| 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 |
| 6400.15(c) | The agency completed a self-assessment of the home on 11/25/24. Regulations .18d through .19a5 were not addressed and were left blank. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| A written summary of corrections was completed and added to the self-assessment to address the areas of noncompliance. This will be kept by the agency for a year. Management was retrained to ensure that all future assessments include a written summary of corrections. A checklist was developed to ensure all components of the self-assessment, including the written summary of corrections, are completed thoroughly. Management will review each self-assessment upon completion to verify that the summary of corrections is included and accurate. |
02/27/2025
| Not Implemented |
| 6400.16 | The agency had a furnace inspection completed on 10/27/23 which stated, "going to need a new furnace soon. The heat exchanger is going bad. Furnace needs replaced." The furnace was not replaced at that time. On 12/6/24, Individual #1 reported that the furnace stopped working "right after Thanksgiving." Individual #1 also reported, "they were supposed to bring me space heaters to keep me warm, but they never did. I just had a bunch of blankets on." Staff interviews on 12/6/24 revealed that staff was using space heaters while they slept in the staff office because, "we had to since the furnace wasn't working." Program Director/ Chief Executive Officer Designee #1 reported that the furnace stopped working on 12/2/24 and was replaced on 12/5/24. Individual #1 was not relocated to an alternative location with a working heat source during the above established periods of time while the reported outdoor temperature lows were approximately 23 degrees Fahrenheit. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The furnace was repaired on 12/5/24. The incident was reported on 12/7/24 as required by regulation. All staff received a refresher training regarding the facility's policies on abuse, neglect, and exploitation, with an emphasis on recognizing and preventing neglect. A quality assurance process has been implemented, including random, unannounced observations by a site inspector and management to ensure compliance with rights and supervision policies. |
02/27/2025
| Implemented |
| 6400.21(d) | Direct Support Professional #2, with a date-of-hire on 9/3/24, completed a Pennsylvania Criminal History Record Check on 9/3/24 that reads, "Request under review for control R31656641." The agency did not provide documentation of the final report. | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| The criminal history check for the staff member in question came back with a final report and no disqualifying results were found. The hiring process was revised to ensure that no staff begin employment without documented completion of a criminal history check. Human Resources staff were retrained reguarding the requirements for criminal history checks and documentation prior to the start of employment. |
02/27/2025
| Not Implemented |
| 6400.43(b)(1) | Program Director/ Chief Executive Officer Designee #1 did not ensure that staff were properly trained on the following policies to ensure implementation: a) Freedom Now Home Care's "Emergency Evacuation Procedure" states, "In the event of an emergency, staff will assist in evacuating the individual(s) out of the residence, contact the Manager immediately, and then contact the American Red Cross who will provide temporary emergency shelter for the immediate area. Individual #1 was not relocated to a temporary emergency shelter from their residence that lacked a functioning furnace during the period shortly after Thanksgiving to 12/5/24, therefore, subjecting Individual #1 to a home with indoor temperatures below 65 degrees Fahrenheit; b) Freedom Now Home Care's "Unusual Incident Policy and Procedures" states, "all staff must remain vigilant and report any unusual incidents immediately to their supervisor or the designated Incident Coordinator," and that "staff must complete an 'Unusual Incident Report Form' within 24 hours of the incident and to submit the form to the Incident Coordinator for review and further action;" c) Staff had not reported maintenance issues to their supervisor(s), as Individual #1 was residing in a home without adequate heat and an operating furnace during the period shortly after Thanksgiving to 12/2/24, when Program Director/ Chief Executive Officer Designee #1 reported awareness that the home's furnace had stop working; and d) At 1:28 PM on 12/6/24, the Department informed Program Director/ Chief Executive Officer Designee #1 via email to file an incident of neglect for Individual #1 into the Enterprise Incident Management System. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The CEO/Director conducted a full review of administrative and management practices to identify gaps and ensure compliance with regulatory responsibilities. The CEO/Director retrained staff on safety and rights policies. A formal management oversight plan was implemented to ensure regular monitoring of all administrative and operational functions. The Management team completed additional training regarding their responsibilities under Chapter 6400.43(b)(1). |
02/27/2025
| Implemented |
