| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 11/25/24, was not conducted either within 3-6 months of the current license's expiration date of 2/22/2025 or within 6-9 months following the last annual inspection by the Department completed 12/20/23. [Repeated Violation-12/19/23, et al] | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A compliance calendar has been implemented to ensure timely completion of the annual self-assessment. Management was trained regarding the requirements for completing and documenting the annual self-assessment. |
02/27/2025
| Implemented |
| 6400.62(a) | Individual #1's Individual Support Plan, last updated on 12/2/24, states they "can safely use poisons with verbal prompts and line-of-sight supervision." At 11:47 AM on 12/6/24, a 56-fluid-ounce bottle of Giant Eagle Dish soap was found on the kitchen counter with instructions to contact Poison Control is swallowed or ingested. The following poisonous materials were found unlocked in the basement: a 2.53-quart bottle of Clorox disinfecting bleach; a 33-ounce container of DAP premium spackle; a one-quart can of Behr Ceiling flat paint; and a one-gallon can of Behr enamel paint. The door to the staff office located on the home's upper level is not equipped with a lock. At 12:05 PM, the following cleaners were found unsecured in this room: a 16-fluid ounce spray bottle of Mr. Clean Clean Freak Multi-Purpose Cleaner; a 25-ounce spray can of Scrubbing Bubbles Bathroom Cleaner; and a 32-fluid ounce bottle of Lysol Toilet Bowl Cleaner. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Staff was retrained on proper poison storage. |
02/27/2025
| Implemented |
| 6400.66 | At 11:35 AM on 12/6/24, there was no operable light or any other nearby sufficient lighting source outside of the kitchen door leading to the backyard. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Management repaired the light fixture. |
02/27/2025
| Not Implemented |
| 6400.67(a) | At 12:17 PM on 12/6/24, the toilet seat in the home's only bathroom located on the upper level was detaching from the back of the toilet, rendering it loose and wobbly, as it was overhanging approximately three inches to the left side of the porcelain seating base. [Repeated Violation-12/19/23, et al] | Floors, walls, ceilings and other surfaces shall be in good repair. | Management contacted the contracted maintenance provider to replace the toilet seat. |
02/27/2025
| Not Implemented |
| 6400.67(b) | At 11:42 AM on 12/6/24, the dryer vent filter was covered in its entirety with a thick layer of lint, dust, and fabric particles. [Repeated Violation-12/19/23, et al] | Floors, walls, ceilings and other surfaces shall be free of hazards. | Staff was retrained on the responsibility of keeping the home free of hazards. The Program Specialist posted a sign stating the lint trap is to be cleaned after every use. |
02/27/2025
| Not Implemented |
| 6400.72(a) | At 12:13 PM on 12/6/24, all three windows located in the home's accessible finished attic did not have screens. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Management replaced the screens. |
02/27/2025
| Not Implemented |
| 6400.72(b) | At 11:35 AM on 12/6/24, the weatherstripping on the left side of the kitchen door was detached near the bottom of its frame in a section measuring one-half feet in length. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Screens, windows and doors shall be in good repair. | Management contacted the contracted maintenance provider to replace the weatherstripping. Management was retrained on identifying maintenance issues in the residential homes. |
02/27/2025
| Not Implemented |
| 6400.81(k)(6) | At 12:00 PM on 12/6/24, there was no mirror in Individual #1's bedroom. Their Individual Support Plan, last updated on12/2/24, does not document or explain a behavioral need that could be exacerbated by having a mirror in their bedroom, and Individual #1's behavior support plan completed on 1/6/24 does not have a component approved by a human rights team to restrict the use of a mirror in their bedroom. Additionally, Individual #1's Individual Support Plan, last updated on 12/2/24, did not document their choice to decline having a mirror in their bedroom. [Repeated Violation-12/19/23, et al] | In bedrooms, each individual shall have the following: A mirror. | Management purchased a mirror for the bedroom. |
02/27/2025
| Implemented |
| 6400.104 | The local fire department notification letter dated 12/11/23 for this home indicates that Individual #1 requires physical assistance to evacuate in the event of an actual fire but does not include a description or diagram of the exact location of their bedroom. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Management sent a formal written notification to the local fire department, including the home's address and a detailed floor plan indicating the exact locations of bedrooms for the individual requiring evacuation assistance. Staff were trained on the importance of maintaining current evacuation information and the proceedure for updating the fire department. |
02/27/2025
| Implemented |
| 6400.107 | At 12:02 PM on 12/6/24, two Hisense-brand portable space heaters were found in the spare bedroom located on the home's upper level. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| Management removed the heater from the residence immediately upon discovery. |
02/27/2025
| Not Implemented |
| 6400.111(c) | At 11:30 AM on 12/6/24, there was no fire extinguisher with a minimum 2A-10BC rating located in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Management contacted the contracted fire extinguisher provider to replace the extinguisher. Management will increase the contracted fire extinguisher provider's inspections. |
02/27/2025
| Not Implemented |
| 6400.112(d) | The fire drill conducted on 8/1/24 did not document the evacuation of an individual from the home within two minutes, thirty seconds. This section was left blank. [Repeated Violation-12/19/23, et al] | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Management and staff were retrained on proper fire safety procedures. |
02/27/2025
| Implemented |
| 6400.112(g) | According to the written fire drill record submitted from 1/1/24 to 11/1/24, all drills were conducted on the first day of every month. | Fire drills shall be held on different days of the week and at different times of the day and night. | Management was retrained on proper fire safety documentation and procedures. |
02/27/2025
| Implemented |
| 6400.141(a) | Individual #1, date of admissiona 12/3/22, had an annual physical examination completed on 1/8/24 but had not record of one completed in 2023.Therefore, compliance could not be measured. [Repeated Violation-12/19/23, et al] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Management requested a copy of the individual's 2023 physical. |
02/27/2025
| Implemented |
| 6400.141(c)(7) | Individual #1's date-of-birth is 7/8/95.. Neither their 1/8/24 physical examination, nor content of records included a completed gynecological examination. [Repeated Violation-12/19/23, et al] | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Management requested an updated copy of the individual's gynecological records from the medical provider. Management was retrained on the elements of proper maintenance of individual files. |
