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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Individual #1 was left on the floor of their home for three consecutive days asking staff to help them. Shared Values policy 2.5 Abuse, Neglect, Exploitation, and Protective Services Policy 1. INDIVIDUAL RIGHTS
states in part that individuals:
· Be free from abuse, neglect, exploitation, retaliation, and mistreatment.
· Be treated with dignity and respect.
· Report concerns without fear of retaliation.
· Access protective services and advocacy resources.
Individual #1 was not afforded any of the stated rights based on testimony obtained during the certified investigation and therefore the CEO did not ensure that this policy was being implemented. Individual #1 was on the floor of her home asking staff to "help me" for three days from March 1, 2026, to March 3, 2026. Witnesses stated that Individual #1 didn't appear to be able to get up on their own and staff did not offer to help individual #1 up off the floor.
On March 3, 2026, an OAPS (older adult protective services) worker arrived at home for a wellness check to find individual #1 on the floor naked and still asking for help. The OAPS worker determined that individual #1 needed to go to the ER and called 911 to have individual #1 transported to the ER. The investigator asked why Individual #1 was naked and staff said she had refused to get dressed, however when the investigator asked Individual #1 if they would get dressed, they agreed to get dressed. Both staff #'s 2 & 3 said that Individual #1 was on the floor because it is a behavior that they do when they don't want to do something. Individual #1 was stating "help me" repeatedly while on the floor and staff did not help Individual #1 get up from the floor. The nurse (staff #4) arrived at the home and argued that Individual #1 did not need to go to the ER. Emergency Services arrived and transported Individual #1 to the ER. It was determined at the hospital that Individual #1 was a day away from a life-threatening situation.
Per incident report #9800203, individual #1 was admitted to the hospital on March 3rd due to complications related to their gallbladder. Individual #1 was transferred to Horsham Center on 03/07/2026 with a cholecystostomy tube (biliary drain) in place due to gallbladder stones because they were too weak to have the surgery. Individual #1 was later scheduled for a cholecystectomy (gallbladder removal) on 04/14/2026. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | DPOC, MJF, Licensing Supervisor 9-14-26
Annual training to include all individual rights and how they are expressed (6400.32.A-R)
Competency-Based Training
All training must have post assessments to verify competency.
Training to include annual and as needed training:
- Individual rights (6400.32A-R) include all individual rights and how they are expressed.
- The difference between communication, behavior and a medical issue.
- The process for having someone evaluated either medically or behavioral should staff see changes in the individual including communication changes. |
| Not Implemented |
| 6400.43(b)(3) | In January 2026, the heat in the home stopped working and portable space heaters were brought in to substitute for the heat. Portable space heaters are prohibited. When the heater broke, the individuals should have been relocated to another home or to a hotel until the heater was repaired. The CEO is responsible for the health and safety of the individuals in their care. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Abuse, Neglect, Exploitation, Protective Services, and Individual Rights Training
To address the cited deficiency and prevent future occurrences, the Compliance Director developed and conducted mandatory agency-wide training on Abuse, Neglect, Exploitation, Protective Services, and Individual Rights for all employees responsible for supporting individuals receiving services.
The training was designed to reinforce staff knowledge of Pennsylvania ODP Chapter 6100/6400 regulations, agency policies, mandatory reporting requirements, and each employee's responsibility to protect the health, safety, rights, and welfare of the individuals served.
The training included, but was not limited to, the following topics:
· Definitions and examples of abuse, neglect, exploitation, mistreatment, and rights violations.
· Staff responsibilities for preventing abuse and protecting individuals from harm.
· Recognition of signs and indicators of abuse, neglect, exploitation, and potential rights violations.
· Immediate actions required when abuse or neglect is suspected or witnessed.
· Mandatory reporting requirements, timelines, and notification procedures.
· Protective Services requirements, including reporting to law enforcement and Older Adult Protective Services (OAPS) or other protective service agencies when applicable.
· Individual rights as outlined in Pennsylvania regulations, including dignity, respect, privacy, choice, freedom from restraint, and access to services.
· Staff responsibilities for maintaining and protecting individual rights during all interactions.
· Documentation expectations, including incident reporting and completion of required reports.
· Agency expectations regarding zero tolerance for abuse, neglect, exploitation, retaliation, or rights violations.
· Consequences for failure to report or failure to protect individuals.
Training was conducted by the Compliance Director and included opportunities for staff questions, discussion of real-life scenarios, and review of agency policies and reporting procedures to ensure compliance.
To ensure ongoing compliance, the Compliance Director will conduct training audits at least quarterly to verify compliance with annual training and all other regulatory requirements pertaining to employment eligibility. |
06/25/2026
| Accepted |
| 6400.107 | In January 2026, the heat in the home stopped working and portable space heaters were brought in to substitute for the heat. Portable space heaters are prohibited. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The Maintenance Manager (or designee) is responsible for completing and documenting all required quarterly environmental and building systems inspections for each residential home.