| 6400.43(b)(3) | Program Director/ Chief Executive Officer Designee #1 did not ensure the health and safety of Individual #1 in the following manner: a) Staff were not properly trained to implement the agency's "Emergency Evacuation Procedure" and its "Unusual Incident Policy and Procedures"; b) On 12/6/24, Individual #1 reported that the furnace stopped working "right after Thanksgiving." Individual #1 also revealed, "they were supposed to bring me space heaters to keep me warm, but they never did. I just had a bunch of blankets on." Staff interviews conducted on 12/6/24 informed that staff were using space heaters while they slept in the staff office because, "we had to since the furnace wasn't working." Additionally, Program Director/ Chief Executive Officer Designee #1 reported that the furnace stopped working on 12/2/24 and was replaced on 12/5/24. However, Individual #1 was not relocated to an alternative location with a working heat source while the reported outdoor temperature lows were approximately 23 degrees Fahrenheit during the above established periods of time when the home's furnace was not operational; c) Staff had not reported maintenance issues with the home's furnace to their supervisor(s), as Individual #1 revealed that the home lacked a functional furnace and adequate heat approximately just after Thanksgiving to 12/2/24, when Program Director/ Chief Executive Officer Designee #1 reported awareness that the home's furnace had stop working. Staff provided further corroboration in interviews conducted on 12/6/24, revealing that they had been using space heaters while they slept in the staff office because the furnace had not been working; d) At 1:28 PM on 12/6/24, the Department informed via email to file incidents of neglect for Individual #1 into the Enterprise Incident Management System; and e) Program Director/ Chief Executive Officer Designee #1 did not protect Individual #1 from hazards, as interviews conducted on 12/6/24 revealed that Individual #1 had been left with the understanding that the agency was supposed to provide space heaters, which are strictly prohibited, to keep warm when the home's furnace was not functioning and that, instead, it was staff who informed that they had been actually utilizing space heaters in the staff office when the furnace was not working, thus, exposing Individual #1 to a potential fire hazard. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | A safety plan was developed to ensure safety of individuals is maintained at all times with contingency plans for unexpected incidents. The Management team completed training on emergency and backup planning. |
02/25/2025
| Implemented |
| 6400.63(a) | At 10:44 AM on 12/6/24, the hot water temperature measured 136.7 degrees Fahrenheit at the sink in the kitchen of the home. | 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. | Management turned down the hot water tank and retested for compliance. Management was retrained on proper water temperatures in the home. |
02/27/2025
| Implemented |
| 6400.64(a) | At 11:07 AM on 12/6/24, there were very thick cobwebs in the corners, hanging from the ceilings in both the basement and garage. At 11:09 AM on 12/6/24, there was an inordinate number of boxes located in the staff office, the garage, and the basement of the home that were filled with miscellaneous articles of trash. At 11:10 AM on 12/6/24, a wall area measuring approximately five feet by two feet in the garage of the home had water damage and what appeared to be mold. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Clean and sanitary conditions shall be maintained in the home. | Management had the staff thoroughly clean the home. Management contacted the contracted maintenance provider to address and repair the source of the mold in the garage. Management conducted a retraining with staff on proper sanitation of the home. A form will be implemented with shift specific cleaning duties and posted in the home. |
02/27/2025
| Not Implemented |
| 6400.64(f) | At 10:20 AM on 12/6/24, a furnace was discarded on the sidewalk in front of the home. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Management staff had a waste provider remove and discard the furnace outside of the home. |
02/27/2025
| Implemented |
| 6400.66 | At 11:15 AM on 12/6/24, the only light in the interior stairway leading to the second floor of the home was inoperable. | 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 in the stairway leading to the second floor of the home. |
02/27/2025
| Not Implemented |
| 6400.67(a) | At 11:07 AM on 12/6/24, the ceiling and walls in both the basement and garage of the home had cracked and peeling paint that appeared to be from water damage. [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 assess the water damage in the basement and garage and repaint. |
02/27/2025
| Not Implemented |
| 6400.67(b) | At 11:06 AM on 12/6/24, the dryer lint trap vent in the basement of the home was stuck inside the dryer and was unable to be cleaned of covering lint, dust, and particles. [Repeated Violation-12/19/23, et al] | Floors, walls, ceilings and other surfaces shall be free of hazards. | Management contacted the contracted maintenance provider to repair the lint trap. 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
| Implemented |
| 6400.68(b) | At 10:53 AM on 12/6/24, the hot water temperature measured 131.1 degrees Fahrenheit at the shower in the bathroom located on the first floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Management turned down the hot water tank and retested for compliance. Management was retrained on proper water temperatures in the home. |
02/27/2025
| Implemented |
| 6400.71 | At 10:36 AM on 12/6/24, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not located on or near the telephones in the living room and Individual #1's bedroom. | 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.
