| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | On 2/25/25 at approximately 10:25AM, near the conclusion of the entrance conference, Associate Operations Director #1 was given an overview of the 3-day inspection. A Department Licensing Representative informed Associate Operations Director #1 that licensing would like to review Enterprise Incident Management open incidents and sample a couple investigations on the last day of the inspection which would be 2/27/25. Associate Operations Director #1 stated that the certified investigator has all that information and would be made available. On 2/26/25 at approximately 10:25AM, Director of Operations #2 was informed by a Department Licensing Representative that the certified investigator would need to be available on 2/27/25 to do a review of some incidents and the investigations associated with them. Director of Operations #2 stated that he was aware and that a message has been sent out. At approximately 11:50AM, Associate Operations Director #1 was reminded by the Department Licensing Representative about needing to speak with the certified investigator on 2/27/25. Associate Operations Director #1 stated that she sent a text message to the team to let them know. On 2/27/25 at approximately 10:05AM, Associate Operations Director #1 was reminded about needing to speak with the certified investigator. At approximately 2:30PM, Director of Operations #2 informed the Department Licensing Representative that no one from the agency has been able to get ahold of the agency's certified investigator. Director of Operations #2 stated that the certified investigator is the only one that has access to these investigations. The agency did not provide access to the request incident management information. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | 55 PA Code Chapter 20.34 ¿ Authorization DHHS Agents Access to Facility Records
The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. Ensuring Full Access to Facility and Records During Inspections
Corrective Actions:
1. Staff Training & Awareness
o Conduct mandatory training for all employees on the requirements for DHHS inspections.
o Post notices in key staff areas outlining procedures for handling inspections.
2. Designated Compliance Officer
o Assign a compliance officer or administrator responsible for facilitating inspections.
o Ensure the officer is available to assist inspectors during all shifts.
3. Access to Records
o Maintain an organized and up-to-date record-keeping system.
o Store all required documents in a secure but easily accessible location for review.
4. Facility Readiness
o Conduct regular internal audits to ensure all areas remain in compliance with state regulations.
o Establish a checklist for facility preparedness before inspections.
5. Immediate Corrective Action for Non-Compliance
o If access is delayed or denied during an inspection, immediately notify the facility administrator/CEO.
o Provide written justification for any access restrictions and resolve the issue within 2 hours. |
05/30/2025
| Not Implemented |
| 6400.15(a) | The self-assessment completed 1/3/2025 did not measure and record compliance with the following 6400 regulations: 33a, 142e, 142g, 142h, 186, 195a, 207.3, 204c, 245a. These were left blank. [Repeated violation: 7/23/2024 et al] | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| ¿ 55 PA Code Chapter 6400.15(a) ¿ Self Assessment.
55 Pa. Code Chapter 6400.15(a) requires agencies operating homes serving eight or fewer individuals to complete a self-assessment within 3-6 months before their certificate of compliance expires, to measure and record compliance with the chapter.
Corrective Actions:
¿ Establish a Compliance Calendar ¿ Schedule reminders for the self-assessment deadline at least six months in advance.
¿ Assign a Compliance Coordinator ¿ Designate a responsible staff member to oversee and complete the assessment.
¿ Conduct Internal Review ¿ Begin the self-assessment at least four months before the expiration date.
¿ Documentation & Submission ¿ Maintain a record of completed assessments and submit them as required. |
05/30/2025
| Not Implemented |
| 6400.62(a) | On 2/26/25 at 11:48AM, a 19 fluid ounce bottle of Lysol all-purpose cleaner was located on top of the kitchen counter. On 2/26/25 at 11:50AM, the cabinet below the kitchen sink did not have a locking mechanism and contained the following cleaning supplies: Two 32 fluid ounce bottles of Great Value multi-purpose cleaner, a 24 fluid ounce bottle of Clorox Clinging Bleach Gel, which all contain instructions to contact poison control if ingested. In the safety precaution section of Individual #1's individual plan, last updated on 2/12/25 reads, "[Individual #1] knows to avoid poisonous materials and would not attempt to ingest any. However, because of his impulsivity and tendency to destroy property, it is best to keep all chemicals and cleaners away from [Individual #1]." [Repeated Violation -- 7/23/24, et al and 11/21/24] | Poisonous materials shall be kept locked or made inaccessible to individuals. | ¿ 55 PA Code Chapter 6400.62(a)(c) ¿ Poisons
Poisonous materials shall be kept locked or made inaccessible to individuals and stored in their original, labeled containers.
Corrective Actions:
¿ Secure Storage ¿ All poisonous materials (e.g., cleaning supplies, chemicals) will be stored in locked cabinets or designated secure areas.
