|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 2/26/2025 during the inspection the following instances of unclean and unsanitary conditions were identified: At 11:56AM, an open white trash bag filled with trash was located in the garage; at 11:38AM, the floor vent located in the staff office was covered in dirt and debris; at 11:53AM food remnants were smeared into the basement carpet; at 11:54AM saw dust, dirt, and debris covered the garage floor; at 11:59AM under the sink in the first-floor bathroom there was a dirty wash cloth, water-logged brown toilet paper roll, and a layer of brown sludge covering the bottom of the cabinet; and at 12:09PM the floor vent in the dining room was clogged with dust and debris. | Clean and sanitary conditions shall be maintained in the home. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Not Implemented |
| 6400.64(e) | On 2/26/2025 at 11:58AM, the 10-gallon trash receptacle in the basement of the home did not have a lid. [Repeated Violation -- 7/23/24 et al, 10/7/24, 11/21/24] | Trash receptacles over 18 inches high shall have lids. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.67(b) | On 2/26/2025 at 11:55AM the following hazardous conditions were observed: trim on the dining room entryway and the living room entryway was broken off, and the lattice in the basement to the right of the staircase was broken off and left with jagged edges. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Not Implemented |
| 6400.72(a) | On 2/26/2025 at the following windows did not contain screens: at 12:11PM the second-floor vacant bedroom window , at 12:03PM the staff office window, at 12:15PM both of Individual #1's bedroom windows, and the dining room window. [Repeated Violation -7/23/24 et al, 10/7/24, 11/21/24, and 1/23/25] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Implemented |
| 6400.72(b) | On 2/26/2025 at 12:14PM the second-floor vacant bedroom did not have a bedroom door. Staff interviews revealed that it was broken by Individual #1 and leaning on the side of the wall in the vacant bedroom. The basement door had been removed by Individual #1 and was broken in the garage. At 12:14PM, Individual #1's bedroom door was cracked near the door knob. [Repeated Violation - 7/23/24 et al, 10/7/24, and 11/21/24] | Screens, windows and doors shall be in good repair. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Not Implemented |
| 6400.73(a) | On 2/26/2025 at 11:50AM, the basement twelve step stairway did not have a handrail. [Repeated Violation - 7/23/24 et al and 10/7/24] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Implemented |
| 6400.76(a) | On 2/26/2025 the following hazardous and not sturdy furniture and equipment were observed: at 12:13PM a broken box fan in the vacant second floor bedroom, at 12:01PM the first-floor bathroom sink was leaking under the sink while the water was running, at 12:02PM the cross bar support for the bottom of the dining room table was broken, at 12:01PM there were kitchen cabinets doors and drawer faces missing, and at 12:15PM the curtain-rod in Individual #1's bedroom was bent in the middle and not operable. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Not Implemented |
| 6400.80(a) | On 2/26/2025 11:23AM, the front porch of the home had green outdoor carpet, which was lifting at the front entrance, between the front porch railings posing a tripping hazard. [Repeated Violation - 7/23/24 et al, 11/21/24, and 1/23/25] | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Not Implemented |
| 6400.80(b) | On 2/26/2025 at 12:06PM, there were at least four pieces of varying length splintered wall trim stacked next to the brick wall partially across the patio in the rear of the home posing a laceration hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Sanitation & Environmental Safety Compliance
Violations were found concerning cleanliness and environmental maintenance under 55 PA Code Chapter 6400.64(a), 6400.64(e), 6400.67(b), 6400.72(a), 6400.72(b), 6400.73(a), 6400.76(a), 6400.80(a), and 6400.80(b). To correct these deficiencies, a comprehensive facility-wide deep cleaning will be completed by April 201 2025. All damaged or unsafe flooring, windows, and furniture will be repaired or replaced by April 21, 2025. A monthly sanitation and maintenance inspection checklist will be implemented to ensure ongoing compliance. Staff will be retrained on proper cleaning, sanitation, and maintenance reporting procedures by April 15, 2025.
Corrective Actions:
¿ We hired a cleaning company to conduct a deep cleaning of the entire home.
¿ We Implemented a daily and weekly cleaning schedule with assigned staff responsibilities for each shift.
