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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(l) | On 2/19/2026 at 12:38pm, it was observed that Individual #2's bed was a crib-style bed with bilateral solid sides that measured more than 12 inches high. The bilateral sides were two continuous, horizontal, parallel white metal rails that spanned from the headboard to the footboard with 30 vertical white metal rails running perpendicular between the horizonal rails. The agency obtained a prescription for a "pediatric crib bed to promote safety during hours of sleep related to inability to safely ambulate without assistance" on 7/30/2025. Although the crib bed is prescribed by the medical practitioner, crib beds with solid sides measuring more than 12 inches high are not permitted. | Beds and cribs, with solid sides over 12 inches high or with closed domes or tops, are not permitted. | In response to the deficiency cited under 55 PA Code Chapter 6400.81(l) regarding the use of a crib-style bed with solid sides exceeding 12 inches for Individual #2, the following corrective actions have been taken:
On 2/27/2026, Individual #2 Support Team met to review and provide additional communication /education to Individual #2's father regarding the violation of use of the crib-style bed with rails exceeding 12 inches. Individual#2's father serves as Legal Guardian. After discussion, the Team agreed the crib-style rails should be removed, as their use is not permitted under the regulation, and alternative measures should be employed for safety. Individual#2 PCP was also notified regarding this change. Verland Program Specialist and Facilities Team, coordinated with Individual #2's father a meeting at the house to remove Individual #2 rails from the bed. The Team further agreed upon obtaining a full-sized adjustable bed with bed alarm. The complete date for full implementation of these changes is 3-4-26
To prevent recurrence, all Front-Line Supervisors including Program Specialists will be retrained regarding the requirements of 55 PA Code Chapter 6400.81(l), specifically the prohibition of beds and cribs with solid sides over 12 inches high or with closed domes or tops. Re-training of all Front-Line Supervisors and Program Specialists will be completed by 4-1-2026. These actions will ensure ongoing compliance with the cited regulation and prevent similar future reoccurrence. |
03/04/2026
| Implemented |
| 6400.163(h) | Individual #1 is prescribed Potassium CL 10% (20mEq/15) with instructions to "GIVE 7.5 ML (10 MEQ) VIA G-TUBE 2 TIMES PER DAY ONLY WHEN TAKING LASIX FOR SUPPLEMENT **WAIT TO REORDER**" On 2/19/2026 at 12:27pm, this medication was observed with an expiration date of 3/25/2025 on the pharmacy issued medication label. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The facility has Immediately addressed the expired medication for Individual #1 by removing it during the inspection and disposing it via the SMART method to ensure safe and compliant destruction. The expired medication was also immediately re-ordered to prevent any lapse in prescribed treatment. Also, the facility will retrain all Front-line Supervisors and Program Specialists on medication management protocols, with a specific focus on checking medication expiration dates monthly and re-ordering medications in advance of their expiration to prevent recurrence of this issue. This training will be completed by 4-1-2026. In addition, the Health Services Coordinator will oversee this process by conducting monthly systematic reviews of all medications stored in the homes to ensure ongoing compliance and timely identification of any medications approaching expiration. Moreover, this process will be monitored by the resident services director Quarterly to ensure implementation, compliance, and prevent future similar deficiencies from reoccurring. Furthermore, the facility has begun implementation of an Electronic Medication Administration Record (Emar) system as of March 2026. This system clearly displays the expiration date of each medication, allowing for timely re-ordering and reducing the risk of expired medications remaining in use |
03/04/2026
| Implemented |
| 6400.207(5)(III) | On 2/19/2026 at 12:38pm, Individual #2's bed contained full bilateral bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for a "pediatric crib bed to promote safety during hours of sleep related to inability to safely ambulate without assistance" on 7/30/2025. Although the bed rails are prescribed by the medical practitioner, Individual #2's current assessment, completed by Program Specialist #1 on 6/2/2025, does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's support plan, last updated 10/1/2025, does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | ·On 2-24-26 Verland CLA Directors conducted a meeting with the Residential Department to verify no other bed rail devices are in use for any other individual residing in the Community Living Arrangements. And no other mechanical restraint is in use across the agency as defined by 55 PA Code Chapter 6400.207(5)
·Team met on 3-4-26 to address Individual #2 the use of Bed rails and on, with Team agreement, an alternative adjustable bed without rails is now in use for Individual#2. Individual #2 Assessment has been updated on -3-4-26 and shared with Support Team members to include the Individual Support Coordinator and is consistent with equipment in use.
·All Front-Line Supervisors, Program Specialists, and Regional Directors will receive re-training by 4-1-26. This training will specifically address the identification and application of the relevant regulations to ensure compliance and understanding among supervisory staff.
·Additionally, all Program Specialists will be re-in-serviced by 4-1-26 to ensure that every individual's assessment consistently and accurately reflects the individual support plan.
. Verland remains committed to seeking alternative and least restrictive measures to ensure the safety and independence of individuals receiving services. The organization will continue to review and implement best practices to minimize the use of restrictive devices and promote a person-centered approach to care. This process will be monitored by the Resident Services Director quarterly to ensure compliance and prevent reoccurrence of similar future deficiencies. |
03/04/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace has not been inspected and cleaned annually by a professional furnace cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The facility has hired an outside company, Climatech, Inc / ATECH Mechanical, to inspect and clean all the furnaces in the 13 homes. The technician from the Climatech Company is schedule to start the furnace inspections on Friday, 02/26/2021 and will be done by Friday, 03/05/2021. In addition, we will inspect the rest of all verland homes by the end of March, 2021. Also, all program specialists, Residential Managers, and Maintenance staff will be in-service on making sure that all furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company and written documentation of the inspections must be kept. This in-service will be completed by 03/15/2021. This process will be monitored by program Specialist Manager to ensure furnaces in all homes are inspected and cleaned by the end of March, 2021, and this process will be repeated every December of each future year to ensure compliance and prevent future similar deficiency from reoccurring. [The furnace inspection for the home was completed 3/1/2021 by a professional furnace cleaning company and staff training was received by the department on 3/9/2021. Documentation of all trainings and furnace cleanings shall be kept. (DPOC by RM, HSLS on 3/9/2021)] |
02/25/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | The hinge on the lower corner cabinet in the kitchen was broken. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The facility will ensure all furniture and equipment are nonhazardous, clean and sturdy by in-servicing all Direct Support Professionals, Program Specialists, Program Coordinators , and nurses on completing a maintenance request when a furniture or equipment needs repaired or replaced. This in-service will be completed by November 25, 2014. The hinge on the lower corner cabinet in the kitchen of Boxfield House was repaired on 10/09/2014. Program Coordinators will be monitoring every house once a month using a monitoring form. Program Coordinator Manager will make sure the monitoring is taking place by reviewing the monitoring forms in order to prevent reoccurrence in the future. |
11/08/2014
| Implemented |
| 6400.171 | An open bag of chicken tenders was in the refrigerator. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The facility will ensure that all food will be protected from contamination while being stored, prepared, transported, and served by implementing the following:
a. In-service all Program specialists, Program Coordinators, nurses, and all Direct support professionals on making sure all food will be protected from contamination while being stored , prepared, transported and served. This in-service will be completed by November 25, 2014.
b. Program Coordinators will be monitoring every house once a month by using a monitoring form and the Program Coordinator Manager will make sure the monitoring is taking place by reviewing the monitoring forms in order to prevent reoccurrence in the future.
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11/08/2014
| Implemented |
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