¿ Staff Training ¿ Conduct mandatory training for all employees on safe storage procedures.
¿ Facility Checks ¿ Perform an immediate inspection to identify and secure any unsecured poisonous materials.
¿ Labeling & Signage ¿ Clearly label all storage areas containing hazardous substances. |
05/30/2025
| Not Implemented |
| 6400.62(c) | On 2/26/25 at 11:50AM, an unlabeled bottle containing a yellow liquid substance was in the cabinet below the kitchen sink with bottles of cleaning supplies. | Poisonous materials shall be stored in their original, labeled containers. | ¿ 55 PA Code Chapter 6400.62(a)(c) ¿ Poisons
Poisonous materials shall be kept locked or made inaccessible to individuals and stored in their original, labeled containers.
Corrective Actions:
¿ Secure Storage ¿ All poisonous materials (e.g., cleaning supplies, chemicals) will be stored in locked cabinets or designated secure areas.
¿ Staff Training ¿ Conduct mandatory training for all employees on safe storage procedures.
¿ Facility Checks ¿ Perform an immediate inspection to identify and secure any unsecured poisonous materials.
¿ Labeling & Signage ¿ Clearly label all storage areas containing hazardous substances. |
05/30/2025
| Not Implemented |
| 6400.64(a) | On 2/26/25 at 12:49PM, there were black areas from what appeared to be mold and/or mildew on the caulking below faucet, the front interior and on the ceiling along the back wall of the bathtub in the bathroom on the first floor of the home. [Repeated Violation -- 10/7/24] | Clean and sanitary conditions shall be maintained in the home. | 55 PA Code Chapter 6400.64(a) ¿ Clean and Sanitary Conditions
Violation: The home was found to have unsanitary conditions, including dirt accumulation, clutter, unsanitary toilets and possible pest infestation.
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, clean and sanitary bathrooms and toilets 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. |
05/30/2025
| Not Implemented |
| 6400.64(e) | On 2/26/25 at 12:33PM, the two trash receptacles measuring 29 inches in height containing discarded items in the attached garage did not have a lids. Repeated Violation -- 7/23/24, et al; 10/7/24; 11/21/24] | Trash receptacles over 18 inches high shall have lids. | ¿ 55 PA Code Chapter 6400.64(e) ¿ Sanitation/Trash Receptacles
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 |
| 6400.67(a) | On 2/26/25 at 12:42PM, the vacant bedroom where Individual #1 stores clothing had a wall vent grate that was detached from the wall and on the floor. | Floors, walls, ceilings and other surfaces shall be in good repair. | ¿ 55 PA Code Chapter 6400.67(a)(b) 6400.72(a) ¿ Sanitation Floors, Walls, Ceilings, Windows and Doors
The facility was not maintained in a sanitary condition including floors, walls and ceilings. A detailed cleaning schedule will be implemented, and all staff will be trained on sanitation requirements. Daily cleaning checks will be conducted to ensure the facility is maintained in accordance with health and safety standards. All cleaning will be tracked daily by having staff take pictures of different areas in house they cleaned and put into the company group chat platform for review. Also, maintenance will conduct weekly inspections.
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.
¿ Windows and doors are checked by our maintenance team.
¿ 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. |
05/30/2025
| Not Implemented |
| 6400.67(b) | On 2/26/25 at 12:30PM, the floor drain in the basement of the home did not have a cover posing a tripping hazard. [Repeated Violation -- 10/7/24] | Floors, walls, ceilings and other surfaces shall be free of hazards. | ¿ 55 PA Code Chapter 6400.67(a)(b) 6400.72(a) ¿ Sanitation Floors, Walls, Ceilings, Windows and Doors
The facility was not maintained in a sanitary condition including floors, walls and ceilings. A detailed cleaning schedule will be implemented, and all staff will be trained on sanitation requirements. Daily cleaning checks will be conducted to ensure the facility is maintained in accordance with health and safety standards. All cleaning will be tracked daily by having staff take pictures of different areas in house they cleaned and put into the company group chat platform for review. Also, maintenance will conduct weekly inspections.
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.
¿ Windows and doors are checked by our maintenance team.
¿ 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. |
05/30/2025
| Not Implemented |
| 6400.72(a) | On 2/26/25 at 12:04PM, both windows in the staff office contained screens that did not fit the window opening which left approximately a two inch gap. [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. | ¿ 55 PA Code Chapter 6400.67(a)(b) 6400.72(a) ¿ Sanitation Floors, Walls, Ceilings, Windows and Doors
The facility was not maintained in a sanitary condition including floors, walls and ceilings. A detailed cleaning schedule will be implemented, and all staff will be trained on sanitation requirements. Daily cleaning checks will be conducted to ensure the facility is maintained in accordance with health and safety standards. All cleaning will be tracked daily by having staff take pictures of different areas in house they cleaned and put into the company group chat platform for review. Also, maintenance will conduct weekly inspections.