¿ We hired pest control services to inspect and treat any evidence of pest infestation.
¿ Staff was trained on how to properly store food in sealed containers with the dates and remove trash from house daily.
¿ We Conducted staff training on sanitation procedures.
¿ We placed a cleaning check list at site for DSP¿s to sign/initial and date daily cleaning when completed.
¿ Maintenance is inspecting all furniture, flooring, windows and doors to ensure compliance and if anything is damaged, we are repairing or replacing. |
05/30/2025
| Not Implemented |
| 6400.81(k)(4) | On 2/26/2025 at 12:15pm, Individual #1's bedroom did not contain a chest of drawers. | In bedrooms, each individual shall have the following: A chest of drawers. | Bedroom/Bathroom Safety & Fire Safety Compliance
Violations related to bedroom not having chest drawers and bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bedroom drawers, bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.82(f) | On 2/26/2025 at 12:26PM, the bathroom on the second floor of the home did not have a trash receptacle. [Repeated Violation - 7/23/24 et al, 9/20/24, and 10/7/24] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.105 | On 2/26/2025 at 11:53AM, the lint filter in the dryer in the basement of the home was covered with approximately a half an inch of lint and various size clumps of lint and other unidentifiable debris. [Repeated Violation - 7/23/24 et al and 10/7/24] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.111(f) | On 2/26/25 at 12:24PM, the fire extinguisher in Individual #1's bedroom had an inspection date of January 2023. [Repeated Violation - 10/7/24 and 11/21/24] | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Implemented |
| 6400.112(a) | A fire drill was not held in October 2024. Individual #1 moved in to the home on 10/16/2024. [Repeated Violation - 1/23/25] | An unannounced fire drill shall be held at least once a month. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.112(c) | The written fire drill records for the fire drill held on 1/04/2024 and 4/17/2024 do not include if the smoke detectors were operative:. This section was left blank. The written fire drill records for the fire drill held on 3/12/2024, 4/17/2024, 5/16/2024, 6/14/2024, 7/20/2024, and 8/14/2024 had the evacuation time as "2". The written fire drill record for the fire drill held on 3/12/2024 documents the time of the drill as 6:30. The written record for the fire drill held on 7/20/2024 documents the time of the drill as "5". There is not an AM or PM. | 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. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.112(f) | All of the fire drills conducted from January 2024 through February 2025 used the front door as the exit route. The home has additional exit routes. [Repeated Violation - 7/23/24 et al] | Alternate exit routes shall be used during fire drills. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.113(a) | Individual #1's, date of admission 4/19/2023, had fire safety training on 2/27/2025; there is no previous documentation of fire safety training; therefore, compliance could not be measured. [Repeated Violation - 7/23/24 et al] | 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. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.114(b) | The agency's smoking policy documents cigarette's need to be disposed of properly and smoking is prohibited in the home. On 2/26/2025 from 11:52AM to 12:10PM cigarette butts were observed on the garage floor, in the laundry sink, under the bed in the vacant bedroom on the second floor, on the back patio, and below the television in the basement game room. On 2/26/2025 at 12:08PM, Individual #1 was observed lighting a cigarette off of the kitchen stove and smoking it all throughout the home, while flicking ashes on the floor. [Repeated Violation - 7/23/24 et al and 10/7/24] | Written smoking safety procedures shall be followed. | Bathroom Safety & Fire Safety Compliance
Violations related to bathroom accessibility and fire safety were identified under 55 PA Code Chapter 6400.81(k)(4), 6400.82(f), 6400.105, 6400.111(f), 6400.112(a), 6400.112(c), 6400.112(f), 6400.113(a), and 6400.114(b). To correct these, all bathroom grab bars, fire extinguishers, and emergency exits is being inspected and brought into compliance by April 15, 2025. Staff is being retrained on fire drill procedures and fire safety compliance by April 15, 2025. Fire drills and company smoking policy review and implementation are being scheduled monthly, and fire safety inspections is being conducted monthly to ensure continuous adherence to safety regulations.
Corrective Actions:
¿ Implement a fire drill schedule ensuring monthly unannounced drills occur.
