shall be held on different days of the week and at different times of the day and night. A fire drill schedule has been created specific for each home with different date and time of fire drill completion. 08/04/2025 Implemented
6400.141(c)(3)There was no documentation to illustrate that Individual #1 had a Tdap completed as required prior to admission on 5/19/25 or after.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. Individual #1 physical was reviewed and completed by Primary Care Physician (PCP). The physical form completed indicated information related to Individual immunization record that was initially omitted. 08/04/2025 Implemented
6400.181(a)Individual #1 was admitted into the program on 5/19/25. There was no assessment in the record for Individual #1 at the time of inspection record review on 7/22/25. 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. Individual #1 initial assessment has been completed the Program Specialist immediately after licensing inspection. 08/04/2025 Implemented
6400.211(b)(3)At the time of inspection, the name, address and telephone number of the person able to give consent for emergency medical treatment was not easily accessible in the home nor found in Individual #1's record.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Agency has created a medical authorization and consent for emergency treatment form immediately after licensing. The form has been signed by the Individual and all pertinent information listed on it. 08/04/2025 Implemented
6400.52(c)(6)Staff #1 was reported to be a new hire at this location. When the record was requested, it was noted that Staff #1 was not a new hire and did not work at this location. Documentation of training on the Individual Support Plan (ISP) for the individual Staff #1 works with was requested. The document submitted for review did not appear to be an original document with a cut and paste over for his signature. Due to the state of the signature sheet provided the document could not be used as verification that the training had been completed with Staff #1 as required.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.Staff member #1 has been retrained on the Individual¿s current ISP and BSP on July 23, 2025. 08/04/2025 Implemented
6400.165(c)At time of inspection on Wednesday 7/23/25 Individual #1 had a birth control noted to be Noreth/Ethin tab 1mg to be given as "take 1 tablet by mouth daily for contraceptive." The manufacturer blister pack in use was dispensed by the pharmacy on 7/7/25. The medication was documented as being administered each day, including 7/23/25 on the July 2025 Medication Administration Record. The manufacturer blister pack is labeled by the day of the week that the pill is to be administered on. The blister pack in use had the first row of pills popped with the last day popped being a Saturday. The Saturday pill was administered on a Wednesday.A prescription medication shall be administered as prescribed.Individual #1 Pharmacy was immediately contacted after licensing for a new blister pack with matching dates. The medication had been sent by the Pharmacy and now in the individual¿s med box. 08/04/2025 Implemented
6400.166(a)(10)Individual #1 was given their Pro Re Nata Hydroxyz HCL at 8am on 7/18/25. An additional dose is documented as being administered after the 8am administration but no time was recorded for the administration as required.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.All Individual # 1 staff members took a refresher course on PA medication administration training on July 25, 2025. 08/04/2025 Implemented
6400.207(4)(I)At the time of inspection, the July 2025 Medication Administration Records (MARs) for Individual #1 noted an entry for Hydroxyz HCL 25mg "take 1 tablet by mouth every 8 hours as needed for anxiety do not give together with Zolpidem. Give 1 hour prior to Zolpidem." The Pharmacy label indicates that the medication was dispensed on 7/14/25. The July 2025 MARs for Individual #1 indicate that the medication had been administered for anxiety on 7/16/25 8am, 7/17/25 8am & 8pm, 7/18/25 8:00am and an additional dose with no time documented, 7/19/25 8am, 7/20/25 8am, 7/21/25 8am and 7/22/25 at 8:00am. At the time of inspection on 7/23/25 there was no protocol in the home that outlined all required items to administer the Pro Re Nata psychotropic medication. Upon request a protocol was submitted and dated as 7/14/25. Staff reported that the protocol would be in the home on 7/23/25.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The MAR was immediately corrected right after licensing inspection. Agency Director of Operations completed a review and refresher training of PA 15 Medication administration steps for all staff members currently providing care for the individual to ensure that medications are administered as prescribed. 08/04/2025 Implemented
SIN-00250041 Renewal 08/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Both sets of venetian blinds located in Individual #2's bedroom were coated with a thin layer of dust visible to the naked eye and slightly tacky to the touch.Clean and sanitary conditions shall be maintained in the home. Individual #2 sets of venetian blinds were properly cleaned right after licensing inspection. 09/30/2024 Implemented
6400.67(a)One of the two sets of venetian blinds located in Individual #2's bedroom was missing several of its individual slats, while more appeared to be partially broken.Floors, walls, ceilings and other surfaces shall be in good repair. Individual #2-bedroom venetian blinds have been replaced immediately after licensing inspection. 09/30/2024 Implemented
6400.82(f)At the time of inspection, the home's first-floor bathroom lacked individual clean paper or cloth towels.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. Clean paper towels were placed in the bathroom during licensing inspection. 09/30/2024 Implemented
6400.151(a)Per the Staff Record, Staff #1's two most recent physical examinations occurred on 11/11/2021 and 12/19/2023, more than two years apart. This staff did not receive a physical examination at least once every two years as required. 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. An annual physical tracking form has been created to ensure accurate and on time completion of all future staff¿s physicals. Staff will receive a first notice about their upcoming physical 90 days before the physical is due. A second notice will be sent 45 days before the due date and a final notice will be sent 30 days prior to the due date. 09/30/2024 Implemented