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.
¿ Windows and doors are checked by our maintenance team.
¿ 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. |
05/30/2025
| Implemented |
| 6400.81(k)(6) | On 2/26/25 at 12:35PM, Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | ¿ 55 PA Code Chapter 6400.81(k)(6) ¿ Bedroom Mirror
55 Pa. Code § 6400.81(k)(6) requires that each individual in a bedroom within a community home for individuals with intellectual disabilities or autism have a mirror.
Corrective Actions:
¿ Inventory Check ¿ Conduct an immediate inspection to identify bedrooms without mirrors.
¿ Installation of Mirrors ¿ Provide and securely install mirrors in all bedrooms where they are missing.
¿ Personal Preferences ¿ Offer alternative mirror options (e.g., shatterproof mirrors) based on individual needs and safety considerations.
¿ Documentation ¿ Maintain records of mirror installations and any accommodations made. |
05/30/2025
| Not Implemented |
| 6400.82(e) | On 2/26/25 at 11:53AM, the bathtub in the bathroom on the first floor of the home did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | ¿ 55 PA Code Chapter 6400.82(e) ¿ Bathrooms and Showers Nonslip Surface or Mat
55 PA Code Chapter 6400.82(e) mandates that bathtubs and showers in community homes for individuals with intellectual disabilities or autism must have a nonslip surface or mat.
Corrective Actions:
1. Immediate Safety Check ¿ Conduct an inspection of all bathtubs and showers to identify missing or damaged nonslip surfaces.
2. Installation of Nonslip Mats ¿ Provide and install nonslip mats or textured surfaces in all bathtubs and showers.
3. Replacement Plan ¿ Replace worn-out mats regularly to ensure continued safety.
4. Documentation ¿ Maintain records of all installations and replacements. |
05/30/2025
| Not Implemented |
| 6400.82(f) | On 2/26/25 at 11:53AM, the bathroom on the first 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. | To maintain safe and accessible bathrooms, all handrails and grab bars will be inspected for stability and proper installation. Any missing or loose supports will be installed or repaired by March 25, 2025. Staff will also conduct monthly safety checks to ensure all bathrooms remain compliant with accessibility standards.
Corrective Actions:
¿ Trash Receptacles, Paper Towels and clean paper are stored in the basement near the bathroom.
¿ Maintenance is inspecting all handrails and grab bars in all facilities.
¿ Maintenance is fixing and replacing all nonstable handrails and grab bars.
¿ Leads and Residential Directors are conducting handrail and grab bar inspections. |
05/30/2025
| Not Implemented |
| 6400.105 | On 2/26/25 at 12:29PM, the lint filter in the dryer in the basement of the home was covered with approximately a half an inch of dryer lint. [Repeated violation: 7/23/2024, et al and 10/7/2024] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Storage of Flammable Materials ¿ 55 PA Code Chapter 6400.105
All flammable and combustible materials is now stored in a locked cabinet away from heat sources. Fire safety training for staff was conducted March 7, 2025 for all Leads and is currently being conducted for all DSP¿s. All training will be completed by April 20, 2025, and in the future monthly fire safety inspections and dryer lint removal will be conducted to ensure. We are training staff to follow the storage safety instructions on the hazardous material label.
Corrective Actions:
¿ Reorganize storage areas to ensure all flammable materials are stored away from heat sources and in fire-resistant cabinets.
¿ Conducting staff training on safe handling and storage of flammable materials.
¿ Posted clear safety signage in storage areas.
¿ Properly storing all hazardous materials according to storage instructions on label. |
05/30/2025
| Not Implemented |
| 6400.112(c) | The written fire drill records for the fire drills held on 3/12/24, 4/17/24, 6/14/24, 7/20/24, 8/14/24, 9/19/24, and 10/11/24 had the evacuation time for all seven of these drills as "2". Additionally, the written fire drill record for the fire drill held on 8/14/24 had the time as 8:00 and did not include 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. | Fire Drill Documentation ¿ 55 PA Code Chapter 6400.112(c)(f)
A fire drill record-keeping system is being be implemented to document random and different date, time, evacuation duration, exit routes, and any issues encountered. Staff will be trained to accurately document all fire drills, and monthly audits will be conducted to ensure compliance.
Corrective Actions:
¿ Program Specialist trained staff March 7, 2025 on fire drills and how to properly document.
¿ We developed a fire drill tracking system to document and track all fire drills to remain compliant.