| Management made new copies of the emergency numbers and placed them on both phones of the home. |
02/27/2025
| Not Implemented |
| 6400.72(a) | At 11:50 AM on 12/6/24, there was no screen in the window facing the left side of the home in the staff office. [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 screen in the staff office. |
02/27/2025
| Not Implemented |
| 6400.76(a) | At 11:58 AM on 12/6/24, water was leaking from the furnace onto the floor in the basement of the home. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Furniture and equipment shall be nonhazardous, clean and sturdy. | Management contacted the HVAC provider to assess for the status of the furnace and to complete any neccessary repairs. |
02/27/2025
| Not Implemented |
| 6400.80(a) | At 10:39 AM on 12/6/24, the wooden deck and exterior stairs in the back of the home leading from the kitchen exit were covered with snow and had not been shoveled or salted. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Management shoveled and salted the back porch and stairs. |
02/27/2025
| Implemented |
| 6400.81(k)(2) | At 10:59 AM on 12/6/24, Individual #1's mattress and box spring were on the floor with no bedframe. Their Individual Support Plan, last updated on 5/28/24, does not document or explain a need for Individual #1 to not have a bedframe or solid foundation in their bedroom, and Individual #1's behavior support plan does not have a component approved by a human rights team to restrict the use of a bedframe or solid foundation in their bedroom. Additionally, Individual #1's Individual Support Plan, last updated on 5/28/24, did not document their choice to decline having a bedframe or solid foundation in their bedroom. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Management purchased a new bedframe for the individual and had them sign a document of their choice to decline a bedframe. |
02/27/2025
| Implemented |
| 6400.81(k)(3) | At 11:00 AM on 12/6/24, there was no pillowcase on the pillow on Individual #1's bed. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | Management purchased a new pillowcase for the individual and had them sign a document of their choice to decline a pillowcase. |
02/27/2025
| Implemented |
| 6400.83(c) | At 10:42 AM on 12/6/24, several soiled silver spoons, a bowl, a plate, a small pot, and a baking sheet were unwashed in the sink in the kitchen of the home. It was reported that Individual #1 had not eaten since the prior evening. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | Management retrained staff on sanitation policies. |
02/27/2025
| Implemented |
| 6400.101 | At 10:36 AM on 12/6/24, a sliding latch lock was on the inside of the exit door in the kitchen of the home. At 10:36 AM on 12/6/24, the trash receptacle was kept directly in front of the exit door in the kitchen of the home. At 10:38 AM on 12/6/24, a chain lock was on the inside of the storm door adjoined to the exit door in the kitchen of the home. At 10:50 AM on 12/6/24, two sliding latch locks were at the top and bottom of the door leading to the basement of the home. [Repeated Violation-12/19/23, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Management contacted the contracted maintenance provider in order to remove the slide locks on the doors. Management received retraining on unobstructed throughways. |
02/27/2025
| Not Implemented |
| 6400.104 | The local fire department notification letter dated 10/19/24 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 11:13 AM on 12/6/24, a portable space heater was next to a mattress on the floor in the staff office on the second floor of the home. | 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 |
| 6400.110(c) | At 11:16 AM on 12/6/24, the only smoke detector on the second floor of the home was located in the locked staff office. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | Management ensured there is a smoke detector in a more common and accessible area of the second floor. |
02/27/2025
| Not Implemented |
| 6400.111(e) | At 11:16 AM on 12/6/24, the fire extinguisher on the second floor of the home was kept in the locked staff office, rendering it inaccessible to the individual. | A fire extinguisher shall be accessible to staff persons and individuals. | Management reached out to the contracted extinguisher provider to get another extinguisher installed on the second floor. |
02/27/2025
| Not Implemented |
| 6400.112(e) | According to the written fire drill record submitted from January 2024 to November 2024, the only fire drill conducted during sleeping hours was completed on 6/1/24, but documents that Individual #1 was awake during the fire drill. [Repeated Violation-12/19/23, et al] | A fire drill shall be held during sleeping hours at least every 6 months. | Management was retrained on proper fire safety documentation and procedures. |
02/27/2025
| Implemented |
| 6400.112(g) | According to the written fire drill record submitted from January 2024 to November 2024, 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(c)(1) | Individual #1's physical examination, completed on 12/12/23, did not include a review of their previous medical history. | The physical examination shall include: A review of previous medical history. | Management was retrained on the elements of proper individual physical documentation requirements. |