SIN-00229127 Renewal 07/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The trash receptacle located outside of the home on the back deck did not have a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.A new trash can with an attached lid that meets ODP regulatory standard has been purchased for the home on 8/7/2023. 08/21/2023 Implemented
6400.112(e)Fire drills must be held during sleeping hours at least every 6 months. A fire drill was held during sleeping hours on 8/17/2022, then not again until 3/08/2023; a span of seven months.A fire drill shall be held during sleeping hours at least every 6 months. Agency August Fire Drill will be held in the beginning of the month and that drill will be held during the night for this home. 08/21/2023 Implemented
6400.51(b)(4)Staff person #3, who was hired on 5/08/2023 and did not complete training in recognizing and reporting incidents as part of orientation training.The orientation must encompass the following areas: recognizing and reporting incidents.Staff person #3 has completed training on recognizing and reporting incidents as part of orientation trainings on 7/26/2023. 08/21/2023 Implemented
6400.52(a)(1)Staff persons #1 and #2 did not complete 24 hours of training during training year 7/01/2022 to 6/30/2023.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Staff person #1 and #2 has completed 24 hours of training and all mandatory ODP annual training hours for this year¿s training calendar on 8/7/2023. 08/21/2023 Implemented
6400.52(c)(1)Staff persons #1 and #2 did not complete training during training year 7/01/2022 to 6/30/2023 in person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.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.Staff person #1 and #2 has completed 24 hours of training and all mandatory ODP annual training hours for this year¿s training calendar on 8/7/2023. 08/21/2023 Implemented
6400.52(c)(2)Staff persons #1 and #2 did not complete training during training year 7/01/2022 to 6/30/2023 in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adult Protective Services Act, the Child Protective Services Law and the Adult Protective Services Act.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.Staff person #1 and #2 has completed 24 hours of training and all mandatory ODP annual training hours for this year¿s training calendar on 8/7/2023. 08/21/2023 Implemented
6400.52(c)(3)Staff persons #1 and #2 did not complete training during training year 7/01/2022 to 6/30/2023 in Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff person #1 and #2 has completed training on Individual rights. 08/21/2023 Implemented
6400.52(c)(4)Staff persons #1 and #2 did not complete training during training year 7/01/2022 to 6/30/2023 in Recognizing and Reporting Incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff person #1 and #2 has completed training on in Recognizing and Reporting Incidents. 08/21/2023 Implemented
6400.169(a)Staff #3 did not successfully complete a Department-approved medication administration course and was passing medication. The staff person passed the test portion of the medication administration course, but there is no record that the required Medication Administration Observations were completed. The Medication Administration Record for May 2023 shows that the staff has been administering medication since May 14, 2023.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).A staff training on Medication Administration has been completed by staff member #1 on 8/8/2023. Staff member number 1 has also completed Recognizing and reporting incidents training on 7/26/2023. 08/21/2023 Implemented
SIN-00216955 Unannounced Monitoring 01/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #2 is prescribed Baqsimi One Pow 3mg, spray one device (3mg) in one nostril to treat severe hypoglycemia. The medication was not in the home at the time of inspection. Agency staff reported to licensing representative that Individual #2 recently returned from being home with their mother and the medication is there. Pharmaceuticals that are prescribed for the individual shall be provided.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The Pharmacy for individual #2 was called immediately after licensing inspection was completed for a refill. The medication was immediately delivered. 02/05/2023 Implemented
SIN-00213712 Unannounced Monitoring 10/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(8)Individual #1 is prescribed Novolog ASPA INJ Flexpen. The pharmacy label and the Medication Administration Record (MAR) state: Use carb ratio 1:5 with meals plus sliding scale. TDD to 60 units. The MAR did not indicate the route of the medication. (Repeat Violation July 26, 2022 and Sept 2022)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The Individual¿s Doctor was contacted and has issued a new script that indicated documentation of the route of his medication on the MAR. The individual¿s Medication Administration Record has been corrected as a result and the route of the medication has therefore been added on his MAR. All this was effective the day the last licensing check was completed. 11/13/2022 Implemented
6400.166(a)(11)Individual #1 is prescribed Levocetirizi, Lisinopril, montelukast, and melatonin. The October Medication Administration Record (MAR) does not include the diagnosis or purpose of the medication. (Repeat Violation July 26, 2022 and Sept 2022)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 Individual¿s Doctor was contacted and has issued a new script that indicated documentation of diagnosis on the MAR for his Levocetirizi, Lisinopril, montelukast, and melatonin. The individual¿s Medication Administration Record has been corrected as a result and the diagnosis of the medications listed above has therefore been added on his MAR. All was effective the day the last licensing check was conducted. However, his Levocetirizi has been discontinued. 11/13/2022 Implemented