¿ Residential Director is conducting monthly audits of fire drills to ensure compliance and address any issues to remain compliant.
¿ Program Specialist is tracking to make sure all fire drills are being conducted randomly different times and days using alternate exit routes. |
05/30/2025
| Not Implemented |
| 6400.112(f) | The monthly fire drills from 1/4/24 through 2/18/25 used front door as the exit route. There are other exits from the home. [Repeated Violation -- 7/23/24, et al] | Alternate exit routes shall be used during fire drills. | Fire Drill Documentation ¿ 55 PA Code Chapter 6400.112(c)(f)
A fire drill record-keeping system is being be implemented to document random and different date, time, evacuation duration, exit routes, and any issues encountered. Staff will be trained to accurately document all fire drills, and monthly audits will be conducted to ensure compliance.
Corrective Actions:
¿ Program Specialist trained staff March 7, 2025 on fire drills and how to properly document.
¿ We developed a fire drill tracking system to document and track all fire drills to remain compliant.
¿ Residential Director is conducting monthly audits of fire drills to ensure compliance and address any issues to remain compliant.
¿ Program Specialist is tracking to make sure all fire drills are being conducted randomly different times and days using alternate exit routes. |
05/30/2025
| Not Implemented |
| 6400.113(a) | Individual #1 has not been instructed in fire safety. | 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. | ¿ 55 PA Code Chapter 6400.113(a) ¿ Fire Safety Training
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 are 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 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) | On 2/26/25 at 11:34AM, there was a multitude of cigarette butts on the side of the home. Additionally, there were cigarette butts around the front and rear egresses of the home. The homes smoking policy states that staff or visitors are to dispose of all cigarette butts in a receptacle with a lid. [Repeated Violation -- 7/23/24, et al and 10/7/24] | Written smoking safety procedures shall be followed. | 55 PA Code Chapter 6400.114(b) ¿ Smoking Safety
Plan of Correction
Issue: Smoking policy is not being followed by staff and consumers with special needs.
Action Steps:
1. Re-educate all staff and consumers on the smoking policy, including designated smoking areas and health/safety protocols.
2. Post clear signage in all appropriate areas.
3. Provide additional support to consumers with special needs to help them understand and follow the policy (e.g., visual aids, staff reminders). |
05/30/2025
| Not Implemented |
| 6400.141(c)(10) | Individual #1's physical examination, completed 8/28/24 does not address communicable disease. This section was left blank. | 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. | 55 Pa. Code § 6400.141(c)(10) addresses individual physical examinations, specifically outlining the need for documentation of specific precautions if an individual has a communicable disease to prevent its spread to others.
Health assessments were not completed in a timely manner and communicable disease protocols are not being followed by staff and consumers with ID/A. A schedule tracking system will be created to ensure that all individuals receive annual health assessments on time. Health assessments will be documented and reviewed by a qualified healthcare professional, and any follow-up care will be promptly arranged and overseen by Program Specialist.
OCS has implemented a structured health assessment process. A compliance review team consisting of two Program Specialist, Residential Director, Compliance Director, Assigned Lead¿s/DSP¿s is conducting health assessments and is documenting all findings. Training on health assessment procedures including physical examination and communicable disease compliance will be completed by April 21, 2025, with ongoing quarterly reviews to ensure future compliance.
Corrective Actions:
¿ Training staff on the new structured health assessment process
¿ Created a health assessment tracking document that will alert staff and management when the assessments are getting close to the compliance certificate due date within 6 months and three months of renewal.
¿ Provide immediate re-training for staff on communicable disease prevention (e.g., hand hygiene, PPE use, symptom reporting).
¿ Educate consumers with special needs using accessible materials (visuals, simple language).
¿ Ensure availability of hygiene supplies (soap, sanitizer, masks) throughout the facility. |
05/30/2025
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 8/28/24 does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | ¿ 55 PA Code Chapter 6400.141(c)(14) ¿ Medical Records Pertinent to Diagnosis
Medical records were incomplete or outdated. All medical records will be reviewed and updated monthly to ensure they are complete and accurate. A regular monthly audit process will be put in place to ensure that medical records are updated as needed and that all necessary information is included. Program Specialist will oversee this process to ensure accurate and up to date documentation of all medical records.
A document control system will be developed to ensure that all required resident records are maintained and up to date. Staff will be trained on record-keeping protocols by April 15, 2025. OCS is purchasing services with HAA Exchange which is a document management, tracking and control software that will help us better document and store all client and staff documentation.
Corrective Actions:
¿ DSP¿s and Leads are currently being trained in how to document and update clients¿ medical records in Therapp and HAA Exchange.
¿ Residential Directors conduct weekly audits to ensure compliance of client medical records.