¿ Document all fire drills with:
o Date and time
o Exit route used
o Time taken for evacuation
o Problems encountered
o Verification of fire alarm activation
o Fire drills will be conducted at various times, days and shifts without any notice
o Fire safety training will be added to annual staff development.
o All bathroom grab bars and is being inspected to ensure sturdiness and safety.
o Fire extinguishers are being inspected daily for compliance expired extinguishers will be discarded.
o Emergency exits are being identified via training and proper signage. |
05/30/2025
| Not Implemented |
| 6400.141(a) | Individual #1 had a physical examination 4/14/2023 and then again 7/09/2024. [Repeated Violation - 7/23/24 et al] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.144 | Individual #1 had a podiatry appointment 4/17/2024, recommending the individual be seen every 3 months for callous trimming. There is no documentation of any follow up appointments being scheduled. Individual #1 was seen in the emergency room 10/24/2024 and recommended to follow up with outpatient psychiatrist upon discharge. There is no documentation of a follow-up appointment being scheduled. Individual #1's physical examination completed 7/09/2024, documented the individual's vision as abnormal and no follow-up with a specialist has been scheduled. [Repeated Violation - 7/23/24 et al, 9/20/24, and 1/23/25] | 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.
| Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.151(a) | The physical examination completed for Direct Service Worker #1 was not dated; therefore, compliance could not be measured. [Repeated Violation - 7/23/24 et al] | 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. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.151(c)(2) | The Tuberculin test for Direct Service Worker #1 did not include the completion date; therefore compliance could not be measured. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.171 | On 2/26/2025 at 12:08PM, there was a half-full 38-ounce bottle of Tomato Ketchup with instructions to refrigerate after opening on top of the refrigerator in the kitchen of the home. [Repeated Violation - 7/23/24 et al, 9/20/24, 10/7/24, and 11/21/24] | Food shall be protected from contamination while being stored, prepared, transported and served.
| Food Contamination/Individual Rights & Record Compliance
Violations were also identified concerning individual rights and recordkeeping under 55 PA Code Chapter 6400.171, 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.34(a), 6400.213(1)(i). To rectify these, a comprehensive site/file review will be conducted to ensure that all food storage, individual records, assessments, and personal rights documents are accurate and up to date by April 15, 2025. Staff will be retrained on documentation requirements and the importance of maintaining complete and accurate records by April 25, 2025. Regular monthly audits will be implemented to ensure compliance.
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission and annually thereafter. Staff will receive training on residents' rights by April 25, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
| 6400.181(d) | Individual #1's assessment completed 6/10/2024 was not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | Individual Rights & Record Compliance
Violations were also identified concerning individual rights and recordkeeping under 55 PA Code Chapter 6400.171, 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.34(a), 6400.213(1)(i). To rectify these, a comprehensive file review will be conducted to ensure that all individual records, assessments, and personal rights documents are accurate and up to date by April 15, 2025. Staff will be retrained on documentation requirements and the importance of maintaining complete and accurate records by April 25, 2025. Regular monthly audits will be implemented to ensure compliance.
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission and annually thereafter. Staff will receive training on residents' rights by April 25, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed 6/10/2024 did not include a lifetime medical history. [Repeated Violation - 7/23/24 et al] | The assessment must include the following information: A lifetime medical history. | Individual Rights & Record Compliance
Violations were also identified concerning individual rights and recordkeeping under 55 PA Code Chapter 6400.171, 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.34(a), 6400.213(1)(i). To rectify these, a comprehensive file review will be conducted to ensure that all individual records, assessments, and personal rights documents are accurate and up to date by April 15, 2025. Staff will be retrained on documentation requirements and the importance of maintaining complete and accurate records by April 25, 2025. Regular monthly audits will be implemented to ensure compliance.
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission and annually thereafter. Staff will receive training on residents' rights by April 25, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
| 6400.181(e)(11) | Individual #1's assessment completed 6/10/2024 did not include a psychological evaluation. [Repeated Violation - 7/23/24 et al] | The assessment must include the following information: Psychological evaluations, if applicable. | Individual Rights & Record Compliance
Violations were also identified concerning individual rights and recordkeeping under 55 PA Code Chapter 6400.171, 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.34(a), 6400.213(1)(i). To rectify these, a comprehensive file review will be conducted to ensure that all individual records, assessments, and personal rights documents are accurate and up to date by April 15, 2025. Staff will be retrained on documentation requirements and the importance of maintaining complete and accurate records by April 25, 2025. Regular monthly audits will be implemented to ensure compliance.