02/27/2025
| Not Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, completed on 12/12/23, did not include a vision and hearing screening, and their content of records did not include a vision and hearing examination completed in 2023 or 2024. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Management was retrained on the elements of proper individual physical documentation requirements. |
02/27/2025
| Not Implemented |
| 6400.141(c)(6) | Individual #1's date-of-admission is 11/17/23. Individual #1's content of records indicated that they have not completed an initial Tuberculin skin testing by Mantoux method or any other applicable testing procedure. [Repeated Violation-12/19/23, et al] | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Management requested an updated copy of the individual's TB tests from the PCP. Management was retrained on the elements of proper maintenance of individual files. |
02/27/2025
| Not Implemented |
| 6400.141(c)(7) | Individual #1's date-of-birth is 4/13/68, and their date-of-admission is 11/17/23. Their content of records indicated they have not completed a 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)(8) | Individual #1's date-of-birth is 4/13/68, and their date-of-admission is 11/17/23. Their content of records indicated they have not completed a mammogram. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Management requested an updated copy of the individual's mammogram from the PCP. Management was retrained on the elements of proper maintenance of individual files. |
02/27/2025
| Not Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed on 12/12/23, did not include an assessment of the individual's health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Management was retrained on the elements of an individual's physical exam documentation. |
02/27/2025
| Not Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, completed on 12/12/23, did not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | Management was retrained on the elements of an individual's physical exam documentation. |
02/27/2025
| Not Implemented |
| 6400.141(c)(13) | Individual #1's physical examination, completed on 12/12/23, did not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | Management was retrained on the elements of an individual's physical exam documentation. |
02/27/2025
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed on 12/12/23, 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 |
| 6400.141(c)(15) | Individual #1's physical examination, completed on 12/12/23, did not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Management was retrained on the elements of an individual's physical exam documentation. |
02/27/2025
| Not Implemented |
| 6400.142(a) | Individual #1's date-of-admission is 11/17/23. Individual #1's content of records indicated they have not completed a dental examination, including a checkup and cleaning. | 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 |
| 6400.151(a) | Program Specialist #3 completed a physical examination on 12/4/23. Their previous physical examination was not provided, and therefore, compliance could not be measured. | 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. | Management requested a copy of Program Specialist #3's physical. |
02/27/2025
| Implemented |
| 6400.151(b) | Direct Support Professional #2's date-of-hire is 9/3/24. They completed a physical examination on 8/27/24. This physical examination was not signed and dated by a licensed physician, certified nurse practitioner, or licensed physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Management reached out to the medical provider to have the physical exam from 8/27/24 signed and retained the copy. |
02/27/2025
| Not Implemented |
| 6400.171 | On 12/6/24, the following expired, unprotected food items were found in the refrigerator located in the home's kitchen: At 10:45 AM, a carton of eggs with a use-by-date of 11/16/24; a partially eaten, unsealed package of premade chocolate chip cookie dough squares; a partially opened slice of individually packaged cheese; a quart of chocolate milk with a sell-by-date of 11/26/24; a pint of milk with a best-by-date of 10/17/24; a bag of Kraft shredded taco cheese with an expiration date of 11/10/24; and a jar of cheese dip with mold inside. At 10:46 AM, a pot containing used cooking oil with remnants of food was discovered on the top rack inside the oven in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Staff removed and discarded all expired food items. Management retrained staff on the proper food storage and discarding procedures. |
02/27/2025
| Not Implemented |
| 6400.181(e)(10) | Individual #1's current assessment, completed on 12/12/23, 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 |