¿ HR is conducting weekly audits of client¿s medical records to ensure compliance. |
05/30/2025
| Not Implemented |
| 6400.144 | Individual #1 had a physical examination completed on 8/28/24 and the physician ordered the following test to be completed: CBC, Comprehensive metabolic panel, hemoglobin a1c, lipid panel, lithium level, Thyroid stimulating hormone with reflex to free thyroxine, however the home does not have any documentation of these tests being completed. Individual #1 was seen at a hospital emergency department on 1/19/25 and was directed to see a physician for reevaluation within 4 days, however there is not documentation of this visit being scheduled and/or completed. [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.
| 55 PA Code Chapter 6400.144 ¿ Medication Records and Health Services
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. Medication records were not properly maintained. A new system for tracking medication administration will be implemented, including daily documentation by staff members. Regular audits will ensure that all medication records are accurate, complete, and up to date. Program Specialist will oversee the properly tracking of all medication and maintain an accurate account of all medical records.
Corrective Actions:
¿ Review all individual service plans (ISPs) to identify any missed or delayed services.
¿ Assign staff to coordinate and schedule all required health services.
¿ Ensure proper documentation of all appointments, follow-ups, and outcomes.
¿ 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 2/26/25 at 11:44AM, Individual #1 was not home; however, a covered plate of cooked white rice, black beans, and whole kernel corn, was on the dining room table. [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.
| 55 PA Code Chapter 6400.171 ¿ Food Safety
To protect food from contamination, all kitchen storage areas will be inspected weekly, and expired or improperly stored food will be removed. All food items will be properly stored according to their storage labels. Staff will receive training on proper food handling and storage procedures by April 21, 2025.
¿ Corrective Actions:
Staff were trained March 7, 2025, on how to label and store food.
¿ Staff daily are properly storing and labelling food.
¿ Staff is checking storage containers to make sure they are safe and compliant to store food. |
05/30/2025
| Not Implemented |
| 6400.181(a) | Individual #1's most recent assessment was completed on 2/1/24. [Repeated Violation -- 11/21/24] | 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. | ¿ 55 PA Code Chapter 6400.181(a) ¿ Assessments
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. Issue: Initial and annual assessments, including adaptive behavior and skill level evaluations, are not being completed within required timeframes.
Plan of Correction
¿ Action Steps:
¿ Immediately review all current resident files to identify missing or overdue assessments.
¿ Schedule initial and annual assessments to ensure timely completion going forward.
¿ Train staff on assessment timeline requirements and documentation procedures. |
05/30/2025
| Not Implemented |
| 6400.181(e)(10) | Individual #1's most recent assessment dated 2/1/24 did not include a lifetime medical history. This section indicated the lifetime medical history was attached; however, it was not attached. [Repeated violation: 7/23/2024 et al] | The assessment must include the following information: A lifetime medical history. | 55 PA Code Chapter 6400.181(e)(10)(11) ¿ Resident Assessments & Plans
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments to include lifetime medical history.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.181(e)(11) | Individual #1's most current undated assessment did not include a copy of the individual's psychological evaluation. This section indicated the Psychological Evaluation was attached; however, it was not attached. [Repeated violation: 7/23/2024 et al] | The assessment must include the following information: Psychological evaluations, if applicable. | 55 PA Code Chapter 6400.181(e)(10)(11) ¿ Resident Assessments & Plans
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments to include lifetime medical history.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.214(b) | Individual #1's individual plan that was at the home was last updated on 6/6/24. The most recent individual plan for Individual #1 was updated 2/12/25. [Repeated Violation -- 9/20/24 and 10/4/24] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| ¿ 55 PA Code Chapter 6400.214(b) 216(a) ¿ Maintain Records
Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. A document control system will be developed to ensure that all required resident records are maintained and up to date. Staff will be trained on record-keeping protocols by April 15, 2025. OCS is purchasing services with HAA Exchange which is a document management, tracking and control software that will help us better document and store all client and staff documentation.
Corrective Actions:
¿ Re-train all staff on the requirement to keep records locked when unattended.
¿ Ensure that secure, lockable storage is available and accessible for use.
¿ Post reminders near record storage areas regarding confidentiality and security protocols.
¿ DSP¿s and Leads are currently being trained in how to document and update clients¿ records.
¿ Residential Directors conduct weekly audits to ensure compliance of client records.