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission and annually thereafter. Staff will receive training on residents' rights by April 25, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
| 6400.34(a) | Individual #1 was informed of individual rights on 1/03/2024 and then again 2/27/2025. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual Rights & Record Compliance
Violations were also identified concerning individual rights and recordkeeping under 55 PA Code Chapter 6400.171, 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.34(a), 6400.213(1)(i). To rectify these, a comprehensive file review will be conducted to ensure that all individual records, assessments, and personal rights documents are accurate and up to date by April 15, 2025. Staff will be retrained on documentation requirements and the importance of maintaining complete and accurate records by April 25, 2025. Regular monthly audits will be implemented to ensure compliance.
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission and annually thereafter. Staff will receive training on residents' rights by April 25, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
| 6400.46(a) | Program Specialist #2, date of hire 1/24/2025, has not been trained in fire safety. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Training & Staff Compliance
Deficiencies in staff training and compliance were noted under 55 PA Code Chapter 6400.46(a), 6400.46(b), 6400.51(b)(4), and 6400.50. To correct these violations, all staff including Program Specialist, will complete required training by April 30, 2025. A new training tracking system will be implemented to ensure all future training requirements are met on time. Supervisors will conduct random monthly compliance checks to confirm staff are adhering to policies and procedures. |
05/30/2025
| Not Implemented |
| 6400.46(b) | Direct Service Worker #1 was most recently trained in fire safety on 1/10/2024. [Repeated Violation - 7/23/24 et al] | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Training & Staff Compliance
Deficiencies in staff training and compliance were noted under 55 PA Code Chapter 6400.46(a), 6400.46(b), 6400.51(b)(4), and 6400.50. To correct these violations, all staff will complete required training by April 30, 2025. A new training tracking system will be implemented to ensure all future training requirements are met on time. Supervisors will conduct random monthly compliance checks to confirm staff are adhering to policies and procedures. |
05/30/2025
| Not Implemented |
| 6400.51(b)(4) | Program Specialist #2, date of hire 1/24/2025, has not been trained in recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | Training & Staff Compliance
Deficiencies in staff training and compliance were noted under 55 PA Code Chapter 6400.46(a), 6400.46(b), 6400.51(b)(4), and 6400.50. To correct these violations, all staff will complete required training by April 30, 2025. A new training tracking system will be implemented to ensure all future training requirements are met on time. Supervisors will conduct random monthly compliance checks to confirm staff are adhering to policies and procedures.
1. Immediate Review: The Behavior Support Plan will be reviewed by the HRT within the next 30 days and/or by April 20, 2025, to ensure all restrictive procedures are necessary, appropriate, and in compliance with applicable regulations.
2. Policy Update: A formal policy will be established, ensuring that restrictive procedures are reviewed no less than every six months.
3. Training: Staff members involved in implementing behavior support will receive training on restrictive procedure policies, recognizing and reporting incidents, documentation requirements, and the role of the HRT in reviewing and revising plans.
4. Individualized Review Schedule: Each individual's plan will be assigned a review schedule with clear due dates to prevent lapses in review.