A comprehensive quarterly preventive maintenance inspection will be conducted to ensure the continued safety, functionality, and regulatory compliance of each residence. The inspection includes, but is not limited to:
· HVAC system operation and filter status
· Water heater condition and temperature settings
· Electrical panel accessibility and labeling
· Ground Fault Circuit Interrupter (GFCI) outlet testing
· Smoke and carbon monoxide detector inspection
· Emergency lighting (where applicable)
· Plumbing fixtures and leak assessment
· General structural and environmental safety concerns
· Additional life safety and building systems identified on the Quarterly Preventive Maintenance Checklist
The initial quarterly inspection process began in June 2026, and all residential locations were reviewed using the newly implemented Quarterly Preventive Maintenance Checklist.
Inspections started in June and will continue at least quarterly thereafter. Any deficiencies identified during an inspection will be documented and addressed within 48 hours. Repairs requiring outside contractors will be scheduled within 72 hours and tracked through completion.
Maintenance Management will utilize the standardized Quarterly Preventive Maintenance Checklist to document each inspection, identify any deficiencies, and record corrective actions taken. Completed checklists will be submitted to the Compliance Director for review and maintained as part of the agency's quality assurance documentation.
To ensure consistent implementation of the process, Maintenance Management received training on the Quarterly Preventive Maintenance Checklist and inspection procedures on May 13, 2026. |
05/13/2026
| Accepted |
| 6400.18(f) | As part of an investigation regarding Individual #1 being on the floor of her home for 3 days, interviews were conducted with multiple staff. During interviews with Staff 2 and 3, they both stated that Individual #1 was sick for from a week and two weeks including vomiting and diarrhea prior to Individual #1's hospitalization. Staff 3 stated that Individual #1 was vomiting green liquid, that she wasn't eating much and that when the nurse was called, they said the green liquid was mucus. When the nurse came to the home, they determined that Individual #1 had a cold. Staff #2 stated that Individual #1 had a virus for a week or two prior to the hospitalization. Staff #2 said the diarrhea was more than usual and when the nurse was called, the nurse (staff #4) said to give her the BRAT diet. Staff #2 stated that the weekend prior to Individual #1 going to the ER, she was vomiting and had diarrhea and so they called the nurse and the house manager but neither gave staff #2 any instructions.
Staff #2 said that Individual #1 had been throwing up all weekend and was weak and so Individual #1 was afraid of falling due to their weakened condition and so was on the floor. Staff #2 said Individual #1 was undressed for a shower due to the diarrhea and had a towel and brief on but Individual #1 took the towel off and was naked on the floor. This is how Individual #1 was found when the OAPS investigator arrived and subsequently called 911 and individual #1 was transported to the emergency room. The investigator asked why Individual #1 was naked and staff said she had refused to get dressed, however when the investigator asked Individual #1 if they would get dressed, they agreed to get dressed. Both staff #2 & 3 said that Individual #1 was on the floor because it is a behavior that they do when they don't want to do something. Individual #1 was stating "help me" repeatedly while on the floor and staff did not help Individual #1 get up from the floor. The nurse (staff #4) arrived at the home and argued with the OAPS investigator as to whether Individual #1 should go to the ER.
It was determined at the hospital that Individual #1 was a day away from a life-threatening situation. Individual #1 was diagnosed with gall stones but was too weak to have the surgery immediately and so they went to rehab to build up their strength and then had the surgery approximately one month later. Individual #1 and their family did not want Individual #1 to return to Shared Values and moved to another provider. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | DPOC, MJF, Licensing Supervisor 9-14-26
Review all medical information for each individual to ensure appropriate treatment.
Review/Update HRST information for each individual.
Review updated HRST information with all DSPs and nursing.
Review medical and behavioral sections of all ISPs to ensure they are up to date and in alignment with individual assessments and behavior support plans. |
| Not Implemented |
| 6400.32(c) | After reviewing the Neglect/Failure to Provide Needed Care incident report, 9800162, and being informed of OAPS (Older Adult Protective Services) wellness visit on March 3rd, ODP learned that Individual #1 was found naked on the floor and complaining of stomach pain by Staff #5 (Protective Services, Office of Aging Services)
A member of another individual's family who was video calling their loved one on March 1, 2026, could see individual #1 on the floor of the home saying, "help me" and the individual did not appear to be able to get up on their own. Staff did not help the individual up off of the floor while the family member was on the phone. On March 2, 2026, during another video conference, the individual could still be seen to be on the floor still saying that they needed help. The family member could hear staff telling individual #1 to get up even though the individual did not appear able to do so independently. The family member of the housemate called 911 and stated that they can hear staff yelling at individual #1 and calling them names. Police arrived at the home and individual #1 was still on the floor but police said they couldn't intervene. Staff did not attempt to help individual #1 off of the floor, instead yelled at them to get up until the police arrived.