¿ HR is conducting weekly audits of client¿s records to ensure compliance. |
05/30/2025
| Not Implemented |
| 6400.216(a) | On 2/26/25 at 12:39PM, the vacant bedroom across the hall from Individual #1's bedroom contained a dresser full of unlocked medical records for Individual #1 and an individual that is no longer living at this home. [Repeated Violation -- 10/7/24] | An individual's records shall be kept locked when unattended.
| ¿ 55 PA Code Chapter 6400.214(b) 216(a) ¿ Maintain Records
Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. A document control system will be developed to ensure that all required resident records are maintained and up to date. Staff will be trained on record-keeping protocols by April 15, 2025. OCS is purchasing services with HAA Exchange which is a document management, tracking and control software that will help us better document and store all client and staff documentation.
Corrective Actions:
¿ Re-train all staff on the requirement to keep records locked when unattended.
¿ Ensure that secure, lockable storage is available and accessible for use.
¿ Post reminders near record storage areas regarding confidentiality and security protocols.
¿ DSP¿s and Leads are currently being trained in how to document and update clients¿ records.
¿ Residential Directors conduct weekly audits to ensure compliance of client records.
¿ HR is conducting weekly audits of client¿s records to ensure compliance. |
05/30/2025
| Not Implemented |
| 6400.18(a)(4) | The agency became aware of an allegation of physical abuse on 1/24/25. Incident #9558545 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 1/27/25. Repeated violation -- 7/23/24 et al] | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| ¿ 55 PA Code Chapter 6400.18(a)(4) (5)(13) 18(i)¿ Incident Management & Reporting
All incidents involving potential abuse, neglect, use of restraint, or rights violations, alleged incidents or suspected incidents will be reported immediately in accordance with ODP's incident management guidelines. The incident report system will be updated to ensure that:
Corrective Actions:
¿ Initial reports are being submitted within 24 hours of discovery.
¿ Use of restraint will be reported in 72 hours.
¿ Finalized reports include all follow-up actions and resolutions within 30 days.
¿ Staff receive refresher training on proper incident reporting procedures by April 20, 2025.
¿ Program Specialist will conduct staff training to properly document all General Event Reports and EIM¿s. |
05/30/2025
| Not Implemented |
| 6400.18(a)(5) | The agency became aware of an allegation of neglect on 1/17/25. Incident #9557428 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 1/24/25. [Repeated Violation -- 7/23/24 et al, 9/20/24, 10/7/24] | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| ¿ 55 PA Code Chapter 6400.18(a)(4) (5)(13) 18(i)¿ Incident Management & Reporting
All incidents involving potential abuse, neglect, use of restraint, or rights violations, alleged incidents or suspected incidents will be reported immediately in accordance with ODP's incident management guidelines. The incident report system will be updated to ensure that:
Corrective Actions:
¿ Initial reports are being submitted within 24 hours of discovery.
¿ Use of restraint will be reported in 72 hours.
¿ Finalized reports include all follow-up actions and resolutions within 30 days.
¿ Staff receive refresher training on proper incident reporting procedures by April 20, 2025.
¿ Program Specialist will conduct staff training to properly document all General Event Reports and EIM¿s. |
05/30/2025
| Not Implemented |
| 6400.18(a)(13) | The agency became aware of an allegation of a violation of individual rights on 1/21/25. Incident #9557433 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 1/24/25. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
A violation of individual rights. | ¿ 55 PA Code Chapter 6400.18(a)(4) (5)(13) 18(i)¿ Incident Management & Reporting
All incidents involving potential abuse, neglect, use of restraint, or rights violations, alleged incidents or suspected incidents will be reported immediately in accordance with ODP's incident management guidelines. The incident report system will be updated to ensure that:
Corrective Actions:
¿ Initial reports are being submitted within 24 hours of discovery.
¿ Use of restraint will be reported in 72 hours.
¿ Finalized reports include all follow-up actions and resolutions within 30 days.
¿ Staff receive refresher training on proper incident reporting procedures by April 20, 2025.
¿ Program Specialist will conduct staff training to properly document all General Event Reports and EIM¿s. |
05/30/2025
| Not Implemented |
| 6400.18(i) | Enterprise Incident Management incident #9557428 for allegation of neglect had a finalization due date of 2/16/25. As of 2/27/25, the incident has not been finalized, and an extension has not been requested. Enterprise Incident Management incident #9557433 for allegation of physical abuse had a finalization due date of 2/20/25. As of 2/27/25, the incident has not been finalized, and an extension has not been requested. Enterprise Incident Management incident #9558545 for allegation of physical abuse had a finalization due date of 2/23/25. As of 2/27/25, the incident has not been finalized, and an extension has not been requested. [Repeated Violation -- 7/23/24 et al] | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | ¿ 55 PA Code Chapter 6400.18(a)(4) (5)(13) 18(i)¿ Incident Management & Reporting
All incidents involving potential abuse, neglect, use of restraint, or rights violations, alleged incidents or suspected incidents will be reported immediately in accordance with ODP's incident management guidelines. The incident report system will be updated to ensure that:
Corrective Actions:
¿ Initial reports are being submitted within 24 hours of discovery.
