| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. There was a significant layer of dust going all along the molding on both sides of the steps leading from the main level of the home to the second level. The ceiling vent in the bathroom had a significant amount of dust on it. There were several areas of green/white congealed toothpaste on the wall of the tub/shower. There were multiple areas in the tub/shower that had a brown/reddish substance on it as well as a several areas of a white substances/streaks on it. There were also multiple areas around the rim and edge of the tub where hairs were located. The metals track for the doors of the shower/tub also had a buildup of brown/black substance in it as well as numerous areas on the track that contained hairs in it. (Repeat Violation 5/20/24) | Clean and sanitary conditions shall be maintained in the home. | QLHS designated staff and Supervisor cleaned the bathroom vent to ensure it is in clean and sanitary conditions. QLHS also removed the Country Sausage Gravy from the kitchen cabinet during inspection. |
08/11/2025
| Not Implemented |
| 6400.82(d) | Privacy shall be provided for toilets by partitions or doors. Located in the basement of the home in the corner next to the washer and dryer was a toilet with running water to it and a plunger next to it as well. The toilet was open to the basement with no privacy protections. | Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. | QLHS contacted the landlord to inform him that the toilet in the basement needs a door for privacy for the individual and staff. |
08/30/2025
| Implemented |
| 6400.104 | Individual #1 date of admission is 6/17/24. There is not record or documentation that the agency notified the local fire department that the individual moved into the home. | 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.
| QLHS Director Assistance will notify the local fire department of the date the individuals moved into the home. |
08/01/2025
| 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 upper level of the home where Individual #1's bedroom is located the fire extinguisher was locked in the staff office. The agency staff did contact maintenance during the inspection, and they came to work on mounting it in the hallway. | A fire extinguisher shall be accessible to staff persons and individuals. | QLHLS maintenance has mount the fire extinguisher on the upper level of the home of the hallway to ensure the home is compliance with ODP regulations. |
06/30/2025
| Implemented |
| 6400.113(a) | An individual shall be trained upon initial admission on fire safety. Individual #1 date of admission was 6/17/2024 and they received fire safety training on 1/5/25. This exceeds the requirement. | 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. | QLHS staff will be retrained on the important of reviewing the fire safety training with all individuals that is admitted into our residential homes as required by ODP regulations. |
08/30/2025
| Implemented |
| 6400.141(c)(10) | Individual #1's physical exam dated 5/2/25 but signed by the physician on 5/10/25 did not include if they were free from communicable disease section was left blank on the exam form. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | QLHS supervisor will take individual #1 physical exam paperwork back to the doctor office to be filed out in its entirety. |
08/30/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's physical exam dated 5/2/25 but signed by the physician on 5/10/25 did not include physical limitations as this section was left blank on the exam form. | The physical examination shall include: Physical limitations of the individual. | QLHS supervisor will take individual #1 physical exam paperwork back to the doctor office to be filed out in its entirety. |
08/30/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical exam dated 5/2/25 but signed by the physician on 5/10/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency as this section was left blank on the exam form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | QLHS Supervisor has taken individual #1 physical exam form back to the doctors off to get the form completed and its entirety to ensure that the form has the pertinent diagnosis and treatment in case of an emergency to ensure that we are incompliance withe ODP Regulations. |
09/01/2025
| Implemented |
| 6400.143(a) | On 10/3/24 Individual had a dental appointment, and the dental form noted "no exam x-rays possible patient uncooperative". There was no record or documentation for Individual #1's 10/3/24 appointment that the Individual #1 was trained about the importance for dental care. (Repeat Violation 5/20/24) | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | QLHS supervisor will train individual #1 on the importance of attending his scheduled dental appointments as required by ODP regulations. |
08/01/2025
| Implemented |
| 6400.144 | Individual #1The pharmacy labels for their prescription Hydroxyzine HCL 50 mg, 1 tab every 8 hours as needed (sleep or alarming behavior) the pharmacy labels do not have the labels do not have the proper instruction/orders, pharmaceutical services not being provided.