| 6400.212(b) | Individual #1 was reportedly informed of and explained individual rights on 11/17/23. This form that was signed, dated and initialed by both Individual #1 and Program Director/ Chief Executive Officer Designee #1, was photocopied with the same signatures and initials but with the original date having been whited out and written over with a new date of 11/15/24. Individual #1 was reportedly trained in fire safety on 11/17/23. This form that was signed, dated and initialed by both Individual #1 and Program Director/ Chief Executive Officer Designee #1, was photocopied with the same signatures and initials but with the original date having been whited out and written over with a new date of 11/15/24. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| Management was retrained on proper documentation of client records. Management reviewed the document with the individual and provide a new copy to sign as to ensure validity and individual's understanding of the document. |
02/27/2025
| Not Implemented |
| 6400.32(r)(1) | At 11:01 AM on 12/6/24, there was a doorknob with a lock mechanism on the inside with no mechanism to lock and unlock the door from the outside of Individual #1's bedroom. | 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. | Management contacted the contracted maintenance provider to have them change the doorknob on the individual's bedroom door. |
02/27/2025
| Not Implemented |
| 6400.32(r)(4) | At 11:01 AM on 12/6/24, there was a doorknob with a lock mechanism on the inside with no mechanism on the outside to allow easy and immediate access by the individual and staff to lock and unlock the door from outside Individual #1's bedroom in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Management contacted the contracted maintenance provider to have them change the doorknob on the individual's bedroom door. |
02/27/2025
| Not Implemented |
| 6400.51(b)(1) | Direct Support Professional #2, with a date-of-hire on 9/3/24, completed orientation training on 9/4/24. which included person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. This training was completed by "self-reading" the materials. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Management implemented a revised checklist to ensure all new hires complete orientstion training, including person-centered practices, prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.51(b)(2) | Direct Support Professional #2, with a date-of-hire on 9/3/24, completed orientation training on 9/4/24, which included the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse. This training was completed by "self-reading" the materials. | The orientation 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 implemented a revised checklist to ensure all new hires complete orientation training, including The Prevention, Detection and Reporting of Abuse, Suspected Abuse, and Alleged Abuse, prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.51(b)(3) | Direct Support Professional #2, with a date-of-hire on 9/3/24, completed orientation training on 9/4/24, which included recognizing and reporting incidents. This training was completed by "self-reading" the materials. | The orientation must encompass the following areas: Individual rights. | Management implemented a revised checklist to ensure all new hires complete orientation training, including Individual Rights, prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.51(b)(5) | Direct Support Professional #2, with a date-of-hire on 9/3/24, completed orientation training on 9/4/24, which included job related knowledge and skills. This training was completed by "self-reading" the materials. | The orientation must encompass the following areas: Job-related knowledge and skills. | Management implemented a revised checklist to ensure all new hires complete orientation training, including job related knowledge and skills prior to starting their duties. Management was trained on verification and documentation of all required orientation components for new staff. |
02/27/2025
| Not Implemented |
| 6400.52(c)(1) | Program Director/ Chief Executive Officer Designee #1 did not complete training on Person Centered Practices, community integration, individual choice, and supporting individuals to develop and maintain relationships during the 2023 calendar annual training year. Program Specialist #3 did not complete training on Person Centered Practices, community integration, individual choice, and supporting individuals to develop and maintain relationships during the 2023 calendar annual training year. | 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) | Program Director/ Chief Executive Officer Designee #1 did not complete training on the prevention detection and reporting of abuse, suspected abuse, and alleged abuse during the 2023 calendar annual training year. Program Specialist #3 did not complete training on the prevention detection and reporting of abuse, suspected abuse, and alleged abuse during the 2023 calendar annual training year. | 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) | Program Director/ Chief Executive Officer Designee #1 did not complete training on individual rights during the 2023 calendar annual training year. Program