5. Documentation Enhancement: All reviews, revisions, and justifications for restrictive procedures will be documented in the individual¿s record and accessible for audits. |
05/30/2025
| Not Implemented |
| 6400.163(a) | The pharmacy label for Tinactin Spray prescribed to Individual #1 was worn and illegible. [Repeated Violation - 7/23/24 et al and 1/23/25] | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Diphenhydramine 25mg Capsule, with instructions to take 1 capsule by mouth every 12 hours as needed for EPS symptoms. Direct Service Worker #3 did not know what EPS symptoms were nor what the medication was for. [Repeated Violation - 1/23/25] | 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. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.167(a)(1) | On 2/26/2025 Individual #1's February 2025 medication administration documented the following administrations as not administered: Buspirone tab 10mg: 2/9/2025, 2/16/2025, 2/23/2025, 2/26/2025 at 10:00am, 2/6/2025, 2/7/2025, 2/13/2025, 2/14/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/25/2025 at 4:00pm, and 2/6/2025, 2/7/2025, 2/11/2025, 2/13/2025, 2/14/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025;Divalproex Tab 500mg DR 2/9/2025, 2/16/2025, 2/23/2025, 2/26/2025 at 10:00am, 2/6/2025, 2/7/2025, 2/11/2025, 2/13/2025, 2/14/2025, 2/17/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025 at 10:00pm; Melatonin tab 3mg 2/6/2025, 2/7/2025, 2/11/2025, 2/13/2025, 2/14/2025, 2/17/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025 at 10:00pm; Metformin 500mg tab 2/9/2025, 2/16/2025, 2/23/2025, 2/26/2025 at 10:00am, 2/6/2025, 2/7/2025, 2/11/2025, 2/13/2025, 2/14/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/25/2025; Olanzapine 20mg tab 2/9/2025, 2/16/2025, 2/23/2025, 2/26/2025 at 10:00am, 2/6/2025, 2/7/2025, 2/11/2025, 2/13/2025, 2/14/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025 at 10:00pm; Propranolol 20mg tab: 2/9/2025, 2/10/2025 at 10:00am, 2/6/2025, 2/7/2025, 2/11/2025 at 10:00pm; Tinactin Aer 1% Spray: 2/9/2025, 2/16/2025, 2/23/2025, 2/26/2025 at 10:00am; Vitamin D3 1000 IU (25mcg) 2/9/2025, 2/16/2025, 2/23/2025, and 2/26/2025 at 10:00am. During the inspection 2/26/2025 at 11:33am Individual #1's 10:00am medication administrations for the following medications had not been administered: Buspirone 10mg Tab, Divalproex 500mg Dr Tab, Metformin 500mg Tab, Olanzapine 20mg Tab, Propranolol 20mg Tab, and Vitamin D3 1000 IU. Individual #1's Propranolol 20mg Tab had not been administered since 2/13/2025. Direct Service Worker #3 stated the medication could not be administered due to waiting for the medication to be refilled by the pharmacy. [Repeated Violation - 10/7/24, 11/21/24, and 1/23/25] | Medication errors include the following: Failure to administer a medication. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.169(a) | Direct Service Worker #1 completed their initial medication administration training on 8/2/2023. The subsequent annual practicum that was due to be completed on 8/2/2024 was not completed as the training documentation only included one medication administration observation completed on 1/2/2024 and medication administration record review completed on 3/4/2024. Although Direct Service Worker #1 was not renewed to administer medications, Direct Service Worker #1 documented that they administered medications to Individual #1 at the following times: 2/4/2025 at 4:00pm and 6:00pm; 2/5/2025 at 4:00pm, 6:00pm, and 10:00pm; 2/8/2025 at 10:00am; and 2/12/2025 at 4:00pm, 6:00pm, and 10:00pm. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.169(d) | Program Specialist #2 completed medication administration training 9/14/2024 and there is no documentation of the medication trainer. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Medical & Health Compliance
Violations related to medical and health care compliance were found under 55 PA Code Chapter 6400.141(a), 6400.144, 6400.151(a), 6400.151(c)(2), 6400.163(a), 6400.166(a)(11), 6400.169(a), and 6400.169(d). To address these violations, all required medical examinations, screenings, and medication documentation will be completed by April 10, 2025. All staff medical clearances and TB tests is being reviewed and updated. Staff responsible for medication administration is undergoing retraining on medication protocols by April 20, 2025. Medication audits and observation is being conducted daily to prevent future medication-related violations.
Corrective Actions:
¿ All medications is being stored in a locked med box to prevent unauthorized access and stored in a locked room.
¿ Daily medication documentation audits is being conducted to ensure proper documentation of medical appointments and screenings are scheduled.
¿ Physician reviews of psychiatric medications is being monitored and updated every three months, with documentation maintained in each resident¿s file.
¿ HR and Program Specialist created a medical appointment tracking system to track and document any appointments
¿ Program Specialist are conducting meds observations daily until every DSP has its three observations per compliance.
