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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | On 07/09/26, at 9:50 AM, the shower stall flooring of the full bathroom located in the home's basement had an exposed, uncovered, circular drain that measured approximately eight inches in diameter, creating a falling or tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The maintenance director added drain cover to the Highland basement shower stall on 7.9.26. Each home was reviewed to ensure that all surfaces were in good repair and free from hazards. |
07/09/2026
| Implemented |
| 6400.77(b) | On 07/09/26, at 10:22 AM, the home's first aid kit did not contain antiseptic. | 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. | Antiseptic was added to the First Aid Kit at Highland Rd. making it complete with all necessary items 7.9.26 All other first aid kits used in other homes were checked to ensure all items were present. |
07/09/2026
| Implemented |
| 6400.101 | On 07/09/26, at 10:27 AM, the interior door leading to a storage area that provides access to the basement's only exterior exit through a breezeway was equipped with key-locking doorknob assembly. However, when this door was locked, the agency did not have a key to disengage its lock. Agency maintenance had to remove the door trim in order to open this door. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Maintenance Director changed the described locking doorknob on 7/9/26, to a non-locking doorknob. |
07/09/2026
| Implemented |
| 6400.207(5)(III) | On 07/09/26, at 9:43 AM, Individual #1's hospital bed was equipped with bilateral, partial bed rails located at the head of the bed. However, the agency did not execute the required elements from precluding Individual #1's bed rails as a mechanical restraint. Individual #1's current physician script, dated 5/13/2025, included an order for bed rails with a medical diagnosis and specified safety concern that read, "Diagnosis: R29.6---Repeated falls" to reduce risk of frequent falls. Individual #1's current assessment, completed on 11/24/2025, read, "Adaptive equipment: Bed rails. Physical Limitations: Fall risk. Staff on duty should check Individual #1 every two hours. When in bed, every two hours, staff while awake should ask if Individual #1 would like the bed rails down." However, Individual #1's current assessment did not address or include the medical diagnosis(-es) relative to the specified safety concern for the use of bed rails. In addition, Individual #1's current assessment neither assessed Individual #1's ability to lower or adjust the bed rails on their own, nor Individual #1's ability to request staff to lower or adjust the bed rails immediately upon being asked for temporary, periodic relief to allow movement if Individual #1 was determined as unable to independently remove or adjust the bed rails. Furthermore, Individual #1's current assessment did not include staff directives on how often they should be conducting bed checks at night to provide temporary, periodic relief for movement. Individual #1's Service Plan, last updated 7/1/2026, read exclusively as follows: "[Individual #1] [is] to be repositioned every two hours during awake hours. [Individual #1] has a hospital-style bed with rails." However, Individual #1's Service Plan, last updated 7/1//2026, did not include following requirements: The medical diagnosis(-es) relative to the specified safety concerns for the use of bed rails; Individual #1's ability to lower or adjust the bed rails on their own; Individual #1's ability to request staff to lower or adjust the bed rails immediately upon being asked for temporary, periodic relief to allow movement if Individual #1 was determined as unable to independently; and directives for how often staff should be checking on Individual #1 at night in order to provide such temporary, periodic relief to allow movement. [Repeat Violation 7/22/25, et. al.] | 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. | Received orders from Individual PCP on 7.16.26 that their bed rails were no longer clinically necessary so that a less restrictive method of precaution could be used. Bedrails were removed from the bed on 7.18.26. An email was sent to the SC notifying that the ISP needed updated to document that bed rails will no longer be used 8.3.26. The assessment will be completed no later than 8.23.26, which will remove the use of bedrails. |
07/17/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | On 7/23/2025 at 12:37pm, the blind covering the window at the foot of Individual #3's bed was in disrepair with 5 broken horizontal slats near the bottom of the blind. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The blind covering the window at the foot of Individual #3's bed will be replaced. |
08/01/2025
| Implemented |
| 6400.141(c)(9) | Individual #1's physical examination, completed 7/3/2025, did not include a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual #1 is scheduled for a prostate exam on 09/08/2025 with urology |
09/08/2025
| Implemented |
| 6400.181(a) | Individual #1, date of admission 5/21/2025, had their initial residential assessment completed on 7/21/2025; 61 days after their admission into the program. | 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. | Individual's assessment was completed 7/21/25. |
07/21/2025
| Implemented |
| 6400.214(b) | On 7/23/2025 at approximately 12:30pm, the following documents from Individual #1's record were not accessible at the residential home: current physical examination and current dental examination. The agency utilizes Therap to digitally store individual record information; however, these documents had not been uploaded to Individual #1's electronic record. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most current copies of record information required in § 6400.213(2)(14) will be uploaded to an electronic file accessible to staff in all ResHab locations. |
09/15/2025
| Implemented |
| 6400.207(5)(II) | On 7/23/2025 at 12:38pm, Individual #2's bed contained bilateral upper-half bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for bed rails on 5/13/2025. Although the bed rails are prescribed by the medical practitioner, Individual #2's most current assessment, completed 9/10/2024, 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 7/9/2025 does indicate the need for a hospital style bed with rails; however, it 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: Balance or support to achieve functional body position, 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. | Bedrails will be removed from individual #2's bed. Wedges will be used to ensure the individual¿s safety. Staff will continue to reposition the individual every 2 hours and document overnight. |
08/15/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The evacuation time for the fire drill held on 10/24/16 was 4 minutes and 30 seconds. The evacuation time for the fire drill held on 11/22/16 was 2 minutes and 48 seconds. The evacuation time for the fire drill held on 1/25/17 was 4 minutes. The evacuation time for the fire drill held on 4/9/17 was 4 minutes and 30 seconds. The most recent extended evacuation time of 6 minutes specified in writing by a fire safety expert was completed December 2, 2011. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A letter was sent certified 7/12/2017 to Hermitage Fire Chief John Flynn, about the 6 minute extended evacuation time at 1604 Highland Ave. group home. . There has been no response as of 7/18/2017, a phone call log will be kept of attempts and letters sent will be logged until we are able to speak to someone and get a response about the letter that was sent. CEO will also follow up with Hermitage Fire Department as needed. [On 7/18/17, at 3:00AM, a fire drill was conducted with an evacuation time of 2 minutes and 28 seconds. Within 30 days of receipt of the plan of correction, the CEO or designated management shall develop and implement policies and procedures for staff persons who conduct fire drills to implement when fire drills held at community homes encounter problems including exceeding required evacuation times. Within 60 days of receipt of the plan of correction, all staff responsible for conducting fire drill shall be trained in aforementioned policies and procedures. Documentation of training shall be kept. At least monthly for 3 months and continuing at least quarterly, a designated management staff person shall review fire drill records to ensure fire drill are conducted and documented as required. Documentation of reviews shall be kept. (AS 7/27/17)] |
07/27/2017
| Implemented |
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