| 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. |
12/15/2023
| Implemented |
| 6400.62(a) | At 11:08AM, aerosol spray cans of Easy Off Oven Cleaner, Lysol Disinfectant Spray and glass cleaner and bottles of Mr. Clean, Lysol, Orange Glo and bleach cleaner were on a shelf in an unlocked closet in the living room on the second floor of the home. [Repeat Violation, 12/22/2022] | Poisonous materials shall be kept locked or made inaccessible to individuals. | We received this violation because cleaners were in the closet but the lock was not locked during the time of the unannounced inspection. |
11/22/2023
| Not Implemented |
| 6400.63(a) | At 10:18AM, the hot water temperature measured 138.2F at the sink in the kitchen of the home. [Repeat Violation, 5/10/2023] | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | We received this violation due to multiple adjustments of the hot water tank in a new site. We turned the water temperature down until we were within optimum regulation temperatures. |
11/22/2023
| Implemented |
| 6400.64(d) | At 10:20AM, a white bag filled with trash was on top of a mop bucket and a cardboard box containing a white bag filled with trash and other trash were on the floor in the kitchen of the home. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | We received this violation due to multiple items being thrown away due to move in. We had boxes/bags that were not immediately covered by move in staff. We resolved the issue within 1 hour of the unannounced inspection. |
12/29/2023
| Not Implemented |
| 6400.64(f) | At 10:11AM, an uncover trash receptacle containing full white trash bags was outside in front of the home. [Repeat Violation, 12/22/2022] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | We received this violation due to multiple items being thrown away due to move in. We had boxes/bags that were not immediately covered by move in staff. We resolved the issue within 1 hour of the unannounced inspection. |
12/29/2023
| Not Implemented |
| 6400.68(b) | At 11:09AM, the hot water temperature measured 126.6F at the bathtub in the bathroom on the second floor of the home. [Repeat Violation, 5/10/2023] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | We received this violation due to multiple adjustments of the hot water tank in a new site. We turned the water temperature down until we were within optimum regulation temperatures. |
12/29/2023
| Implemented |
| 6400.72(b) | At 11:11AM, there was four inch long tear in the screen in the window across from the doorway in the living room on the second floor of the home. [Repeat Violation, 6/29/2023, 7/25/2023] | Screens, windows and doors shall be in good repair. | We received this violation due to a tear in the screen. We had the screen repaired |
12/29/2023
| Implemented |
| 6400.74 | At 11:05AM, the interior stairs, leading to the basement and to the second floor of the home, did not have a nonskid surface. [Repeat Violation, 4/20/2023] | Interior stairs and outside steps shall have a nonskid surface.
| This issue occurred due to a scheduling conflict with our contractor to do the work. On 11.23.2023, the anti skid mats were installed |
12/29/2023
| Implemented |
| 6400.76(c) | At 11:10AM, the living room on the second floor of the home was furnished with only a small ottoman. | Furniture shall be comfortable and home-like. | We received this violation due to the fact on the move in date, the professional movers could not not fit through the front door or the side door of the home the original couch. We order a new couch that had to be built in the home to resolve this issue. |
01/05/2023
| Implemented |
| 6400.77(b) | At 11:15AM, the first aid kit did not contain tape. [Repeat Violation, 12/22/2022] | 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. | We received this violation because the thermometer¿s batteries were low. We replaced the batteries in the thermometer within 4 hours of the unannounced inspection. |
12/29/2023
| Implemented |
| 6400.110(e) | At 11:34AM, the smoke detector in the basement of the three story home was not interconnected with the smoke detectors on the first and second floors of the home. [Repeat Violation, 12/22/2022] | 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. | We installed an interconnected smoke detector in the basement |
12/29/2023
| Implemented |
| 6400.163(d) | Individual #1's prescribed medication, Lorazepam, a controlled substance, was not double locked. At 11:21AM, a biohazard box with used pre-filled Abilify syringes was on the shelf in an unlocked closet in the living room of the home. [Repeat Violation, 4/20/2023] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | We received this violation due to our controlled substance being in locked containment box but not locked in closet. We resolved by locking in containment item immediately in closet. |
11/25/2023
| Implemented |
| 6400.166(a)(2) | Individual #1's November 2023 Medication Administration Record documented an incorrect physician as the prescriber of the medications. [Repeat Violation, 12/22/2022] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | We received this violation due to incorrect information populated regarding physician. We have reviewed each individuals MAR to verify that each prescibber listed on the pharmacy label is also listed on the MAR. We have found that each prescribing will at times have a physicians assistant submit the prescription to the pharmacy which then causes the pharmacy to list that specific physicians assistant on the pharmacy label. We have written in each prescribing physicians name on the MAR. |
12/29/2023
| Not Implemented |
| 6400.186 | Individual #1's Individual Plan, last updated 7/21/2023, states Individual #1 requires 24-hour supervision within eyesight. Staff interviews revealed that staff are not always in visual range supervision with Individual #1 and staff will conduct visual checks every so often. | The home shall implement the individual plan, including revisions. | We interviewed staff about concerns of not being in visually accessible to the individual. We scheduled a training regarding supervision for all staff in the home. we also hosted a training session on 12/1/23 to address this issue ( WE DID NOT ACTUALLY HOST THIS TRAINING I DON'T KNOW WHAT TO SAY BECAUSE SHE WENT TO THE HOSPITAL THE 12/1/23) |
12/01/2023
| Implemented |