¿ All staff is being trained on medication protocols, policies and procedures and educated on past medical violations so they do not repeat them. |
05/30/2025
| Not Implemented |
| 6400.195(b) | Individual #1's behavior support plan, last updated 4/17/2024, states sharps need to be locked and during a behavior the room would need cleared out of any people. There is no record of the behavior support component being reviewed by the human rights team. On 2/26/2025 at 11:36AM, the first aid kit was observed locked in the staff office, due to having scissors in them. Direct Service Worker #3 stated glass and sharp objects need to be locked in the individual's safety. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Issue Identified:
The restrictive procedures within the Behavior Support Plan were not reviewed and revised as necessary by the Human Rights Team (HRT) within the required six-month timeframe.
Corrective Actions:
1. Immediate Review: The Behavior Support Plan will be reviewed by the HRT within the next 30 days and/or by April 20, 2025, to ensure all restrictive procedures are necessary, appropriate, and in compliance with applicable regulations.
2. Policy Update: A formal policy will be established, ensuring that restrictive procedures are reviewed no less than every six months.
3. Training: Staff members involved in implementing behavior support will receive training on restrictive procedure policies, documentation requirements, and the role of the HRT in reviewing and revising plans.
4. Individualized Review Schedule: Each individual's plan will be assigned a review schedule with clear due dates to prevent lapses in review.
5. Documentation Enhancement: All reviews, revisions, and justifications for restrictive procedures will be documented in the individual¿s record and accessible for audits. |
05/30/2025
| Not Implemented |
| 6400.213(1)(i) | Individual #1's record documented the admission date as 4/09/2023 and the actual date of admission was 4/19/2023. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual Rights & Record Compliance
Violations were also identified concerning individual rights and recordkeeping under 55 PA Code Chapter 6400.171, 6400.181(d), 6400.181(e)(10), 6400.181(e)(11), 6400.34(a), 6400.213(1)(i). To rectify these, a comprehensive file review will be conducted to ensure that all individual records, assessments, and personal rights documents are accurate and up to date by April 15, 2025. Staff will be retrained on documentation requirements and the importance of maintaining complete and accurate records by April 25, 2025. Regular monthly audits will be implemented to ensure compliance.
To ensure that all residents are informed of their rights, the facility will develop an Individual Rights Acknowledgment Form to be signed by each resident upon admission and annually thereafter. Staff will receive training on residents' rights by April 25, 2025, and information on rights will be displayed in common areas.
Corrective Actions:
¿ Staff is being trained on Individual Rights regulations.
¿ Staff is being trained on Individual Right¿s policy.
¿ Staff is being trained to observe, acknowledge and understand when client Individual Rights are not being protected.
¿ HR created a survey to address any Individual Rights concerns and documenting the results to ensure all client¿s Individual Rights are being protected.
¿ HR created a posting to be placed at all sights that promote protection of client¿s Individual Rights. |
05/30/2025
| Not Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 11:25AM, a sticky, brown substance was in the bottom of the right crisper drawer in the refrigerator. At 11:17 AM, a sock; a blue disposable glove; three dryer lint sheets; paper; a piece of cardboard; and small remnants of clothes tags were strewn throughout on the floor of the laundry room in the basement of the home. At 11:35 AM, five empty toilet paper rolls were on the floor in the bathroom of the home. | Clean and sanitary conditions shall be maintained in the home. | We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.66 | At 10:04 AM, the light receptacle above the porch in the backyard did not have a light bulb. There is not another source of light in this area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Implemented |
| 6400.67(a) | At 11:50AM, the trim, on the bottom left side of interior door on the main level leading to the basement, was detached from the door frame. At 11:52 AM, two metal vent prongs were rusted, broken, and collapsed inward on the floor air-duct register in the kitchen of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.67(b) | At 11:11AM, there was a ten inch by six-inch section hole in the duct work exposing sharp edges in the basement of the home. At 11:35AM, there was a section of duct work with duct tape exposing sharp metal edges was on the floor of the basement of the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.70 | At 11:55 AM, the telephones in the living room and staff office of the home were inoperable. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| To address the inoperable telephones in the living room and staff office, we will replace both phones to ensure they are functional and accessible. Comcast has been contacted to troubleshoot the issue, and if necessary, a technician will be scheduled to resolve any connectivity problems with the phone lines. This will ensure that each phone provides an outside line that is accessible to individuals and staff. |
12/16/2024
| Not Implemented |
| 6400.71 | At 11:55 AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control were not on or by the telephones in the living room and staff office of the home.[Repeated violation 7/23/2024 et al.] | 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.
