| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's assessment states that the individual requires poisons to be locked within the home. Poisons were not locked in the home including dish soap on the kitchen sink, a large bottle of moisturizer in the upstairs hallway, laundry and cleaning supplies in the basement. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 9/19/2025 the program specialist completed a home visit and provided assistance to the DSPs to lock up all of the poisons around the home. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that all poisonous materials are locked up and inaccessible to individuals, as well as reviewing this during weekly home assessment by 55 PA Code Chapter 6400.62 Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring all poisonous materials are locked up and inaccessible to individuals as outlined by 55 PA Code Chapter 6400.62 |
09/19/2025
| Implemented |
| 6400.64(a) | There were empty water bottles and beverage bottles littering the floor in individual #2's bedroom. The upstairs hallway closet, which had no door, contained trash from old boxes on the floor of the closet. In the upstairs bathroom, there was an empty toilet paper roll and loose pieces of toilet paper thrown upon the sink. Two toothbrushes for the individuals in the home, along with a used bar of soap were found intermingling and unprotected laying in a pull-out compartment in the bathroom vanity. In the vacant bedroom, there was dirty clothing, including underwear, on the floor of the bedroom and the floor of the closet. Staff stated that this clothing belonged to a housemate who had moved out, and the things were left in this manner and not cleaned. | Clean and sanitary conditions shall be maintained in the home. | On 9/19/2025 DSPs assisted the individual to clean up the empty water bottlers, pick up trash throughout the bathroom area and clean out the trash from the hall way closet. It was coordinated on 9/19/2025 for the individual not residing in the home to come and clean up his belongings in the bedroom. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on maintaining clean and sanitary conditions in the home as outlined by 55 PA Code Chapter 6400.64 Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on maintaining clean and sanitary conditions within the home as outlined by 55 PA Code Chapter 6400.64 exhibit A. |
09/19/2025
| Implemented |
| 6400.67(a) | The upstairs hallway closet had hinges exposed where a door previously had been. The shelves in the closet were visibly broken. The light switch in the upstairs bathroom was missing the face plate. Most kitchen cabinets were missing doors, and hinges were exposed on some cabinets where doors remained. Ceiling lights in the kitchen were either missing or did not have covers and cords were protruding. Drywall repairs were completed throughout the home without being painted over upon completion. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 9/23/2025 Maintenance secured the light switch face plate, ceiling lights in the kitchen were covered and cords were closed up, and the drywall in the kitchen was repainted. On 9/26/2025 the door in the hallway closet was replaced and the shelves fixed. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that floors, walls, and ceilings are in good repair and escalating concerns to maintenance within 24-hours as outlined by 55 PA Code Chapter 6400.67 Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring that floor, walls, and ceilings are in good repair and to escalate any concerns to the program specialist within 24-hours as outlined by 55 PA Code Chapter 6400.67 Exhibit A. |
09/23/2025
| Implemented |
| 6400.72(a) | The window on the left side in individual #1's bedroom is missing a screen. The living room windows at the front of the home have operators to open but do not have screens. There was no screen in the window of the basement bathroom. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | On 9/23/2025 Maintenance replaced the window screen in individual #1 bedroom. An order was placed for the window screens for the living room window same day, as the window requires special order. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that windows and doors were securely screened when windows and doors are opened and if concerns are identified to maintenance within 24-hours as outlined by 55 PA Code Chapter 6400.72(a) Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring that windows and doors were securely screened when windows and doors are opened and escalate any concerns to the program specialist within 24-hours as outlined by 55 PA Code Chapter 6400.72(a) Exhibit A. |
09/23/2025
| Implemented |
| 6400.72(b) | The window screen on the right side in individual #1's bedroom has a hole approximately the size of a half dollar. | Screens, windows and doors shall be in good repair. | On 9/23/2025 Maintenance replaced the window screen in individual #1 bedroom. An order was placed for the window screens for the living room window same day, as the window requires special order. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that windows and doors were securely screened when windows and doors are opened and if concerns are identified to maintenance within 24-hours as outlined by 55 PA Code Chapter 6400.72b Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring that windows and doors were securely screened when windows and doors are opened and escalate any concerns to the program specialist within 24-hours as outlined by 55 PA Code Chapter 6400.72b Exhibit A. |
09/23/2025
| Implemented |