¿ Use of restraint will be reported in 72 hours.
¿ Finalized reports include all follow-up actions and resolutions within 30 days.
¿ Staff receive refresher training on proper incident reporting procedures by April 20, 2025.
¿ Program Specialist will conduct staff training to properly document all General Event Reports and EIM¿s. |
05/30/2025
| Not Implemented |
| 6400.32(n) | On 2/26/25 at 11:57AM, the only telephone in the home was in the staff office which is kept locked. [Repeated Violation -- 10/7/24] | An individual has the right to unrestricted and private access to telecommunications. | ¿ 55 PA Code Chapter 6400.32(n) ¿ Unrestricted and Private Access to Telecommunications.
¿
Plan of Correction
¿
¿ Issue: Consumers are not being provided unrestricted and private access to telecommunications.
¿ Action Steps:
¿ Ensure all individuals have access to a phone or device in a private setting.
¿ Train staff on the individual¿s rights to private telecommunications access.
¿ Remove any unnecessary restrictions unless documented and justified in the individual¿s plan. |
05/30/2025
| Not Implemented |
| 6400.34(a) | Individual Rights were most recently reviewed with Individual #1 on 1/3/24. | 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. | ¿ 55 PA Code Chapter 6400.34. Informing of rights.
¿ (a) 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.
Plan of Correction:
Residential Home Healthcare will revise the admission protocol to ensure that all individuals, and their designated representatives, receive a clear explanation of their rights and the process for reporting rights violations. This information will be provided both at the time of admission and annually thereafter. Staff will be trained on this updated protocol. |
05/30/2025
| Not Implemented |
| 6400.165(g) | Individual #1's psychiatric medication reviews, completed on 3/18/24 and 5/30/24 did not include the reason for prescribing the medications. Individual #1's most recent psychiatric medication review was 5/30/24. [Repeated Violation -- 7/23/24, et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | ¿ 55 PA Code Chapter 6400.165(g) ¿ Medication Management/Psychiatric Evaluations
pertains to prescription medications, specifically regarding psychiatric illnesses, requiring a licensed physician to review the need for continued medication and dosage at least every three months, including documentation of the reason for prescribing.
Corrective Actions:
¿ All psychiatric medications is reviewed every three months by a licensed physician.
¿ Medication strengths and administration times will be accurately recorded at the time of administration.
¿ Only staff who have completed state-approved medication administration training is administer medications.
¿ Program Specialist and Medication Observers conduct daily observations until all staff is observed and will conduct observations every six months as required for compliance.
¿ HR and Program Specialist developed medication review period tracking document to document and track all client¿s medication. |
05/30/2025
| Not Implemented |
| 6400.166(b) | On 2/26/25, Individual #1 is prescribed Benzonatate Cap 200mg with instructions to take 1 capsule by mouth every eight hours as needed for cough. There were 12 capsules of were removed from the blister package of this medication dispensed from the pharmacy on 2/13/2025. There was no documentation of administration for this medication on Individual #1's February Medication Administration Record. [Repeated Violation -- 7/23/24 et al, 10/7/24, 11/21/24, 1/23/25] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | ¿ 55 PA Code Chapter 6400.166(b) 167(a)(4)¿ Medication Administration/Medication Errors
The date and time of medication administration, along with the name and initials of the person administering it, must be recorded in the medication record at the time the medication is given. failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.
Corrective Actions:
All direct care staff will be re-trained by the Program Specialist and/or Medication Trainer on proper medication administration documentation, emphasizing the requirement to record the date, time, and their name/initials in the medication record immediately after administering medication. Staff will be re-educated on the importance of administering medications within the prescribed time frame, specifically within one hour before or after the scheduled time. A medication administration schedule will be posted and reviewed daily to prevent missed or delayed doses. The Medication Administration Policy will be updated to reflect this requirement. |
05/30/2025
| Not Implemented |
| 6400.167(a)(4) | Individual #1 is prescribed the following medications that are to be administered at 8:00PM: Benztropine MES 1mg Tablet, Carbamazepine 200mg Tab, Clonazepam 2mg, Clonidine HCL 0.2mg tablet, Clotrim/Beta Cre Diprop, Glycopyrrolate 2mg tablet, Haloperidol 10mg, Melatonin 3mg, Olanzapine 5mg, Propranolol 40mg, Zolpidem Tartrate 10mg tablet. On 2/12/25 these medications were logged as being administered at 10:30PM. On 2/13/25 these medications were logged as being administered at 9:42pm. On 2/14/25 these medications were logged as being administered at 11:08PM. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | ¿ 55 PA Code Chapter 6400.166(b) 167(a)(4)¿ Medication Administration/Medication Errors
The date and time of medication administration, along with the name and initials of the person administering it, must be recorded in the medication record at the time the medication is given. failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.
