Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260377 Renewal 01/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills held on the following dates did not include the amount of time it took for evacuation: 7/31/2024, 8/5/2024, 8/26/2024, 9/9/2024, 10/27/2024, 11/11/2024, 11/14/2024, 12/30/2024, and 1/6/2025.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. PACC¿s Fire Drill record has been updated to include a yes and no option on the record that all individuals and staff persons were able to evacuate in under 2 and half minutes. Additionally, the record has been updated to include the exact time it took for all individuals to evacuate. The time of evacuation will be recorded in minutes and/or seconds on the designated line. 01/30/2025 Implemented
6400.113(a)Individual #1, date of admission 7/31/2024, participated in fire safety training on 8/1/2024. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. For licensing purposes and the individuals' safety and wellbeing, move in times will be adjusted around a time that allows for a fire drill to be still conducted. Fire drills will occur within reason and when possible, not to disturb the individual's emotional wellbeing. All individuals will participate in a fire drill as well as be trained in fire safety protocols on the day that they move in. 01/30/2025 Implemented
6400.141(b)Individual #1's physical examination, completed 4/10/2024, was not dated by the physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. As per 6400.141(b), the physical examination shall be completed in its entirety, signed, and dated by a licensed physician, certified nurse practitioner or licensed physician¿s assistant. PA Connecting Communities¿ Individual Physical form was revised on 1/29/2025 to include a line for a date next to the physician¿s signature to ensure that this regulation is met. 01/29/2025 Implemented
6400.181(e)(10)Individual #1's assessment, completed 8/28/2024, did not include a lifetime medical history. The agency completed a lifetime medical history report on 7/31/2024; however, this report was not attached to the individual's assessment.The assessment must include the following information: A lifetime medical history. As per 6400.181(e)(10), the assessment must include a lifetime medical history. PA Connecting Communities Assessment was updated on 1/29/25 to include that the lifetime medical history will be filed with the assessment in the individuals¿ charts. The lifetime medical history will be provided to the ID Team with all other requirements pertaining to the individual assessment. 01/29/2025 Implemented
6400.181(e)(11)Individual #1's assessment, completed 8/28/2024, did not include a psychological evaluation. A psychological evaluation was completed 3/26/2001; however, this evaluation was not attached to the individual's assessment.The assessment must include the following information: Psychological evaluations, if applicable. As per 6400.181(e)(11), the assessment must include a psychological evaluation, if applicable. PA Connecting Communities Assessment was updated on 1/29/25 to include that the psychological evaluation will be filed with the assessment in the individuals¿ charts. The psychological evaluation will be provided to the ID Team with all other requirements pertaining to the individual assessment. 01/29/2025 Implemented
6400.181(e)(12)Individual #1's assessment, completed 8/28/2024, did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. As per 6400.181(e)(12), the assessment must include recommendations for specific areas of training, programming and services. PA Connecting Communities Assessment was updated on 1/29/25 to include a separate section labeled `recommendations¿ (including training, programming, and services). During the assessment process, the Program Specialist will document any recommendations pertaining to the individuals¿ needs regarding training, programming and services. 01/29/2025 Implemented
6400.24Individual #2, date of admission 7/31/2024, signed a Room and Board Residency Agreement for the monthly amount of $795.60. Individual #2 then signed a Room and Board Residency Agreement on 1/2/2025, for the monthly amount of $854.64. Individual #1, date of admission 1/6/2025, signed a Room and Board Residency Agreement on 1/6/2025 for the monthly amount of $1,764.00. Regulation 6100.686a1, reads, "An individual's share of room and board may not exceed 72% of the SSI maximum rate plus the Pennsylvania supplement." The SSI maximum rate in 2024 was $943 and Pennsylvania supplement was $22.10. Therefore, the maximum Room and Board payment was not to exceed $694.87. The SSI maximum rate in 2025 is $967.00 and the Pennsylvania supplement is $22.10. Therefore, the current maximum Room and Board payment is not to exceed $712.15.