On March 3, 2026, an OAPS (older adult protective services) worker arrived at the home to find individual #1 on the floor naked and still asking for help. The OAPS worker determined that individual #1 needed to go to the ER and called 911 to have individual #1 transported to the
As part of an investigation interviews were conducted with multiple staff. During interviews with Staff 2 and 3, they both stated that Individual #1 was sick for from a week and two weeks including vomiting and diarrhea prior to Individual #1's hospitalization. Staff 3 stated that Individual #1 was vomiting green liquid, that she wasn't eating much and that when the nurse was called, they said the green liquid was mucus. When the nurse came to the home, they determined that Individual #1 had a cold. Staff #2 stated that Individual #1 had a virus for a week or two prior to the hospitalization. Staff #2 said the diarrhea was more than usual and when the nurse was called, the nurse (staff #4) said to give her the BRAT diet. Staff #2 stated that the weekend prior to Individual #1 going to the ER, she was vomiting and had diarrhea and so they called the nurse and the house manager but neither gave staff #2 any instructions. Staff #2 said that Individual #1 had been throwing up all weekend and was weak and so Individual #1 was afraid of falling due to their weakened condition and so was on the floor. Staff #2 said Individual #1 was undressed for a bath due to the diarrhea and had a towel and brief on but Individual #1 took the towel off and was naked on the floor. This is how Individual #1 was found when the OAPS investigator arrived and subsequently called 911 and individual #1 was transported to the emergency room. The investigator asked why Individual #1 was naked and staff said she had refused to get dressed, however when the investigator asked Individual #1 if they would get dressed, they agreed to get dressed. Both staff #'s 2 & 3 said that Individual #1 was on the floor because it is a behavior that they do when they don't want to do something. Individual #1 was stating "help me" repeatedly while on the floor and staff did not help Individual #1 get up from the floor. As they were waiting for emergency services to arrive, the nurse arrived at the home and argued with the OAPS investigator about whether Individual #1 needed to go to the ER. Emergency services arrived at the home and transported Individual #1 to the hospital.
It was determined at the hospital that Individual #1 was a day away from a life-threatening situation. Per incident report #9800203, individual #1 was admitted to the hospital on March 3rd due to complications related to their gallbladder. Individual #1 was transferred to Horsham Center because they were too weak to have surgery, on 03/07/2026 with a cholecystostomy tube (biliary drain) in place due to gallbladder stones. Individual #1 was later scheduled for a cholecystectomy (gallbladder removal) on 04/14/2026. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | DPOC, MJF, Licensing Supervisor 9-14-26
Completion of a root cause analysis identifying why staff failed to respond to an individual requesting help for three days.
Review all medical information for each individual to ensure appropriate treatment.
Review/Update HRST information for each individual.
Review updated HRST information with all DSPs and nursing.
Review medical and behavioral sections of all ISPs to ensure they are up to date and in alignment with individual assessments and behavior support plans.
A daily health observation log for all individuals, with required staff initials and supervisor review. Special section for tracking vomiting, diarrhea, refusal to eat, falls, and weakness. Special section for tracking vomiting, diarrhea, refusal to eat, falls, and weakness.
A procedure for immediate supervisory involvement when staff disagree about whether to call the nurse or 911. Supervisors must make real-time decisions and document them.
refresher training specifically on neglect, including:
What constitutes medical neglect,
Duty to provide care regardless of perceived behavior,
responsibility under protective service laws.
competency checks and documented corrective coaching for any staff involved.
Behavioral specialists must review BSPs to ensure they do not reinforce ignoring potential medical symptoms. Clear instructions to staff on differentiating refusal behavior from medical inability. |
| Not Implemented |
| 6400.32(d) | Over the course of 3 days (March 1st to 3rd, 2026) individual #1 could be seen on the floor of the home by a housemate's family member who was video calling their loved one. Individual #1 did not appear able to get up from the floor and kept saying "Help me". During this time, staff did not offer to or actually assist individual #1 off the floor and could be heard yelling at individual #1 to get up off the floor herself. Additionally, it was discovered during subsequent interviews of DSPs that they routinely tell individual #1 that their brother is coming to visit in order for them to get individual #1 to do what they want them to do. They also stated that Individual #1 had a behavior of dropping to the floor when they don't want to do something. There is no behavior support plan for Individual #1.
An interview was conducted with CPS staff on 4/14/26 and that worker (staff #1) stated that Individual #1 could be seen in front of the window facing the street being dressed. The curtains were open and staff #1 could see everything. Another time, Individual #1 was dressed in a sweatshirt and sweatpants in the summer when it was very hot. Individual #1 would also complain of being hungry because staff didn't give them breakfast. Staff #1 also said that staff would not allow Individual #1 to listen to their radio or watch TV, that they yelled at Individual #1 and that they threw water on them. Staff #1 also said that individual #1 was often unkept with their nails too long and their hair disheveled. | An individual shall be treated with dignity and respect. | DPOC, MJF, Licensing Supervisor 9-14-26
Completion of a root cause analysis identifying why staff failed to respond to an individual requesting help for three days.
Annual training to include all individual rights and how they are expressed (6400.32.A-R)
Specific training on how to treat individuals with dignity and respect in all aspects of their lives. This training should occur now and then as needed throughout the year. |
| Not Implemented |
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