| 6400.76(a) | The front panel of the oven door is missing with the insulation inside the door exposed. An unknown whitish substance had spilled or poured down the front of the oven as well, leaving visible residue. | Furniture and equipment shall be nonhazardous, clean and sturdy. | On 10/1/2025 the oven was completely replaced by maintenance. Old oven was discarded and a new one was installed to ensure that all furniture and equipment is nonhazardous, clean an sturdy per 55 PA Code Chapter 6400.76. |
10/01/2025
| Implemented |
| 6400.77(b) | The first aid kit did not contain tweezers, antiseptic or a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | On 9/19/2025 the program specialist replaced the first aid kit to ensure all supplies were available. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that the first aid kit contained antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, as outlined by 55 PA Code Chapter 6400.77b Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring that that the first aid kit contained antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, and notify the program specialist of any missing items to replace the first aid kit within 24-hours as outlined by 55 PA Code Chapter 6400.77b Exhibit A. |
09/19/2025
| Implemented |
| 6400.77(c) | The first aid kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | On 9/19/2025 the program specialist replaced the first aid kit to ensure all supplies, including the first aid manual were available. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that the first aid kit contained all required first aid items, including the first aid manual and to ensure this is reviewed during weekly home inspections by as outlined 55 PA Code Chapter 6400.77c Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring that that the first aid kit contained all required first aid items, including first aid manual and notify the program specialist of any missing items to replace the first aid kit within 24-hours as outlined by 55 PA Code Chapter 6400.77c Exhibit A. |
09/19/2025
| Implemented |
| 6400.80(b) | The outside back patio had several areas of broken glass, a toppled broken planter and trash debris. There was an approximately 6-inch long sharp, pointed, rusty metal object consistent with bird spikes laying on the patio. The backyard contained a fallen tree, large fallen branches and excessive weed and grass overgrowth. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | On 10/3/2025 maintenance cleaned up all of the items in the back yard. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that all backyard areas are free of debris and to complete a thorough review when completing weekly supervisory checks, and identified areas of concerns are to be escalated to maintenance within 24-hours as outlined 55 PA Code Chapter 6400.80b Exhibit A. On 10/1/2025 DSPs completed an in-service led by the program specialist and were retrained on ensuring that all backyard areas are free of debris and any identified concerns are to be reported to the program specialist within 24-hours as outlined by 55 PA Code Chapter 6400.80b Exhibit A. |
10/03/2025
| Implemented |
| 6400.82(f) | In the upstairs bathroom that is used mainly by the individuals that reside in the home, the hand soap container was found to be empty. There was no trash can or hand towels available for use. The roll of toilet paper was placed on the sink surface and not available on the roll. | 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. | On 9/18/2025 the program specialist replaced the empty soap dispenser and ensured hand towels were available. On 10/1/2025 the toilet paper holder and trash can were purchased and replaced. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure thorough completion of weekly home supervisory reports and to document any missing or damaged items such as sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacles as per 55 PA Code Chapter 6400.82. On 10/1/2025 in-service was completed for all medication trained DSPs by the medication trainer and program specialist to report any missing or damaged items such as sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacles as per 55 PA Code Chapter 6400.82. exhibit A. |
09/18/2025
| Implemented |
| 6400.144 | The MAR for individual #1 listed that the individual is prescribed Vitamin D3 1000 soft gel, take 1 capsule by mouth daily. There was only an empty bottle labeled vitamin D2 1.25mg (50,000 unit), take 1 capsule by mouth once a week as directed in the box. Guanfacine 2mg, take 1 tablet by mouth twice daily, prescribed for the individual as listed on the MAR was also not present in the medication box. | 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.
| On 9/18/2025 the Program Specialist and CEO reviewed the MAR record and the medication box to ensure all prescribed medications are available, MAR is completed accurately and no refills were required. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure all medications are present, no refills needed, and that MAR matches the current medications as per 55 PA Code Chapter 6400.144 and to complete weekly MAR reviews. On 10/1/2025 in-service was completed for DSPs to ensure all medications are present, no refills needed, and that MAR matches the current medications as per 55 PA Code Chapter 6400.144 exhibit A. |
10/01/2025
| Implemented |
| 6400.216(a) | Individual record books for both individual #1 and individual #2 were stored unlocked on an open shelf in the dining area of the home. | An individual's records shall be kept locked when unattended.