| To address the absence of emergency contact numbers, a list of telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center will be placed next to or on each telephone, including the bedside table in Individual #1's bedroom. Residential Site Supervisors will ensure that these numbers are clearly displayed and securely attached by each phone to prevent future removal or misplacement. |
12/16/2024
| Implemented |
| 6400.72(a) | At 11:18AM, the window above the kitchen sink did not have a screen. At 11:01 AM, both windows in the staff office did not have screens. At 11:40 AM, both windows in the vacant bedroom did not have screens.[Repeated violation 7/23/2024 et al.] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.72(b) | At 11:01 AM, there was a nine-inch vertical crack in the window facing the rear of the home in the staff office. The window facing the side of the home in the staff office slammed shut when opened.[Repeated violation 7/23/2024 et al.] | Screens, windows and doors shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.73(a) | At 10:06 AM, the outside railing, along the eleven-steps between the driveway and the walkway, was loose, wobbly, and unstable.[Repeated violation 7/23/2024 et al.] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Implemented |
| 6400.76(a) | At 10:28 AM, the seat of a wooden rocking chair on the front porch was cracked all the way through. | Furniture and equipment shall be nonhazardous, clean and sturdy. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.80(b) | At 10:06 AM on 10/7/24, a one-inch by one-inch wooden railing spindle with an exposed sharp, splintering end on the walkway to the front door. At 10:10 AM, the exposed end of a downspout running from the front porch and into the front yard was frayed and damaged exposing sharp edges. At 10:40 AM, a shed in the backyard was covered in overgrowth and brush with collapsed walls and a missing door. The shed's interior walls were heavily covered in a black substance appearing to be mold and on the ground inside were four empty plastic water bottles, a blanket, and a carcass of a dead animal. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.82(f) | At 11:37 AM, the bathroom on the second floor of the home did not have a trash receptacle.[Repeated violation 7/23/2024 et al.] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | To address the absence of trash receptacles, as well as prevent lid separation, we are replacing existing bins without attached lids across all bathrooms, kitchens, and outdoor areas with step-on trash cans. One order was received on October 30, with additional orders expected on November 1 and 2. Additionally, an over-the-sink mirror has been ordered and will be installed by the maintenance team upon arrival. Residential site supervisors will verify the presence and functionality of these items during weekly inspections. |
12/16/2024
| Not Implemented |
| 6400.110(e) | At 11:46 AM, the smoke detector on the basement of the three-story home was not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.111(f) | At 11:38 AM, the fire extinguisher on the second floor of the home was most recently inspected and approved in August 2023. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher on the second floor will be inspected and approved by a certified fire safety expert to ensure it meets the annual inspection requirement. The inspection date will be clearly marked on the extinguisher. This inspection will be completed promptly to ensure compliance. |
12/16/2024
| Implemented |
| 6400.171 | At 11:23 AM on 10/7/24, there were two partially used unsealed boxes of cereal on top of the refrigerator in the kitchen of the home. There was an eight-ounce can of Tony Chachere's Original Creole Seasoning with a best-by-date of October 2023, and a partially used unsealed 9.5-ounce bag of Doritos Spicy Nacho Chips in the kitchen cabinet above the counter next to the stove. At 11:25 AM, a half-gallon carton of Giant Eagle Fat-Free Skim Milk with a sell-by-date of 8/24/24 was in the refrigerator.[Repeated violation 7/23/2024 et al.] | Food shall be protected from contamination while being stored, prepared, transported and served.
| To address improper food storage practices, all expired and improperly stored items in the refrigerator, freezer, and kitchen area were immediately discarded. Staff have been reminded of food storage protocols, including checking expiration dates and ensuring food is wrapped and protected from contamination. Additionally, a food safety flyer has been created and will be posted in the kitchen as a reminder of proper storage practices. Residential Site Supervisors will monitor food storage during their weekly inspections to ensure compliance. |
12/16/2024
| Not Implemented |
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