| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agencies expiration date of their certificate of compliance is 3/4/25. The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/4/24 to 1/4/25, and the self- assessment was completed 1/31/25. This exceeds the requirement. Per the Regulatory Compliance Guide (RCG) there is no grace period for this regulation. | 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.
| This reg. is important to measure the record of compliance with the chapter. When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025. |
03/06/2025
| Implemented |
| 6400.21(b) | If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check within 5 working days after the person's date of hire. Staff #2, a Direct Support Professional, who resides outside of the commonwealth date of hire is 11/11/24, and their determination on the document submitted had the results as of 12/16/24. Licensing Representative (LR) requested Staff #2's application from the agency, but it was not provided. It can only be determined from the document with the determination date of 12/18/24 that it was submitted on or around that timeframe and that exceeds the requirement. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| It is important to keep in compliance with this reg. to ensure the protection of the individuals. A staff member that resides outside of PA needed to do FBI criminal history check within 5 days of hire. The fingerprint was scheduled but done late due to limited schedule availability on identogo, it was pushed two weeks ahead. We did the check for a week more than the required timeline; we will now be certain to schedule the FBI check and after before we can start orientation. |
03/18/2025
| Implemented |
| 6400.64(d) | Trash in the kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. At the time of the inspection, located in the kitchen on the backdoor handle/knob there was a white trash bag with an orange cinch hanging from it that contained a ½ drank bottle of water. Also, on the door frame next to where the white trash bag was hanging was a neon green Post it is saying "Recycle Please" with and arrow above and below each word pointing to where the bag was hanging. Agency staff removed the white trash bag from hanging on the door and threw it away in the trash can. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | It is important that the trash container prevents penetration of insects. At the time of the inspection, there was a trash bag hanging with half bottle of water it. According to staff, the individual placed the bottle of water in the bag and did not remember to take it outside into the recycled receptacle. This was corrected doing the time of licensing. |
03/13/2025
| Implemented |
| 6400.67(a) | Floors, walls, ceilings, and other surfaces shall be in good repair. The black metal rod railing located at the top of the attic on the landing was loose and wobbled back and forth when the Licensing Representative (LR) placed their hand on it. | Floors, walls, ceilings and other surfaces shall be in good repair. | The rail being in good repair could prevent serious injury or fall. It was discovered when doing inspection that the top floor railing was loose and wobbling. This is an attic area and people do not normally go there much; therefore, maintenance did not focus on it to tighten the rail as it became loose. The rail was screwed on the day of licensing by the maintenance. |
03/07/2025
| Implemented |
| 6400.71 | The phone located in the living room behind the television did not have the telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center shall be on or by it. | 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.
| This reg. is essential to individuals to enable them reach to emergency worker for help in case of fire, medical, poison ingestion and so on. At the time of the inspection, there were no emergency numbers posted on the phone. The Individual took out the emergency numbers that were posted on the phone. The Supervisor replaced the numbers the same day it was reported. |
03/05/2025
| Implemented |
| 6400.72(b) | Screens shall be in good repair. At the time of the inspection, the screen located in the attic window was ripped all along the top and bottom of the screen. | Screens, windows and doors shall be in good repair. | The regulation is to avoid bugs and other insects from entering the home. At the time of the inspection, the window screen was ripped. The screen was replaced a day before the inspection, the individual wanted to throw something through the window, so he decided to make holes. The screen has been replaced. Picture has been sent. |
03/07/2025
| Implemented |
| 6400.111(e) | A fire extinguisher shall be accessible to staff persons and individuals. At the time of the inspection, the fire extinguisher for the 2nd level of the home was locked in the staff's office making it inaccessible. | A fire extinguisher shall be accessible to staff persons and individuals. | When the fire extinguisher is accessible to staff and individuals, in the event of a small fire they should be able to extinguish the fire. At the time of the inspection, the fire extinguisher on the 2nd floor of the home was placed in a locked room. Due to the outburst of the individual, the staff person was afraid of the extinguisher being next to his room and placed it in the locked office to avoid injury. The fire extinguisher was taken out of the locked room and put on the wall on the 2nd floor. |
03/10/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's date of admission is 9/23/24 and their physical examination dated 1/9/24 documented their tetanus/Diphtheria 11/13/19. The last page of Individual #1's physical noted that patient to go to pharmacy to receive it which is inconsistent with the note to get it. There was no record that he received it prior to admission. The Centers for Disease Control recommends that adults the vaccination every 10 ears for adults. | 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. | It is important that the individual has all vaccines date on the physical for health and safety.