SIN-00212784 Unannounced Monitoring 09/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Fire drills are being held monthly, however fire drills are not being held unannounced. There is a calendar with the date, time, alarm to be use and hypothetical location of the fire located in the fire drill record book making staff and potentially the individual residing in the home aware of when the fire drills will take place. An unannounced fire drill shall be held at least once a month. The fire drills calendar was immediately removed and shredded during licensing inspection last month. 10/21/2022 Implemented
6400.141(c)(13)The physical examination for individual #1 was completed on 12/3/21 with the document being updated to include missing information by the Primary Care Physician on 8/25/2022. The updated physical document did not include information related to allergies located on page 1 of the physical form. (Repeat Violation July 26, 2022)The physical examination shall include: Allergies or contraindicated medications.The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals and the form completed indicated information related to his allergies. 10/21/2022 Implemented
6400.141(c)(14)The physical examination for individual #1 was completed on 12/3/21 with the document being updated to include missing information by the Primary Care Physician on 8/25/2022. The updated physical document did not include information pertinent to diagnosis and treatment in case of an emergency. (Repeat Violation July 26, 2022)The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals and the form completed include information pertinent to diagnosis and treatment in case of emergency. 10/21/2022 Implemented
6400.166(a)(7)Individual #1 is prescribed Novolog ASPA INJ Flex pen. The pharmacy label and the Medication Administration Record (MAR) state: Use carb ratio 1:5 with meals plus sliding scale. TDD to 60 units. The MAR did not indicate the dose of the medication. There is a sliding scale maintained with the MAR, however when Novolog is administered based on the 1:5 carb ratio utilizing the sliding scale, there is no documentation of what the dose being administered is located on the MAR. (Repeat Violation July 26, 2022)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.After series of correspondence with the prescribing doctor for past months, the individual¿s Medication Administration Record has been corrected and the dosage of the medication has been added on the MAR. The Individual¿s Doctor has also issued a new script that indicated documentation of the doses being administered on the MAR for all the insulin administration times. 10/21/2022 Implemented
6400.166(a)(8)Individual #1 is prescribed Novolog ASPA INJ Flexpen. The pharmacy label and the Medication Administration Record (MAR) state: Use carb ratio 1:5 with meals plus sliding scale. TDD to 60 units. The MAR did not indicate the route of the medication. (Repeat Violation July 26, 2022)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.After series of correspondence with the prescribing doctor for past months, the individual¿s Medication Administration Record has been corrected and the route of the medication has been added on the MAR. The Individual¿s Doctor has also issued a new script that indicated documentation of the doses being administered on the MAR for all the insulin administration times. 10/21/2022 Implemented
6400.166(a)(11)Individual #1 is prescribed Ariprazole and Fish Oil. The September Medication Administration Record (MAR) does not include the diagnosis or purpose of the medication. (Repeat Violation July 26, 2022)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.After series of correspondence with the prescribing doctor for past months, the individual¿s Medication Administration Record has been corrected and the diagnosis or purpose of his Ariprazole and Fish oil medication has been added on the MAR. 10/21/2022 Implemented
SIN-00209083 Unannounced Monitoring 07/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Fire drills held on 11/22/21, 12/22/21 and 3/31/22 did not record the time it took for evacuation. Fire drills held on 11/22/21 and 12/22/21 did not indicate AM or PM for time of day. Both drills recorded the time of drill as 1:30. There was no additional information on the fire drill form that would indicate whether the drill was held during AM or PM hours.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drills forms in question were reviewed and corrected. 08/25/2022 Implemented
6400.141(a)Individual #1 was admitted into the program on 11/19/21. The physical presented for Individual #1 was completed on 12/3/21. Physicals must be completed within 12 months prior to admission.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. 08/25/2022 Implemented
6400.141(c)(1)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain a review of previous medical history.The physical examination shall include: A review of previous medical history. The individual physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The individual¿s previous medical history was added on the review and completion. 08/25/2022 Implemented
6400.141(c)(2)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain information to support that a general physical exam had been completed.The physical examination shall include: A general physical examination. The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The completed physical is attached with all supporting documents. 08/25/2022 Implemented
6400.141(c)(3)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain a verification that immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control had been completed.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 individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The physical contained the individual¿s immunization record. 08/25/2022 Implemented
6400.141(c)(6)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain verification that Tuberculin skin testing had been completed as required.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 individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals and the form completed indicated that Tuberculin and skin testing was completed. 08/25/2022 Implemented
6400.141(c)(11)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals and the form completed also indicated an assessment of the individual¿s health maintenance needs, medication regiment and the need for blood work recommendation intervals. 08/25/2022 Implemented
