| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.21(b) | The Agency commenced operation of this Community Home for Individuals with an Intellectual Disability or Autism on November 20, 2023, prior to the submission of an application and approval from the Department. | The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued. | Victory Health Inc received this violation due to an emergency move that was not approved by ODP nor was it relayed through all the proper channels in regards to the individuals team. |
12/23/2023
| Implemented |
| 6400.64(f) | At 12:23PM, five white bags filled with trash and two cardboard boxes filled with cardboard and trash were on the deck in the rear of the home. [Repeat Violation, 12/22/2022] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | This issue occurred during our move in process. We removed the bags and all trash from the deck of the home. |
12/29/2023
| Not Implemented |
| 6400.71 | At 1:08PM, the telephone numbers of the nearest hospital, police department, fire department and ambulance were not on or by the cordless telephone. [Repeat Violation, 6/29/2023, 7/25/2023] | 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.
| The issue occurred due to location mismatch for emergency services. It was not updated We updated the phone numbers on the phone to reflect local information. |
12/29/2023
| Implemented |
| 6400.73(a) | There is not a handrail on the four brick steps between the rear of the home and the road. [Repeat Violation, 4/20/2023] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | This issue occurred due to a scheduling conflict with our contractor to do the work. We had a handrail installed 11/23/2023 |
12/29/2023
| Implemented |
| 6400.74 | At 12:24PM, the outside wooden steps, from the deck in the rear of the home, did not have a nonskid surface. [Repeat Violation, 4/20/2023] | Interior stairs and outside steps shall have a nonskid surface.
| This issue occurred due to a scheduling conflict with our contractor to do the work. On 11.23.2023, the anti skid mats were installed |
12/29/2023
| Implemented |
| 6400.76(a) | At 12:57PM, the top left drawer, of Individual #2's six-drawer dresser, would not stay shut and continued to slide open. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The issue occurred due to the physical move. Once the dresser arrived at the destination, it would not close properly. We had the dresser repaired so the drawers will now close properly. |
01/05/2024
| Implemented |
| 6400.80(a) | At 1:26PM, the bushes, along the walkway in the rear of the home, were overgrown posing an obstructed egress for the rear of the home. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | This violation occurred because the bushes may pose a hazard in the rear sidewalk. We had the bushes trimmed |
12/20/2023
| Implemented |
| 6400.107 | At 1:16PM, a portable space heater was on a shelf in the basement 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.
| The violation occurred due to space heater that belongs to tenant in apartment 1. Although this is shared basement, we explained our situation. They did move the space heater but we cannot guarantee what they place in this shared basement. We will be sending over the lease agreement to ODP for review of this setting. |
11/22/2023
| Implemented |
| 6400.110(a) | There is not a smoke detector in the basement of the home. [Repeat Violation, 12/22/2022] | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | This violation occurred because we did not take into account a shared basement required an interconnected smoke detector. We installed interconnected smoke detector immediately after the unannounced inspection |
12/29/0203
| Implemented |
| 6400.32(r)(1) | There is a locking mechanism on Individual #1's bedroom door. Individual #1 has not been provided a key or other mechanism to exercise the right to lock Individual #1's bedroom door. Individual #1 has not been provided with a key or other entry mechanism to exercise the right to lock and unlock the entrance doors of the home. | 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. | We received this violation due to prioritization of other outstanding items for our maintenance team. We were aware of the issue and it was scheduled to be resolved. We had a key locking doorknob installed and made sure the individual received a copy of the key |
12/29/2023
| Accepted |
| 6400.161(a) | Individual #1 has not been provided with the assistance or opportunity for Individual #1' to self-administration medications. | The home shall provide an individual who has a prescribed medication with assistance, as needed, for the individual's self-administration of the medication. | We received this violation because inspector questioned client on her status for taking medication without assistance. Based on her ISP and knowledge, we have been working with team to get her fully tested to get this goal reached without jeopardizing her safety. |
01/05/2024
| Implemented |
| 6400.193(a) | The scissors, knives and chemicals are locked in a cabinet in the home. Individual #1 does not have a restrictive procedure plan and has been assessed safe to utilize these items. | A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. | This violation occurred because we are in two individuals that have different needs when it comes to sharp items and chemicals. Are default was to choose the most restrictive to protect all clients. All knives, scissors and poisons were removed from the staff closet. |
01/05/2024
| Not Implemented |