| On 10/1/2025 the program specialist delivered a lock to the home and provided assistance tot he DSPs to lock up records when not in use. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure all individual binders are locked up when not in use as per 55 PA Code Chapter 6400.216a and when completing weekly home assessments to review said component. On 10/1/2025 in-service was completed for DSPs by the program specialist to ensure all all records are secured when not in use as per 55 PA Code Chapter 6400.216 exhibit A. |
10/01/2025
| Implemented |
| 6400.18(a)(5) | Individual #1 experienced an incident that was discovered on 8/15/25. The agency did not enter EIM #9678009 for the individual until 8/19/25. This incident was required to be entered within 24-hours and should have been entered by 8/16/25. | 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:
Neglect.
| The incident was logged immediately after a team discussion and identification of the incident. On 9/30/2025 the program specialist and management staff were retrained by the CEO and Administrator or promptly reporting and reporting incidents upon identification as per the Incident Management Bulletin and 55 PA Code Chapter 6400.18 exhibit A. |
09/30/2025
| Implemented |
| 6400.24 | Individual #1 is prescribed Clobazam, which is a schedule IV-controlled substance and requires a count to be kept. The controlled medication count for individual #1's Clobazam 10mg (take 0.5 tab by mouth at bedtime) was incorrect. On 9/16, staff administered one half pill and listed the count as 21.5 pills. On the day of the inspection (9/17/25 morning), there were twenty half tablets present in the bottle, not 21.5. It was also noted that on shifts on 9/15/25 at 11pm and on 9/17/25 at 7am, when zero tablets were administered, the staff wrote "0" for the number administered and then incorrectly wrote "0" for the total count. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 9/18/2025 the CEO recounted the controlled medication to ensure accurate count of controlled substance. On 9/30/2025 in service was completed for the program specialist and management staff by the CEO to ensure accurate documentation is maintained. On 10/1/2025 in-service was completed for DSPs by the medication trainer and program specialist to ensure accurate counting and documentation of schedule IV-controlled substances and documentation is sufficiently filled out per 55 PC Code Chapter 6400.24 exhibit A. |
10/01/2025
| Implemented |
| 6400.34(a) | Individual #1 was admitted to the home on 3/4/25. Documentation shows that individual rights were not reviewed and signed until 4/15/25. | 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. | On 9/30/2025 the CEO retrained the program specialist and management staff on timely and accurate documentation of start of care files and annual packets (exhibit A) per 55 PA Code Chapter 6400.34(a). |
09/30/2025
| Implemented |
| 6400.45(d) | Individual #1's ISP states that the individual is to have a 2:1 staffing ratio at all times in the home. When the licensing representative arrived at the home at 9:35am, there was only one staff present with the individual in the home. Another staff did not arrive until approximately 20 minutes later to take the individual to an appointment. It is unknown how long prior to the licensing representative's arrival 1:1 staffing was occurring. 2:1 staffing in the home was to be implemented in response to EIM #9678009 as corrective action. The incident report states that this corrective action was completed 8/18/25. | The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ). | On 9/30/2025, the CEO reviewed the 2:1 ratio as outlined in the current ISP, and the schedule for 2:1 was from 10AM-8PM daily at the time of the inspection. The team is actively working on a request for 24-hour 2:1 ratio, but at the time of the inspection, 2:1 was only from 10AM. On 10/1/2025 DSPs were retrained on maintaining ratio and ensuring ISP plans were followed as per the 55 PA Code Chapter 6400.45(d) exhibit A. Staff were trained to immediately report any deviation in ratio to the program specialist. |
09/30/2025
| Implemented |
| 6400.163(h) | Individual #1's medication box contained Melatonin 3mg tablet, take 1 tablet by mouth at bedtime. This medication was not listed on the MAR. Staff relayed that this medication had been discontinued. However, it was not removed from the medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 9/18/2025 the Program Specialist and CEO reviewed the MAR record and the medication box. The Melatonin was removed form the medication box. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure all medications are discarded from the medication box once discontinued as per 55 PA Code Chapter 6400.163 and to complete weekly MAR reviews. On 10/1/2025 in-service was completed for DSPs by the medication trainer and program specialist to ensure ensure all medications are discarded from the medication box once discontinue as per 55 PC Code Chapter 6400.163 exhibit A. |