6400.141(c)(12)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain a review of the physical limitations of the Individual.The physical examination shall include: Physical limitations of the individual. The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained a review of the physical limitations of the individual. 08/25/2022 Implemented
6400.141(c)(13)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain information pertaining to allergies or contraindicated medications.The physical examination shall include: Allergies or contraindicated medications.The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new form completed contained information pertaining the individual¿s allergies or contraindicated medications. 08/25/2022 Implemented
6400.141(c)(14)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained medical information pertinent to the individual¿s diagnosis and his treatment as well in emergency situations. 08/25/2022 Implemented
6400.141(c)(15)The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained special instructions for the individual¿s diet. 08/25/2022 Implemented
6400.151(c)(3)The physical exam presented for Staff #1 that was completed on 12/28/21 did not contain 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. 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. The staff¿s physical was reviewed and the Doctor that did the initial physical. The new completed form contained a signed statement that the staff person is free of communicable diseases. 08/25/2022 Implemented
6400.181(a)Individual #1 was admitted into the program on 11/19/21 and had an initial assessment completed on 12/9/21. The assessment completed was primarily a checklist. The required sections of Lifetime Medical History, Strengths, Dislikes, Supervision needs, Health, Recreation, Managing Personal Property and Community Integration were either missing or lacked adequate information. The assessment lacked personalization and was not individualized. The assessment cannot be vague or nonspecific. Assessments cannot be completed simply to meet the regulatory or programmatic requirements. Providers must develop assessments that are meaningful, accurate, and useful. 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. Another annual assessment was completed on 8/3/2022 by the agency Program Specialist. The required sections of the individual¿s Lifetime Medical History, Strengths, Dislikes, Supervision needs, Health, Recreation, Managing Personal Property and Community Integration were personalized based on the individual¿s goals and outcomes. 08/25/2022 Implemented
6400.34(a)Incomplete review of individual rights for Individual #1 was completed on 11/19/21. The following rights were not reviewed: 6400.34D, E, F, G, I, P, Q, R, S, T, U and V. Full review is required to satisfy the regulation.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.A staff training on all individual rights statement has been completed on 8/15/2022. The individual was trained as well on his rights. 08/25/2022 Implemented
6400.163(a)At time of inspection on 7/27/22 a prescription Glucagon Emergency Kit was in the locked medication box of Individual #1. There was no pharmacy label on the Glucagon Emergency Kit. At time of inspection on 7/27/22 a prescription Baqsimi Glucagon nasal powder 3mg was in the locked medication box of Individual #1. There was no pharmacy label on the Baqsimi. Staff #4 confirmed that both medications belonged to Individual #1.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.All individual¿s old medication has been returned to the Pharmacy immediately after licensing. Individual¿s Doctors were contacted for new scripts with all medications in question. The Pharmacy was also contacted for new med label with only current medications. All agency staff has been re-trained on PA medication administration training on 8/04/2022. 08/25/2022 Implemented
6400.163(h)At time of inspection on 7/27/22 a Glucagon Emergency Kit that lacked a pharmacy label was located in the locked medication box for Individual #1. The expiration date on the Glucagon Emergency Kit box was 12/2021. An Epinephrine Injection, USP Auto Injector 0.3 mg was located in the locked medication box for Individual #1. The pharmacy label indicated "Discard after 6/28/22." Expiration date on the box was Mar of 2023. Pharmacy label directions are to be followed. Expired medication shall be discarded promptly and as directed.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.All individual¿s old medication has been returned to the Pharmacy immediately after licensing last month. Individual¿s Doctors were contacted for new scripts with all medications in question. The Pharmacy was also contacted for new med label with only current medications. All agency staff has been re-trained on PA medication administration training on 8/04/2022. 08/25/2022 Implemented
6400.165(b)Individual #1 Individual Support Plan last updated on 7/27/22 indicates that Individual #1 has a shellfish and tree nut allergy both with a reaction of throat swelling. The assessment for Individual #1 dated 12/9/21 indicates that Individual #1 has a tree nut allergy with a reaction listed as "Anaphylaxis." An Epinephrine Injection, USP Auto Injector 0.3 mg was located in the locked medication box for Individual #1 at the time of inspection. The pharmacy label indicated "Discard after 6/28/22" and "Refill 3 times until 06/27/2022." The prescription for the Epinephrine Injection, USP Auto Injector 0.3 mg was not current. A prescription order shall be kept current.A prescription order shall be kept current.The individual¿s Primary Care Physician was contacted immediately for a script for his Epinephrine. A script was sent to the Pharmacy and new Epinephrine has been delivered to his home. All agency staff members has been re-trained on PA medication administration training on 8/04/2022. 08/25/2022 Implemented
6400.165(g)Individual#1 had three-month medication reviews on 5/23/22, 3/28/22 and 4/25/22. The 5/23/22 medication review did not record the dosages of the medications. The 3/28/22 medication review did not include the dosages for Buspirone, Effexor or Abilify.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.Individual¿s Psychiatrist has completed another Med review form that includes the dosages the reasons for all his psych medications and the need for him to continue with his current psych medications. 08/25/2022 Implemented