02/27/2025
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 1/8/24, did not include 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. | Management was retrained on the proper elements of a individual physical form. |
02/27/2025
| Not Implemented |
| 6400.142(a) | Individual #1's date-of-birth is 7/8/95. Their most recent dental examination was completed on 1/17/23. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Management requested documentation of the individual's dental appointments from the dentist. |
02/27/2025
| Not Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed on 2/29/24, did not include a lifetime medical history and made no reference to it. | The assessment must include the following information: A lifetime medical history. | Management was retrained on the required elements of an individual assessment. |
02/27/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's diagnoses include bipolar disorder, mood disorder, and depression. Neither their assessment completed on 2/29/24, nor their content of records included a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Management obtained a copy of the individual's psychological evaluation and placed it in their file. Management was retrained on the proper elements of an individual assessment. |
02/27/2025
| Implemented |
| 6400.18(a)(4) | Enterprise Incident Management #: 9482746 involving psychological abuse was discovered on 9/10/24 at 11:21 AM and reported on 9/11/24 at 5:41 PM. Enterprise Incident Management #: 9482753 involving psychological abuse was discovered on 9/10/24 at 11:21 AM and reported on 9/12/24 at 11:59 AM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Management was retrained on incident management. |
02/27/2025
| Implemented |
| 6400.18(a)(5) | Enterprise Incident Management #: 9483123 involving neglect for failure to provide needed care was discovered on 9/11/24 at 11:21 AM and reported on 9/12/24 at 12:20 PM. Enterprise Incident Management #: 9483158 involving neglect for failure to provide needed supervision was discovered on 9/11/24 at 11:21 AM and reported on 9/12/24 at 12:47 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| Management was retrained on incident management. |
02/27/2025
| Implemented |
| 6400.46(b) | Direct Support Professional #1 completed annual fire safety training on 10/16/24 but did not complete any such training in 2023. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Management was retrained on the proper documentation of training records. |
02/27/2025
| Implemented |
| 6400.46(d) | Direct Support Professional #1 completed two-year certification training from the American Red Cross in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 5/26/21, and then completed another two-year certification in this training from the National CPR Foundation on 11/30/23. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Management implemented a revised checklist to ensure the routine training of employees. |
02/27/2025
| Implemented |
| 6400.52(c)(1) | Direct Support Professional #1 completed annual training for the 2023 calendar year, which included training in the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships. This training was completed by "self-reading" the material. | 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. | Management reviewed and revised current agency training to ensure it encompassed The Application of Person-Centered Practices, Community Integration, Individual Choice and Supporting Individuals To Develop and Maintain Relationships. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(2) | Direct Support Professional #1 did not complete annual training for the 2023 calendar year that included the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse. | 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. | Management reviewed and revised current agency training to ensure it encompassed The Prevention, Decection and Reporting of Abuse, Suspected Abuse and Alleged Abuse. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(3) | Direct Support Professional #1 did not complete annual training for the 2023 calendar year that included content on individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Management reviewed and revised current agency training to ensure it encompassed Individual Rights. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(4) | Direct Support Professional #1 did not complete annual training for the 2023 calendar year that included recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Management reviewed and revised current agency training to ensure it encompassed Recognizing and Reporting Incidents. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(5) | Direct Support Professional #1 did not complete annual training for the 2023 calendar year that included individual-specific reviews of the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Management reviewed and revised current agency training to ensure it encompassed The Safe and Appropriate Use of Behavior Supports. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(6) | Direct Support Professional #1 did not complete annual training for the 2023 calendar year that included individual-specific reviews of the implementation of the individual support plan. | 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. | Management reviewed and revised current agency training to ensure it encompassed Implementation of the Individual Plan. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. Individual #1's content of records did not include any medication reviews completed by a licensed physician. | 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. | Management requested the records of the individual's quarterly medication review and ensured they are placed in the individual's residential binder. Management was retrained on the proper documentation and importance of a quarterly medication review. |
02/27/2025
| Not Implemented |
| 6400.182(c) | Individual #1's assessment completed on 2/29/24, and their Individual Support Plan, last updated on 12/2/24, differed in the following manner regarding safety skill domains: Individual #1's assessment stated they are independently able to be safe around poisons but their Individual Support Plan explains that they can safely use poisons with verbal prompts and line-of sight supervision; and Individual #1's assessment indicates that they can evacuate safely in the event of a fire with staff assistance while their Individual Support Plan explains that Individual #1 requires little to no prompting to safely evacuate in the event of a fire. In addition, Individual #1's assessment was completed on 2/29/24, which was after their Individual Support Plan Annual Review Meeting that was held on 1/17/24. Therefore, the assessment used for the annual update of the ISP was not based on a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Management was retrained on the individual support plan and assessment polices and procedures. |
02/27/2025
| Implemented |