During the inspection, while reviewing Individual #1's medications and May 2025 Medication Administration Record (MAR) the Licensing Representative (LR) noticed that Individual #1's MAR did not have documentation for Individual #1 receiving their 8am dose of Januiva 25mg once daily on 5/28/25. When the LR inquired why the 8am administration was not documented on the MAR Staff #2 reported that the medication was not in the home and that the pharmacy delivered it later in the day on 5/28 so. The MAR also noted on the exceptions page for Individual #1 for 5/27/25 at 8:01 am the Januvia 25 mg tablet medication was not on hand. The agency did not arrange or provide pharmaceuticals for Individual #1. (Repeat Violation 5/20/24) | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Directed Plan of Correction: QLHS will audit all medications for all individuals being served in all of their homes. QLHS will work with individuals' healthcare providers to ensure proper instructions for administration are obtained for all medications. QLHS staff will complete daily checks to ensure medications are present in the home and refilled in a timely manner. |
09/30/2025
| Not 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 6/17/24 and their assessment was dated 2/27/25. This exceeds the requirement. (Repeat Violation 5/20/24) | 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. | QLHS will retrain the program specialist on ODP requirements for completing the individual's initial and annual assessment as stated in ODP regulations. |
08/01/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment dated 2/27/25 did not include a lifetime medical history. The assessment noted" see attached updated lifetime medical history", but there was nothing attached to the assessment in the record. (Repeat Violation 5/20/24) | The assessment must include the following information: A lifetime medical history. | QLHS will complete the lifetime medical history form as required by ODP regulations. |
08/01/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment dated 2/27/25 under the Functional skills/money management section, Money handling indicated that Individual #1 was a 2-uses money but does not make or count change correctly. For purchasing indicated Individual #1 was a 1-does not make a purchase. Their level of performance and progress stated in the area of money management, Individual #1 is good with financial purchases. Staff records all receipts of his purchases. At the time of the inspection there were no records or documentation of staff recoding all receipts of his purchases. Individuall #1's Individual Support Plan (ISP) states that Individual #1's rep payee, his father, provides Individual #1 with $20/week of spending money. Individual #1 can manage only $20/week. The agency did not assess Individual #1 appropriately in their financial management/independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| QLHS staff will be retrained on the individual funds policy and individual #1 assessment will be updated to reflect the correct information. |
08/01/2025
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment dated 2/27/25 did not include the current level of managing personal property for Individual #1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | QLHS staff will be retrained on the individual funds policy and individual #1 assessment will be updated to reflect the correct information |
08/01/2025
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 2/27/25 did not include the current level of Community-integration for Individual #1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | QLHS will update the assessment to reflect the current level of community-integration for individual #1 assessment as required by the ODP regulations. |
08/30/2025
| Implemented |
| 6400.15(b) | The agency will use the department licensing inspection instrument for the community homes to measure compliance. The self-inspection tool provided at the time of inspection were completed on incorrect forms. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | QLHS Director that completed the self-assessment form has been shown where to find the correct inspection instrument self-assessment measure form. |
07/01/2025
| Implemented |
| 6400.32(r) | An individual has the right to lock the individual's bedroom door. Individual #1 did not have a lock on his bedroom door. (Repeat Violation 5/20/24) | An individual has the right to lock the individual's bedroom door. | QLHS maintenance replaced the lock on individual #1-bedroom door to ensure the privacy and the security of the individual as required by ODP regulations. |
06/30/2025
| Implemented |
| 6400.46(c) | Staff# 1's date of hire is 8/26/2024 and their first day working with individuals was 9/6/24 and there was no documentation that Staff #1 was trained in first aid techniques before working with individuals. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | As of 6/10/25 Staff #1 is no longer employed with QLHS, However, QLHS will update onsite orientation checklist to list first aid techniques that staff was trained on before working in the individual's home or in a vehicle while individual is being transported.
QLHS will retrain staff on their responsibility to update the onsite orientation form when needed. |
09/01/2025
| Implemented |
| 6400.51(b)(2) | Staff# 1's date of hire is 8/26/2024 and their record did not include documentation that Staff #1's orientation encompassed the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Service Law, and the Adult Protective Services Act. | 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. | Staff #1 is no longer employed with the company. However, QLHS Director will train the new HR staff on all required orientation prevention, detection and reporting of abuse, suspected abuse and alleged abuse before starting in the office to ensure compliance with ODP and Child Protection Services Law, and the Adult Protection Services Act. |
09/30/2025
| Implemented |
| 6400.165(c) | Prescription medication shall be administered as prescribed. Individual #1 is prescribed Januvia 25mg tablet, take 1 tablet by mouth once at 8am. Individual #1's May 2025 Medication Administration Record (MAR) documented that the medication was not administered at 8am on 5/28/25. On the exceptions page of the MAR for Individual #1 it also noted that on 5/27/25 at 8:01 am their Januvia medication was not on hand. The medication is not being administered as prescribed. (Repeat Violation 5/20/24) | A prescription medication shall be administered as prescribed. | QLHS will retrain staff on the importance of administering medication to the individual as prescribed and proper documentation when administering medication to ensure individual i#1 s receiving his medications as prescribed. |
08/30/2025
| Not Implemented |