6400.166(a)(7)The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the dose of the medication. The pharmacy label documents the medication as "Use carb ratio 1:5 with meals plus sliding scale. TDD to 60 units. (DX:Type 1 diabestes mellitus without complications.)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The individual¿s Endocrinologist was contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and carb ratio. The scrip and the medical statement is attached with all supporting documents. 08/25/2022 Implemented
6400.166(a)(8)The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The individual¿s Endocrinologist was contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and carb ratio. The scrip of the medication attached indicated subcutaneously as the the route of the medication. The Pharmacy was notified of the and has been added on the new MAR. 08/25/2022 Implemented
6400.166(a)(9)The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the route of administration. The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the frequency of the administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The individual¿s Endocrinologist was contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and his carb ratio and no specific times. The scrip and the medical statement is attached with all supporting documents. 08/25/2022 Implemented
6400.166(a)(11)The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the diagnosis or purpose of the medication. The July 2022 MAR for Individual #1 did not include diagnoses for Aripiprazole, Fish Oil, Lantus, Levocetirizine, Lisinopril, Flonase, Prilosec, Melatonin, Methylphenidate, Montelukast and Venlafaxine.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 individual¿s Endocrinologist and his Primary Care Physician were contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and carb ratio. The scrip of the medication attached indicated diabetes as the diagnosis or purpose of the medication. The Pharmacy was notified and an addition has been made as well on new MAR for all his current medications. 08/25/2022 Implemented
6400.169(b)(2)July 2022 Medication Administration Records (MARs) for Individual #1 record that Staff #4 administered Lantus injections on 7/8/22 and 7/9/22. July 2022 MARs also record that Staff #4 administered Novolog injections at 8am on 7/8/22, 7/15/22 and 7/18/22. Medication Administration training records for Staff #4 indicate that they were currently certified to administer medications. Review of training records also indicated that Staff #4 received training on Diabetes on 4/28/22 through the Advocacy Alliance which is not a department approved diabetes patient education program. Staff #4 did not meet the qualifications to administer insulin injections as completion of the Department approved medication administration course as well as a Department-approved diabetes patient education program were completed within the past 12 months. Staff #1, #5, #6, #7, #9, #10 and #11 all initialed the July 2022 MAR for Individual #1 to indicate that they had administered doses of Novolog to Individual #1. Reports by Staff #4 and Staff #2 at time of inspection indicated that all staff were trained in Diabetes by The Advocacy Alliance; documentation of the training was requested. Documentation of the training by The Advocacy Alliance or a Department approved diabetes education program was not provided. Diabetes training by The Advocacy Alliance does not satisfy regulation as it is not a Department approved diabetes education program. Training by a Department approved diabetes patient education program within the past 12 months in addition to training as outlined in 6400.169 b1 are required to satisfy regulation and provide staff with necessary training to administer insulin injections as required. Staff #1, #4, #6, and #7 all initialed the July 2022 MAR for Individual #1 to indicate that they had administered doses of Lantus to Individual #1. Reports by Staff #4 and Staff #2 at time of inspection indicated that all staff were trained in Diabetes by The Advocacy Alliance; documentation of the training was requested. Documentation of the training by The Advocacy Alliance or a Department approved diabetes patient education program within the past 12 months in addition to training as outlined in 6400.169 b1 are required to satisfy regulation and provide staff with necessary training to administer insulin injections as required.A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months.As of 7/28/2022 only licensed medical professionals were allowed to inject insulin to all agency individuals only. Agency staff members may administer insulin injections after a successful completion of a department-approved diabetes patient training. 08/25/2022 Implemented
SIN-00207251 Unannounced Monitoring 06/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.51(b)(1)Staff #3 did not receive orientation training in the application of: Person-centered practices, Community integration, Individual choice, and supporting individuals to develop and maintain relationships.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.Staff Number 3 has completed all his required on Person-centered practices, Community integration, Individual choice, and supporting individuals to develop and maintain relationships. His training certificate is attached on the list of supporting documents submitted. 07/23/2022 Implemented
6400.51(b)(2)Staff #3 did not receive orientation training in 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 Service Law (23 Pa.C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704) and applicable protective services regulations.The orientation 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.Staff number 3 has completed his required training in prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act. His training certificate is attached on the list of supporting documents submitted. 07/23/2022 Implemented