At the time of the inspection, the initial physical did not include immunizations record. The individual had this physical about 8 months before he came into our CLA. The physical did not include these. We took him and did another physical that included all the required health information. |
03/21/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's date of admission is 9/23/24 and their physical examination dated 1/9/24 did not include a hearing screening as this section of the examination was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Vision and hearing for Individual 18 and above are recommended and essential to their heath. At the time of the inspection, the individual annual physical did not indicate if he had a vision screening done. The physical was done on 10/07/24 and his vision was scheduled for 1/30/25. |
03/24/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's date of admission is 9/23/24 and their physical examination dated 1/9/24 did not include
Medical information pertinent to diagnosis and treatment in case of an emergency as this section was left blank on the exam. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical information is important for individual health.
At the time of the inspection, the initial physical did not include any directive in case of emergency treatment. The individual had this physical about 8 months before he came into our CLA. We could not change it and his insurance could not pay for new physical before he move in since the current physical was not a year. We took him and did another physical that included all the required health information. |
03/25/2025
| Implemented |
| 6400.151(a) | Staff shall have a physical examination within 12 months prior to employment. Staff #1's date of hire is 4/5/24 and they had a physical examination completed on 4/25/24. Staff #2's date of hire is 11/11/24 and the physical examination was dated 11/14/24. Staff #3's date of hire is 12/9/24 and their physical examination was completed 12/10/24. | 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. | Per the reg. staff should have their physical examination done within 12 months prior employment. During the time of the inspection, staff members physical exams were done after their hire date. In actuality, the staff did their physical exam before they encountered the individual, however their hire date was input based on the date of their background check. |
03/07/2025
| Implemented |
| 6400.151(c)(2) | Staff #1's date of hire is 4/5/24 and they had a Tuberculin skin testing by Mantoux method with negative results on 4/25/24. Staff #2 date of hire is 11/11/24 and there is no record of a negative PPD as their physical examination notes date of test 11/14/24 and "Pt did not return for PPD read-test not valid.". Staff #2 then had a Tuberculin skin testing by Mantoux method with negative results completed on 11/20/24. Staff #3's date of hire is 12/9/24 they had a Tuberculin skin testing by Mantoux method with negative results on 12/12/24. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The Reg is essential for the health and safety of the individual we serve. Doing the time of the inspection, staff members TB were done on their physical exams after the date of hire. The staff did their physical exam and TB test before they met the individual, however their hire date was based on the date of their background check. |
03/07/2025
| Implemented |
| 6400.181(a) | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission. Individual #1's date of admission is 9/23/24 and their assessment was completed on 12/2/24, which was 70 calendar days after admission. | 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. | Initial assessment is important for the individual¿s team to understand and know how to support the individual. During the inspection, the initial assessment was not done within the required time. The program specialist did the initial assessment within the 60 days period; however, the SC did not schedule the ISP in the 90 days¿ time frame. Therefore, the PS changed the initial date to reflect the ISP review date. |
03/18/2025
| Implemented |
| 6400.46(a) | Program specialists and direct service workers shall be trained before working with individuals in: General fire safety. Staff #3's date of hire is 12/9/24 and according to the agencies 6400 spreadsheet submitted to the Licensing Representative Staff #3's first day working with individual was 1/18/25, and they received fire safety training on 1/22/25. This exceeds the requirement. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | It is important to train staff in fire safety before they work with the individual. In case of fire emergency, they will know how to respond. The fire safety training date was after the hire date of the staff person. This was an administrative error by using the criminal background check dates as a hire date. All our staff are trained before they work with our individuals. |
03/13/2025
| Implemented |