10/01/2025
| Implemented |
| 6400.163(h) | There were two boxes of Earwax removal Ear Drops 6.5% soln. in the medication box for individual #2 that were not listed on the medication administration record (MAR). These were last filled by the pharmacy on 6/16/25 and 7/14/25. Staff stated that this medication was discontinued. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 9/18/2025 the Program Specialist and CEO reviewed the MAR record and the medication box. The boxes of earwax removal ear drops were removed form the medication box. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure all medications are discarded from the medication box once discontinued as per 55 PA Code Chapter 6400.163 and to complete weekly MAR reviews. On 10/1/2025 in-service was completed for DSPs by the medication trainer and program specialist to ensure ensure all medications are discarded from the medication box once discontinue as per 55 PC Code Chapter 6400.163 exhibit A. |
10/01/2025
| Implemented |
| 6400.165(b) | The Medication Administration Record (MAR) did not match the prescription labels on the bottles for the following medications for individual #1:
Risperidone: The MAR listed Risperidone 2mg tablet, take 1 tablet by mouth twice daily. There were two medication bottles in the medication box. Bottle #1 labeled Risperidone 0.5mg, take 3 tablets by mouth in the morning. Bottle #2 labeled Risperidone 4mg tabs take 1 tablet at bedtime-discontinue 2mg.
Carbamazepine: The MAR listed Carbamazepine ER 100mg, take 2 capsules by mouth twice daily. The bottle available in the box was labeled Carbamazepine 100mg, Chew 4 tablets twice daily.
It was noted that staff initialed the MAR without question since the individual returned back to the home from the hospital on 9/9/25, despite the discrepancies between the MAR and the labels on the bottles. | A prescription order shall be kept current. | On 9/18/2025 the CEO/medication trainer reviewed the latest documentation following hospital discharge and completed medication reconciliation to ensure MAR record contained accurate instruction and matched the label on the bottles. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure monthly MARs are accurately documented as per 55 PA Code Chapter 6400.165 and to complete weekly MAR reviews. On 10/1/2025 in-service was completed for DSPs by the medication trainer and program specialist to ensure accurate completion of MAR documentation when entering medications and to escalate discrepancies to the program specialist upon identification of inaccurate information per 55 PC Code Chapter 6400.165 exhibit A. |
10/01/2025
| Implemented |
| 6400.166(a)(11) | The Medication Administration Record (MAR) for individual #2 does not indicate the diagnosis or purpose for the medication for two of the individual's medications: Benzotropine 0.5mg tablets and Fluoxetine HCL 10mg caps. | 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. | On 9/18/2025 the CEO/medication trainer rectified the MAR Record to include the diagnosis and purpose of the medication. On 9/30/2025 in-service was completed for the program specialist and management staff by the CEO to ensure monthly MARs are accurately documented as per 55 PA Code Chapter 6400.166 and to complete weekly MAR reviews. On 10/1/2025 in-service was completed for DSPs by the program specialist and medication trainer to ensure accurate completion of MAR documentation when entering medications per 55 PC Code Chapter 6400.166 exhibit A. |
10/01/2025
| Implemented |
| 6400.186 | Individual #1's ISP states that the individual is to have line of sight supervision by one staff member at all times. During the inspection, singular staff was not within line of sight of the individual and was often on a different floor of the home. When a second staff arrived, they still did not maintain line of sight supervision within the home, as Individual #1 went up to the 3rd floor of the home and the staff were on the 1st and 2nd floor of the home. | The home shall implement the individual plan, including revisions. | On 9/30/2025 the CEO reviewed the ISP to assess supervision requirement. Per ISP, individual #1 has alone time within his room and 30-minute checks. On 9/30/2025, program specialists and supervisors were retrained by the CEO and Director on ensuring that supervision is maintained and followed as outlined in the ISP for each individual, as well as maintaining line of sight as outlined by 55 PA Code Chapter 6400.186 Exhibit A. On 10/1/2025 DSPs completed an in-service led by program specialist and were retrained on ensuring that supervision requirements are maintained by all staff and ratio is followed, as well as any additional requirements as outlined by 55 PA Code Chapter 6400.186 Exhibit A. |
10/01/2025
| Implemented |