6400.51(b)(3)Staff #3 did not receive orientation training in Individual rights.The orientation must encompass the following areas: Individual rights.Staff #3 has completed his required orientation training on the individual's rights. His training certificate is attached with the list of supporting documents submitted. 07/23/2022 Implemented
6400.51(b)(4)Staff #3 did not receive orientation training in recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Staff # 3 has completed his required orientation training in recognizing and reporting incidents. His training certificate is attached with the list of supporting documents submitted. 07/23/2022 Implemented
6400.51(b)(5)Staff #1 did not receive orientation training that encompassed job related knowledge and skills, specifically, Staff #1 was not trained in the Individual Service Plan.The orientation must encompass the following areas: Job-related knowledge and skills.Staff #1 completed the Individual Service Plan training during their orientation training, but failed to sign the Individual Service Plan form. The staff has signed the form and completed the Individual¿s Service Plan training again. The sign training form is attached with the list of supporting documents submitted. 07/23/2022 Implemented
6400.52(c)(6)Staff #2 did not receive training in the implementation of the individual plan if the person works directly with an individual.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.Staff #2 completed the Individual Service Plan training during their orientation training, but failed to sign the Individual Service Plan form. The staff has signed the form and completed the Individual¿s Service Plan training again. The sign training form is attached with the list of supporting documents submitted. 07/23/2022 Implemented
SIN-00201961 Unannounced Monitoring 02/28/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 has a well-documented history of grabbing food and swallowing it without chewing. According to the Individual Support Plan (ISP), this behavior has resulted in a previous choking incident which required hospitalization while with another provider. The Individual's current provider was aware of the food-grabbing behavior and the potential risk for choking, and cited it as one of the reasons the provider needed to increase staffing for Individual #1 from 1:1 to 2:1. The enhanced staffing was approved, effective 12/23/2021, and the provider began billing for enhanced 2:1 staffing on 1/04/2022 through 2/09/2022, the date of Individual#1's death. Individual #2, by default, has 1:1 staffing as the ISP for the Individual states that the Individual requires 24-hour care with no alone time. On the afternoon of 2/09/2022, Staff #1 and Staff #2 were working with Individual #1, and the staff reported that they had taken the Individual out for a walk. When they returned to the home, Individual #2 had pizza (whole pie) that had been obtained by Staff #3 as a "special treat," After eating some pizza, Individual #2 went upstairs. Staff #3 left the home, leaving the staffing level below the required level of 3 staff as Individual #1 required two staff for proper supervision. Staff #2 was in the living room, sitting on the couch, and Staff #1 reports going into the bathroom. Staff #3 had left the pizza sitting on the kitchen counter when leaving the home. Staff #1 reports that shortly after going into the bathroom, he heard Staff #2 yelling, "He got the pizza!" Staff #1 reported that he left the bathroom and found individual #1 attempting to get to the stairs leading to the bedrooms. Individual #1 appeared to be choking, having shoved a whole slice of pizza in his mouth. Staff #1 began to administer back blows and the Heimlich maneuver while staff #2 called 911, first from the house phone but got no answer, then from a personal cell number which did go through. Staff #1 reported to this Licensing Representative that staff stopped administering aid because staff thought the choking resolved, and Individual #1 ran to the stairs, but collapsed on the stairs with lips turning blue. Staff resumed back blows and the Heimlich maneuver, as well as administering rescue breaths until the Emergency Medical Services arrived on the scene. Emergency Medical Technicians (EMT) took over, transported Individual #1 to the hospital where Individual #1 was pronounced dead. EMT's report that while rendering aid, they attempted to do a tracheotomy but were unable to as the individual's airway and esophagus was so packed with food and vomitus. Individual #1 was neglected as staff did not maintain adequate supervision ratios and failed to ensure the safety of Individual #1 by leaving a whole pizza accessible and unmonitored on the kitchen counter in reach of Individual #1 despite staff being aware of Individual #1's food seeking behavior and choking risk.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.The program specialist will ensure that all ISP training will include directives requiring all individuals to be closely monitored during meals as appropriate based on individuals needs with a clear instruction of where staff should be seated in relation to individuals during meals. Also, directives would include that all unfinished meals will be removed from dining area by DSPs and properly stored according to the needs of the individuals at a home immediately after meal period is complete. The program specialist will ensure that supervision protocols (including handoff and supervision procedures when a staff has to use bathroom at the home or in community) will be reviewed with staff in all programs by 4/15/22 and then at least quarterly during house staff meetings. 03/28/2022 Not Implemented
6400.181(d)The Program Specialist did not sign and date the Initial Assessment. The Initial Assessment was completed on 1/17/2022 by the residential program supervisor; and was signed and dated by the residential program supervisor.The program specialist shall sign and date the assessment. All current assessments will be audited by the program specialists and any missing components will be completed by 4/1/2022. 03/28/2022 Not Implemented
6400.181(e)(4)The Initial Assessment completed on 1/17/2022 does not document the Individual's need for supervision. The assessment must include the following information: The individual's need for supervision. All assessments will be audited by the program specialist and any missing components will be completed by 4/1/14 and the individuals supervision level will be included in all assessments 03/28/2022 Not Implemented