| 6400.166(c) | Individual #1 is prescribed Clobetasol 0.05% ointment, apply top, to all aff, areas 2x daily @8am-8p. Individual #1 refused the 8am administration of the medication on March 2, March 3, March 4, and March 5. There is no documentation that the refusal was reported to the prescriber. Individual #1 is prescribed Fenapt 6 mg tablet, take 1 tablet by mouth twice daily at 8am and 4pm. Individual #1 refused their 8am dose of Fenapt 6mg on March 3. There is no documentation that the refusal was reported to the prescriber. Individual #1 is prescribed Pulmicort 90 MCG Flexhale, inhale 1 puff my mouth twice daily at 8 am -8 pm. Individual #1 refused the 8am administration of the medication on March 3, March 4, and March 5. There is no documentation that the refusal was reported to the prescriber. Individual #1 is prescribed Kenalog 0.1 % cream, apply topically to affected area(s) daily at 8am. Individual #1 refused the 8am administration of the medication on March 2, March 3, March 4, and March 5. There is no documentation that the refusal was reported to the prescriber. Individual #1 is prescribed Ketoconazole 2% shampoo, mix w/sm amt h20 app to dry scalp, let sit x 5-15 mins, then rinse 3x/wk M, W,F at 8 am. Individual #1 refused the 8am administration of the medication on March 3 and March 5. There is no documentation that the refusal was reported to the prescriber. Individual #1 is prescribed Omerprazole DR 40 mg capsule, take 1 capsule by mouth daily at 7 am. Individual #1 refused the 8am administration of the medication on March 2. There is no documentation that the refusal was reported to the prescriber. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | As per the reg. refusal shall be reported to the prescriber. By reporting it, the prescriber may instruct the next step in keeping the individual safe. At the time of the inspection, the refusal was not reported to the prescriber. It was only documented via agency policy The refusals were documented but the supervisor did not contact the doctor about the refusal. The agency reached the prescriber and informed him about the refusal, the doctor now decided to give him an injection and D/C the cream. |
03/21/2025
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan (ISP) last updated 2/4/25 states under the Supervision Care Needs, Home Supervision, Individual #1 would need to have 24 hour supervision due to being incarcerated for a long period of time to make sure that there is no behavioral concerns show up after begin released. He requires 1:1 staffing. Community Supervision, Individual #1 would need to have 24 hour supervision due to being incarcerated for a long period of time to make sure that there is no behavioral concerns show up after begin released. He requires 1:1 Individual #1 requires 24-hour supervision while in the community to ensure his safety. He is able to take 15 minute walks if he is upset in order to cope and regulate his emotions. Individual #1 is able to walk independently as long as staff are aware of where Individual #1 has reported he will be during his walk. After 15 minutes Individual #1 must report back to his staff member. If Individual #1 after 15 minutes has reported back to his staff member, he can be allowed an additional 15 minutes of alone time in which he can use to further regulate his emotions. Before going for his walk Individual #1 must identify to his staff member the area in which he is going to walk around. Staff should keep this area where Individual #1 has reported he is walking within eyesight to ensure his safety and ensure that he is not engaging in negative behaviors. Individual #1 should not be out of staff's eyesight for any longer than 15 minutes at a time to ensure he is not engaging in negative behaviors. While Individual #1 is utilizing his alone time, staff should not approach nor follow Individual #1. He may become verbally aggressive if he is followed. Individual #1 can have up to two consecutive 15 minutes periods of alone time at a time. Individual #1 must check in with staff after each 15-minute period. Individual #1 can repeat this every three hour until 9:00pm. After 9:00pm, Individual #1 should remain within eyesight until 6:00am. Between 6am-9am: Individual #1 can have up to two consecutive 15 minutes periods of alone time at a time. Individual #1 must check in with staff after each 15-minute period. Between 9am-12pm: Individual #1 can have up to two consecutive 15 minutes periods of alone time at a time. Individual #1 must check in with staff after each 15-minute period. Between 12pm-3pm: Individual #1 can have up to two consecutive 15 minutes periods of alone time at a time. Individual #1 must check in with staff after each 15-minute period. Between 3pm-6pm: Individual #1 can have up to two consecutive 15 minutes periods of alone time at a time. Individual #1 must check in with staff after each 15-minute period. Between 6pm-9pm: Individual #1 can have up to two consecutive 15 minutes periods of alone time at a time. Individual #1 must check in with staff after each 15-minute period. Individual #1's assessment dated 12/2/24 states under the General Need for Supervision-Requires 24-hour supervision; eyesight, Ability to be left alone- Cannot be left alone-Individual #1 requires eyesight supervision while in the home. Individual #1 is familiar to the area due to previously living in the area. He has 1:1 24 hours a day. The assessment and ISP do not match. The individual plan shall be revised annually and revised when an individual's needs change based upon 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. | Updates of the ISP are essential for the support of the individual. The individual ISP was not updated to match the assessment date. The SCO did not update the ISP on time when our PS submitted the initial assessment. The PS has reach out to the county and SC to ensure the ISP reflect the initial assessment. |
03/21/2025
| Implemented |