Specialist #3 did not complete training on individual rights during the 2023 calendar annual training year. | 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) | Program Director/ Chief Executive Officer Designee #1 did not complete training on recognizing and reporting incidents during the 2023 calendar annual training year. Program Specialist #3 did not complete training on recognizing and reporting incidents during the 2023 calendar annual training year. | 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) | Program Specialist #3 did not complete training on the safe and appropriate use of behavior supports during the 2023 calendar annual training year. | 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) | Program Specialist #3 did not complete training on the implementation of the individual plan during the 2023 calendar annual training year. | 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 |
| 6400.163(a) | At 10:56 AM on 12/6/24, Individual #1's prescribed, Clobetasol Propionate Ointment, the tube of the ointment was on the nightstand next to the bed in their bedroom. The original labeled container was not present in the home. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Staff and management were retrained on proper storage and administration responsibilities of medications. |
02/27/2025
| Not Implemented |
| 6400.163(d) | At 10:56 AM on 12/6/24, Individual #1's prescribed, Clobetasol Propionate Ointment, the tube of the ointment was on the nightstand next to the bed in their bedroom. At 10:58 AM on 12/6/24, a bottle of Individual #1's prescribed, Otix Ear Wax Removal drops, was on a stand near the door in their bedroom. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Staff and management were retrained on proper storage and administration responsibilities of medications. |
02/27/2025
| Not Implemented |
| 6400.163(g) | At 11:40 AM on 12/6/24, a white, oval shaped tablet of what appeared to be Individual #1's prescribed, CA/MG/2N, was at the bottom of a plastic, slide-lock bag that contained other medications in blister packs. The blister pack of CA/MG/2N was located in a separate plastic, slide-lock bag. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | Staff and management were retrained on proper storage of medications. |
02/27/2025
| Not Implemented |
| 6400.165(g) | Individual #1's date-of-admission 11/17/23, and they are prescribed medication to treat symptoms of a psychiatric illness. Individual #1's content of records revealed that they have not had 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 |
| 6400.166(a)(4) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the name of their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(5) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the strength of their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(6) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the dosage form of their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(7) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the dose of medication for their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(8) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the route of administration for their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(9) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the frequency of administration for their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(10) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the administration times of their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(a)(11) | On 12/6/24, Individual #1's December 2024 Medication Administration Record did not include the diagnosis or purpose of their prescribed, One-Daily Multi-Vite Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Management conducted a review of the individual's MAR to make sure all information was included and correct. Management was retrained on the proper documentation of all information to be included on a MAR. |
02/27/2025
| Not Implemented |
| 6400.166(b) | On 12/6/24, all of Individual #1's 8 AM medications were initialed as having been administered by Direct Support Professional #1. Staff and Individual interviews conducted on 12/6/24 revealed that Direct Support Professional #2 had actually administered all of Individual #1's 8 AM medications on 12/6/24. [Repeated Violation-12/19/23, et al] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Management retrained staff on proper recording of medication administration. A form was implemented for weekly documentation and review by management staff to ensure proper medication administration. |
02/27/2025
| Not Implemented |
| 6400.183(c) | Individual #1's record did not include the list of persons who participated in the Individual Plan meeting held on 5/28/24. | The list of persons who participated in the individual plan meeting shall be kept. | Management requested the sign in sheet from the individual plan meeting from the Service Coordinator and ensured it was placed in the individual's residential binder. Management was retrained on proper record keeping. |
02/27/2025
| Not Implemented |