6400.45(e)An individual may not be left unsupervised solely for the convenience of the home or the direct service worker. Staff #3 left the home sometime in the early afternoon on 2/09/2022 to go to the store, according to Staff #1 and the Agency's Chief Operating Officer who also conducted the certified investigation for the agency. This left only Staff #1 and Staff #2 in the home with both Individuals. Individual #1 required 2:1 staffing; and Individual #2, whose Individual Support Plan (ISP) stated that the Individual requires staffing 24 hours per day, required 1:1 staffing by default. Three staff should have been in the home at all times when both Individuals were present. By leaving the home to go to the store, Staff #3 left Individuals without proper supervision.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.The Chief Executive Officer would reveal the schedule for each hours to ensure that the required number of staff are scheduled for each shift. All staff members for each individual would be retrained on the person¿s ISP with emphasis on the supervision level. 03/28/2022 Not Implemented
6400.51(b)(1)Staff #1 and Staff #2 did not receive training during orientation in the areas of the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.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.Staff# 1 and Staff #2 would receive the recommended training by 4/15/22 before resuming work duties. Also, HR person would review training records of all staff and ensure each staff completes the required training. 03/28/2022 Not Implemented
6400.51(b)(2)Staff #1 and Staff #2 did not receive training during orientation in the areas of the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Service Law, the Adult Protective Service Act and applicable protective services regulations.The orientation 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.Staff #1 Staff #2 would receive the recommended training by 4/15/22. Also, HR person would review training records of all staff and ensure each staff completes the required training. 03/28/2022 Not Implemented
6400.51(b)(4)Staff #1 and Staff #2 did not receive training during orientation in the area of recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Staff #1 and Staff #2 would receive the recommended training by 4/15/22. Also, HR Manager would review training records of all staff and ensure each staff completes all required trainings. 03/28/2022 Not Implemented
6400.186The home shall implement the plan. Records indicate that Staff #1 and Staff #2 were trained in the Individual Support Plan for Individual #1 but did not provide adequate supervision to the Individual on the afternoon of 2/09/2022 which resulted in the individual grabbing pizza that was easily accessible swallowing it whole and choking.The home shall implement the individual plan, including revisions.Staff # 1 and Staff #2 would receive the recommended training by 4/15/22. Also, HR person would review training records of all staff as well and ensure each staff completes the required training . Individuals supervision levels will be reviewed and covered as well. 03/28/2022 Implemented
SIN-00189879 Unannounced Monitoring 07/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70The home does not have an operable telephone line.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. A phone handset was installed at the home when licensors came to the home for licensing, but no phoneline was connected. A phone line has been connected now as of 7/7/2021 . A copy of the work order has been sent to licensing for further verification. A phone line was not initially connected in the home because we are currently not serving any individual in the home. Our plan was to fix a phone line before bringing an individual in. 07/07/2021 Implemented
SIN-00183451 Unannounced Monitoring 02/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)(5)Both bedroom number #1 and bedroom number #2 did not have locks on the door that provided staff with a entry device to lock or unlock the doors. The locks located on the bedroom doors were hairpin locks. Immediately following inspection the agency contacted the licensor and provided photos of the locks and keys of the door locks that were previously on the bedroom doors and were being reinstalled.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.The hairpin door locks on Bedroom #1 and Bedroom #2 have been removed and replaced with keyed entry locks. Copies have been made so that staff will have a key to each room on their person at all times allowing for immediate entry; so that individuals have access at all times; and so that a copy is secured for backup in a location accessible only to staff. 02/19/2021 Implemented
SIN-00153573 Initial review 04/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)This townhouse has an elevated deck in the back, but it is not an exit. The deck is tilting forward. The rails are loose and pulling away from the back siding of the townhouse. There is an uneven sidewalk with a 3-4 inch gap where the house sidewalks meets the street sidewalks, which is a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Regulation: 67 b: Floors, walls, ceilings and other surfaces shall be free of hazards. Why is the regulation important? The regulation is important to ensure the site is free of hazards to ensure the safety of the individuals How was the regulation violated? This townhouse has an elevated deck in the back, but it is not an exit. The deck is tilting forward. The rails are loose and pulling away from the back siding of the townhouse. There is an uneven sidewalk with a 3-4 inch gap where the house sidewalks meets the street sidewalks, which is a tripping hazard. What Caused the Violation? The hazard was not found by LHSS administrative staff during self-licensing inspection survey and therefore was not fixed. What can be done right away to fix the violation? The landlord was made aware of the problem and will have it repaired by May 30, 2019. What can be done to prevent future violations? LHSS administrative staff will carefully completed licensing self-survey when completing licensing for new programs and look for any hazards with uneven sidewalks or any tripping hazards. All self surveys going forward will also be completed by a second individual to ensure no hazards were missed Who will be responsible for preventing future violations? The house supervisor and Alie Kargbo Director of Compliance. 05/30/2019 Implemented
