| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed on 9/3/24. | 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.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. |
12/31/2024
| Implemented |
| 6400.15(c) | The home's self-assessment completed on 9/3/24, identified the following violations: .112 for having no written fire drill records for all of 2023 and January 2024; and .113a for Individual #1 not yet having completed fire safety training in 2024. However, the agency did not provide a corresponding written summary of corrections for each violation. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. Individual #1 had fire safety training on 9/9/24. Program Specialists were retrained on timeframes and grace periods for annual paperwork. |
12/31/2024
| Implemented |
| 6400.22(c) | Individual #1's financial ledger revealed that they had made a purchase on 8/21/24 for "personal supplies" in the amount of $60.69, from Walmart. The agency provided the receipt documenting this purchase and revealing that the above purchase was for hygiene wipes. | Individual funds and property shall be used for the individual's benefit. | Individual #1 will be reimbursed money for personal supplies. Residential home managers have been retrained on the proper use of individuals personal spending. Residential homes managers were retrained on what is covered in the room and board contract to clarify what individuals are responsible for and what CLASS is responsible for. |
12/31/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's 9/11/24 assessment indicates they require verbal and physical assistance in managing finances. The agency does not serve as Individual #1's representative payee. Individual #1 receives money from their representative payee that is disbursed onto new pre-paid Visa gift cards approximately each week. Individual #1's transactions are recorded on checking/ savings account ledgers that are kept in the home. The July 19-21, 2024 financial ledger for a pre-paid Visa gift card showed a remaining balance of $54.03. The 8/21/24 financial ledger for pre-paid Visa gift card displayed a remaining balance of $39.31. The 8/9/24 financial ledger for a pre-paid Visa gift card documented a remaining balance of $26.94. However, the noted remaining balances of the above gift cards were not carried over on to the total balance and, therefore, were unaccounted for each time a new prepaid Visa gift card was disbursed by Individual #1's representative payee. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Residential home managers were retrained on how to properly document and record spending at each home. Residential homes managers were retrained on what is covered in the room and board contract to clarify what individuals are responsible for and what CLASS is responsible for. |
12/31/2024
| Implemented |
| 6400.72(a) | On 9/26/24 at 9:54 AM, the right window located in the home's dining room was observed without a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screen has been put back into place. CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. |
12/31/2024
| Implemented |
| 6400.112(a) | No documentation was provided in the written fire drill record from October 2023 to August 2024, regarding unannounced monthly drills conducted for October 2023, November 2023, and December 2023 as well as January 2024 and February 2024. | An unannounced fire drill shall be held at least once a month. | Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated and reviewed with all residential homes managers on 10/3/2024. |
12/31/2024
| Implemented |
| 6400.141(a) | Individual #1 had physical examinations completed on 6/29/23, and then again on 7/15/24. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Residential homes managers were all retrained on the regulations pertaining to time frames with scheduling medical appointments. |
12/31/2024
| Implemented |
| 6400.141(c)(3) | Individual #1's immunization record indicated that they last received a tetanus-diphtheria vaccine on 12/3/12. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Residential homes managers were all retrained on the regulations pertaining to time frames and needed information on annual physicals with scheduling medical appointments. |
12/31/2024
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination, completed on 7/15/24, did not address their allergies. This field was left blank. | The physical examination shall include: Allergies or contraindicated medications. | Residential homes managers were all retrained on the regulations pertaining to time frames and needed information on annual physicals with scheduling medical appointments. Individual #1 does not have any allergies |
12/31/2024
| Implemented |
| 6400.142(a) | On 9/25/24, Individual #1's record documented that they last had a dental examination completed on 6/14/23. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Residential homes managers were all retrained on the regulations pertaining to time frames with scheduling medical appointments. Dental appointment was scheduled for 11/4/2024 |
12/31/2024
| Implemented |
| 6400.181(e)(1) | Individual #1's current assessment completed on 9/11/24, did not address their functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | CLASS annual assessment has been revised to add Functional strengths, needs and preferences of the individual. |
12/31/2024
| Implemented |
| 6400.181(e)(10) | Individual #1's 9/11/24 assessment did not include a complete lifetime medical history and included only the following information: they were removed from home in 2016; their diagnoses; and that they are legally blind in right eye. | The assessment must include the following information: A lifetime medical history. | Program specialist has reached out to previous residential placement to get lifetime medical history and past psychological evaluations. |
12/31/2024
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, completed on 9/11/24, did not include a psychological evaluation. Their record did not include any documented attempts by the agency to obtain one from their previous placement. | The assessment must include the following information: Psychological evaluations, if applicable. | Program specialist has reached out to previous residential placement to get lifetime medical history and past psychological evaluations. A new psychologist has been found and an initial appointment has been scheduled. |
12/31/2024
| Implemented |
| 6400.20(b) | The agency did not complete a review and analysis of incidents and conduct an incident trend analysis from the second fiscal quarter of 2023 to the second fiscal quarter of 2024. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | Review of incidents was completed on 10/22/2024 and quarterly review meetings were scheduled on the corporate calendar. |
12/31/2024
| Implemented |
| 6400.32(r)(1) | On 9/26/24, Individual #1's bedroom door was observed without a lock. Individual #1's record did not include documentation of their declination of a bedroom door lock or their inability to decide regarding this matter. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Locks were changed to straight locks on bedroom doors. |