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.On 1/29/2025, PACC was made aware that they were overcharging Individual #1 and #2. PACC modified the policies pertaining to room and board contracts, drafted new room and boards contracts for February 2025 and thereafter for both individual #1 and #2. Reimbursements were made to individual #. PACC will keep records of previous room and board contracts in the individuals¿ files. On 1/29/2025, PACC drafted new room and board contracts for both individual #1 and #2. On 1/29/2025, individual #1 was informed that they had been overcharged for room and board, that the checks were not yet processed, and that the checks would be voided. A new room and board contract was signed by the individual. The rep payee was made aware that individual #1¿s checks would not be cashed and were voided. The rep payee was also informed that rent for January 2025 would not be collected and that for February 2025 and ongoing, the new amount would be $712.15. On 1/30/2025, individual #2 was informed that they were overcharged for room in board from 7/31/2024 to 1/30/2025. An updated room and board contract was drafted to reflect the correct amount of $712.15 for 1/30/2025 and thereafter. Individual #2 was informed that for September, October, November, and December of 2024, they were overcharged at the amount of $100.43, for a grand total of $402.92. For January 2025, the individual was overcharged at the amount of $142.49. Individual #2 was issued a check for a total reimbursement of $545.41 on 1/30/2025. The rep payee was made aware of the overcharges for each month and the grand total that would be reimbursed by PACC immediately. On 1/30/2025, individual #2 signed a new room and board that reflects the new charge of $712. 15 for February 2025 and thereafter. On 1/30/2025, PACC included in their existing policy that when calculated and collected, room and board rates for all individuals will not exceed 72% of the SSI Maximum rate, plus the Pennsylvania supplement. 01/30/2025 Implemented
6400.32(h)On 1/29/2025 at 10:50AM, there were cameras at the front door and in all common areas of the home. Staff interviews revealed that the cameras store recordings for thirty days. Individual #2 did not sign a consent form to agree to the usage and storage of video footage.An individual has the right to privacy of person and possessions.On 1/29/2025 after the inspection, [Director of Residential Serives #1] and [Staff #2] returned to [Home] to ensure that Individual #2 was reminded of the video monitoring system within her home and that we needed her signed consent that she acknowledges this. Individual #2 was reminded that per her rights she has the right to privacy of person and possessions. Individual #2 was also reminded that the cameras are not within her bedroom, the bathrooms, or any other individuals¿ bedroom. After discussion, Individual #2 signed the Physical Security Policy and Acknowledgement form. 01/29/2025 Implemented
6400.32(r)(1)On 1/29/2025 at 10:59AM, there were thumbnail locks on the two doors leading to Individual #1's bedroom. Individual #1 has not been provided a mechanism to lock and unlock the doors.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.On 2/09/2025, new doorknobs were purchased for Individual #1¿s two doors. These doorknobs were purchased without a locking mechanism since they chose not to lock their doors according to their consent form signed on 1/06/2025. These passage entry doorknobs were placed on 2/13/2025 for both doors leading to Individual #1¿s bedroom. The individual can easily and immediately exit or access their bedroom in all situations. Additionally, for doors that still have thumbnail locks, such as the two bathrooms in the home, the staff have been provided with a key mechanism that can easily unlock the doors if necessary. The keys are located with the other house keys and labeled for the bathroom doors. 02/13/2025 Implemented
6400.32(r)(4)On 1/29/2025 at 10:59AM, there were thumbnail locks on the two doors leading to Individual #1's bedroom. Staff does not have a designated mechanism to unlock the door.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.On 2/09/2025, new doorknobs were purchased for Individual #1¿s two doors. These doorknobs were purchased without a locking mechanism since they chose not to lock their doors according to their consent form signed on 1/06/2025. These passage entry doorknobs were placed on 2/13/2025 for both doors leading to Individual #1¿s bedroom. Staff can easily and immediately access an individual #1¿s bedroom in the event of an emergency. 02/13/2025 Implemented
6400.50(a)The training records for Chief Executive Officer #1's trainings on abuse, individual rights, and incident management, completed on 5/1/2024, did not include the length of the trainings.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The Chief Executive Officer¿s training records for abuse, individual rights, and incident management completed on 5/01/2024 have been updated to include length of each training. Each training record can be found in the employee¿s file with the updated information. The trainer has updated the training forms to ensure all training includes the source, content, dates, and length of training. If applicable and required, training certificates will also be kept in their training file. The CEO¿s training file will be maintained as per all other staff, which includes the PACC 24 Hour Annual Training Document. 02/13/2025 Implemented
SIN-00244960 Add an Addendum 05/23/2024 Compliant - Finalized