6400.68(b)The water temperature in this residence read 125.4 degrees, exceeding the requirement by 5.4 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Regulation: 68 b: Hot water temperatures in bathtubs and showers may not exceed 120°F. Why is the regulation important? The regulation is important in order to keep water temperatures below 120 degrees to avoid individuals receiving burns from hot water or any other accidents. How was the regulation violated? The water temperature in this residence read 125.4 degrees, exceeding the requirement by 5.4 degrees. What Caused the Violation? Individual completely self-survey did not properly check the hot water temperature through out the house What can be done right away to fix the violation? The water temperature was turned down to below 120 degrees by the landlord on 4/26/19. What can be done to prevent future violations? All sites were provided with thermometers to regularly check and regulate water temperature during safety and maintenance checks. LHSS administrative staff will carefully completed licensing self-survey when completing licensing for new programs and check water temperature. A second individual to ensure no hazards were missed will also complete all self-surveys going forward Who will be responsible for preventing future violations? The house supervisor and Alie Kargbo Director of Compliance. 04/26/2019 Implemented
6400.70There was no landline phone at this residence.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Regulation: 70: A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Why is the regulation important? The regulation is important to ensure all operable, non coin-operated telephone with an outside line that easily accessible to individuals and staff person. How was the regulation violated? There was no landline phone at this residence. What Caused the Violation? There was an oversight in checking the home for a landline phone. What can be done right away to fix the violation? The landline phone has been installed in the residence on 5/10/19. What can be done to prevent future violations? LHSS administrative staff will carefully completed licensing self-survey when completing licensing for new programs. A second individual to ensure no hazards were missed will also complete all self-surveys going forward Who will be responsible for preventing future violations? The house supervisor and Alie Kargbo Director of Compliance. 05/10/2019 Implemented
6400.71There were no emergency numbers posted in this residence.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Regulation: 71: Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Why is the regulation important? The regulation is important for Direct Care Staff to easily identify important phone numbers in case of emergency. How was the regulation violated? There was no list of emergency numbers posted by the telephones as there were no telephones installed at the house at the time of inspection. What Caused the Violation? There was an oversight in checking the home for a landline phone. What can be done right away to fix the violation? Emergency numbers were listed next to the telephone when it was installed on 5/10/19. What can be done to prevent future violations? LHSS administrative staff will carefully completed licensing self-survey when completing licensing for new programs. A second individual to ensure no hazards were missed will also complete all self-surveys going forward Who will be responsible for preventing future violations? The house supervisor and Alie Kargbo Director of Compliance. 05/10/2019 Implemented
6400.72(a)There were no screens in the 2 windows in the living room area of this residence.Windows, including windows in doors, shall be securely screened when windows or doors are open. Regulation: 72 a: Windows, including windows in doors, shall be securely screened when windows or doors are open. Why is the regulation important? The regulation is important because to keep bugs from entering into the home and ensure sanitary conditions of the home. How was the regulation violated? There were no screens in the 2 windows in the living room area of this residence. What Caused the Violation? There was an oversight in checking the home for a landline phone. What can be done right away to fix the violation? Two screens were installed in the missing windows on 5/6/19. What can be done to prevent future violations? LHSS administrative staff will carefully completed licensing self-survey when completing licensing for new programs. A second individual to ensure no hazards were missed will also complete all self-surveys going forward Who will be responsible for preventing future violations? The house supervisor and Alie Kargbo Director of Compliance. 05/06/2019 Implemented
6400.77(b)There were no tweezers in the 1st Aid Kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Regulation: 77b: A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Why is the regulation important? The regulation is important because all homes should have a completed first aid kit to maintain health and safety. How was the regulation violated? There was no tweezers in the first aid kit. What Caused the Violation? There was an oversight in checking the home for a landline phone. What can be done right away to fix the violation? A pair of tweezers were purchased and put in the first aid kit at the home on 4/25/19. What can be done to prevent future violations? LHSS administrative staff will carefully completed licensing self-survey when completing licensing for new programs. A second individual to ensure no hazards were missed will also complete all self-surveys going forward Who will be responsible for preventing future violations? The house supervisor and Alie Kargbo Director of Compliance. 04/25/2019 Implemented
SIN-00216383 Unannounced Monitoring 11/28/2022 Compliant - Finalized
SIN-00187626 Renewal 05/18/2021 Compliant - Finalized
SIN-00181964 Initial review 01/20/2021 Compliant - Finalized