| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | On 9/16/2026 at 11:37 AM, there was an area approximately five-feet by five-feet of water on the floor of the garage of the home, posing a slipping and falling hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Upon discovery of the water - the Director of Programs notified maintenance to address the water in the garage. Maintenance cleaned up the water on 09/16/2026 at 3pm. This was verified by the Program Specialist.
This provider does not agree with the violation. The water was not 5 feet by 5 feet.. The water was contained to a small area in the garage and a maintenance request form was presented to the inspector from 09/15/2026 due to a plumbing issue and ongoing repair. |
09/20/2026
| Implemented |
| 6400.72(b) | On 9/16/1016 at 10:56 AM, the only window in the bathroom, on the second floor of the home, slid closed when it was opened. | Screens, windows and doors shall be in good repair. | During the licensing inspection, it was identified that the bathroom window did not remain open when raised and would slide closed. As a result, the window could not reliably function as the required source of ventilation.Serenity Home Services will have the bathroom window repaired so that it opens properly and remains securely in the open position when being used for ventilation. The repair will include evaluation and correction of the window mechanism, hardware, balance, or other component responsible for the window sliding closed.
Maintenance was notified of the window on 09/16/2026. On 09/18/2026, maintenance ordered a replacement window. The window is expected to arrive with 4 to 6 weeks. |
09/20/2026
| Implemented |
| 6400.101 | On 9/16/2026 at 11:33 AM, there was a hook and eye lock on the storm door on the porch leading from the basement exit of the home, causing an obstructed egress when engaged. At 11:38AM, there was a deadbolt locking mechanism on the basement side, with a keyed locking mechanism on the garage side of the door between the basement and garage of the home posing an obstruced egress form the garage when engaged. There is no swing door exit inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Upon discovery of the hook - the Director of Programs removed the hook. Serenity Home Services will inspect all doors, doorways, hallways, passageways, and exit routes within the home to ensure that there are no hooks, furniture, equipment, personal belongings, storage items, or other objects that could interfere with safe and unrestricted passage. |
09/20/2026
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 7/2/2026, did not include the individual's dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Serenity Home Services will correct the individual's assessment to include the individual's likes, dislikes, and interests as required by 55 Pa. Code § 6400.181(e)(2).
The Program Specialist will gather the necessary information through interviews with the individual and appropriate team members, review of progress notes, observations, and other applicable assessment information. The assessment will be updated to accurately reflect the individual's current likes, dislikes, and interests. The Program Specialist will sign and date the corrected assessment. This will be completed no later than 09/25/2026. |
09/25/2026
| Implemented |
| 6400.163(h) | Individual #1 was prescribed Bacitracin that was discontinued on 8/13/2026. On 9/16/2026 at 11:11 AM, this medication remained in Individual #1's medication box in the staff office. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | It was identified that a medication that had been discontinued by the individual's prescribing practitioner remained present in the individual's medication storage area.
Serenity Home Services immediately removed the discontinued medication from the individual's active medication supply and ensure that it is destroyed/disposed of safely in accordance with applicable medication disposal requirements.
The Program Specialist will review the individual's current physician orders, Medication Administration Record (MAR), and medications physically present in the home to ensure that all medications correspond with current prescriber orders. Training of leads and Program specialist occurred on 09/23/2026 from the director of Programs |
09/23/2026
| Implemented |