Corrective Actions:
All direct care staff will be re-trained by the Program Specialist and/or Medication Trainer on proper medication administration documentation, emphasizing the requirement to record the date, time, and their name/initials in the medication record immediately after administering medication. Staff will be re-educated on the importance of administering medications within the prescribed time frame, specifically within one hour before or after the scheduled time. A medication administration schedule will be posted and reviewed daily to prevent missed or delayed doses. The Medication Administration Policy will be updated to reflect this requirement. |
05/30/2025
| Not Implemented |
| 6400.181(f) | The program specialist did not complete the "Signature Acknowledgement Sheet" as to when Individual #1's most recent assessment, dated 2/1/24 was provided to the Individual #1's plan team members for the individual plan meeting on 12/16/24; therefore, compliance could not be measured. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 55 PA Code Chapter 6400.181(f) ¿ Individual Plan Meeting Documentation/Assessment
To ensure compliance, the facility will:
Corrective Action:
¿ Provide assessments to the individual plan team at least 30 days before meetings.
¿ Maintain documentation of individuals who participated in plan meetings.
¿ OCS assigned individual plan team representatives to conduct follow up meetings to address any compliance issues and correct any issues as a team immediately. |
05/30/2025
| Not Implemented |
| 6400.182(c) | Individual #1's assessment, completed 2/1/24 indicates that Individual #1 is independent with tempering water; however, in the water safety section of Individual #1's individual plan, last updated 2/12/25 reads, [Individual #1] does require some assistance regulating the water temperature, but he is able to tell if the water is too hot or cold." Individual #1's assessment, completed 2/1/24 assesses Individual #1 to independently be able to avoid and use poisonous materials; however, in the safety precaution section of Individual #1's individual plan, last updated 2/12/25 reads, [Individual #1] knows to avoid poisonous materials and would not attempt to ingest any. However, because of his impulsivity to destroy property it is best to keep all chemical and cleaners away from [Individual #1]." [Repeated Violation -- 7/23/24 et al and 11/21/24] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 55 PA Code Chapter 6400.182(c) ¿ Resident Assessments & Plans
The assessment process will be strengthened to ensure that all individuals receive initial and annual assessments, including medical history and psychological evaluations (if applicable). The program specialist will provide assessments to the individual plan team at least 30 days prior to the meeting. Program Specialist will develop a tracking document to accurately document and track completed and upcoming individual assessments.
Corrective Actions:
¿ HR and Program Specialist created a medical assessment tracking system to track and document all assessments.
¿ Each resident¿s initial and annual assessment is being conducted as required, including medical and psychological evaluations.
¿ The individual support plan (ISP) team is receiving training on assessment documentation procedures by April 20, 2025.
¿ A tracking system is being implemented to ensure that assessments are completed and distributed 30 days prior to ISP annual meetings.
¿ HR is viewing all client files to ensure all client files are in compliances as a second set of eyes for Program Specialist, Leads and Residential Directors.
¿ Program Specialist is correcting all client folders and reporting any issues to ISP Team and management to bring client folders compliant. |
05/30/2025
| Not Implemented |
| 6400.186 | On 2/26/25 at 11:48AM, a 19 fluid ounce bottle of Lysol all-purpose cleaner was on the kitchen counter. On 2/26/25 at 11:50AM, the cabinet below the kitchen sink did not have a locking mechanism and contained the following cleaning supplies: two 32 fluid ounce bottles of Great Value multi-purpose cleaner, a 24 fluid ounce bottle of Clorox Clinging Bleach Gel, which all contain instructions to contact poison control if ingested. In the safety precaution section of Individual #1's individual plan last updated on 2/12/25 reads, "[Individual #1] knows to avoid poisonous materials and would not attempt to ingest any. However, because of his impulsivity and tendency to destroy property, it is best to keep all chemicals and cleaners away from [Individual #1]." [Repeated Violation -- 7/23/24 et al, 9/20/24, 10/7/24] | The home shall implement the individual plan, including revisions. | 55 PA Code Chapter 6400.186 ¿ Implementation of the individual plan.
Corrective Actions: Plan of Correction:
All staff will be re-trained on the importance of fully implementing each individual¿s plan, including any updates or revisions. HCSIS is checked monthly to ensure that the most updated version of the ISP is available in each consumer home. The Program Specialist and Residential Director checks the individual home monthly. |
05/30/2025
| Not Implemented |