12/31/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained their rights on 6/16/23, and then again on 6/22/24. | 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. | Program Specialists were retrained on timeframes and grace periods for annual paperwork. |
05/31/2025
| Implemented |
| 6400.52(c)(2) | Temporary Direct Support Professional #3 did not complete required content on the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse for the 2023-2024 fiscal annual training year. Temporary Direct Support Professional #4 did not complete required content on the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse for the 2023-2024 fiscal annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Temporary staff have not been used. |
12/31/2024
| Implemented |
| 6400.52(c)(3) | Temporary Direct Support Professional #3 did not complete required content on individual rights for the 2023-2024 fiscal annual training year. Temporary Direct Support Professional #4 did not complete required content on individual rights for the 2023-2024 fiscal annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Temporary staff have not been used. |
12/31/2024
| Implemented |
| 6400.52(c)(4) | Temporary Direct Support Professional #3 did not complete required content on recognizing and reporting incidents for the 2023-2024 fiscal annual training year. Temporary Direct Support Professional #4 did not complete required content on recognizing and reporting incidents for the 2023-2024 fiscal annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Temporary staff have not been used. |
12/31/2024
| Implemented |
| 6400.52(c)(5) | Temporary Direct Support Professional #3 did not complete required content on recognizing and reporting incidents for the 2023-2024 fiscal annual training year. Temporary Direct Support Professional #4 did not complete required content on recognizing and reporting incidents for the 2023-2024 fiscal annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Temporary staff have not been used. |
12/31/2024
| Implemented |
| 6400.52(c)(6) | Temporary Direct Support Professional #3 did not complete required content on the implementation of the Individual Support Plan(s) for the 2023-2024 fiscal annual training year. Temporary Direct Support Professional #4 did not complete required content on the implementation of the Individual Support Plan(s) for the 2023-2024 fiscal annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Temporary staff have not been used. |
12/31/2024
| Implemented |
| 6400.163(a) | On 9/26/24, Individual #1's prescribed medication, Refresh Tears, was not found in its original box with the medication label. House Manager #1 stated the box had been discarded. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Residential homes managers were all retrained on the regulations pertaining to proper storage and labelling of medications. A new prescription from the pharmacy has been ordered. |
12/31/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. Their record did not include medication reviews by a licensed physician for the following periods of time: October 2023 to April 2024 and June 2024 to September 2024. Additionally, the medication review completed on 5/28/24, did not identify the actual medications reviewed or the need to continue them. | 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. | Residential homes managers were all retrained on the regulations pertaining to medication reviews and needed information. |
12/31/2024
| Implemented |
| 6400.166(a)(4) | On 9/26/24, Individual #1's prescribed pro re nata medication, Children's Acetaminophen 160 mg per 5 ml---Take 5 ml by mouth every 4-6 hours as needed---was found at the home but was not recorded on their September 2024 Medication Administration Record, as the following element was missing: the name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(5) | On 9/26/24, Individual #1's prescribed pro re nata medication, Children's Acetaminophen 160 mg per 5 ml---Take 5 ml by mouth every 4-6 hours as needed. (Medication label does not have a purpose)---was found at the home but was not recorded on their September 2024 Medication Administration Record, as the following element was missing: strength of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(7) | On 9/26/24, Individual #1's prescribed pro re nata medication, Children's Acetaminophen 160 mg per 5 ml---Take 5 ml by mouth every 4-6 hours as needed---was found at the home but was not recorded on their September 2024 Medication Administration Record, as the following element was missing: the dose of medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(8) | On 9/26/24, Individual #1's prescribed pro re nata medication, Children's Acetaminophen 160 mg per 5 ml---Take 5 ml by mouth every 4-6 hours as needed---was found at the home but was not recorded on their September 2024 Medication Administration Record, as the following element was missing: the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(9) | On 9/26/24, Individual #1's prescribed pro re nata medication, Children's Acetaminophen 160 mg per 5 ml---Take 5 ml by mouth every 4-6 hours as needed---was found at the home but was not recorded on their September 2024 Medication Administration Record, as the following element was missing: the frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(11) | On 9/26/24, Individual #1's prescribed pro re nata medication, Children's Acetaminophen 160 mg per 5 ml---Take 5 ml by mouth every 4-6 hours as needed---was found at the home but was not recorded on their September 2024 Medication Administration Record, as the following element was missing: the diagnosis or purpose for the medication. | 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. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(b) | On 9/26/24, Individual #1's September 2024 Medication Administration Record revealed that the following prescribed medications were not signed off as being administered at 8 PM on 9/1/24, 9/6/24, 09/15/24, and 9/19/24: A + D Ointment, Medihoney 100% Paste, Enalapril Maleate 5 mg Tab, Gavilax Powder 17 grams, Quetiapine Fumarate 25 mg tab, and Senna 8.8 mg/ 5 ml Liquid. Additionally, Individual #1's prescribed, Levofloxacin 500 mg Tab which was not signed off as being administered on 9/15/24. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Program specialist reviewed the MAR and the blister pack and determined that this was documentation error. Program specialists determined that medication was given correctly. |
12/31/2024
| Implemented |
| 6400.207(5)(III) | On 9/26/24, one bed rail was observed on the left, front-half portion of Individual #1's bed while the right side was situated tightly against the wall, thus, restricting the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bed rail. Direct Support Professional #2 stated that Individual #1 cannot remove the bedrail. Moreover, Individual #1's most current assessment, completed on 9/11/24, does not address if they can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by Individual #1. Additionally, their individual plan, last updated on 6/18/24, indicates that they utilize a hospital bed, does not include the use of bedrails and 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. | Residential homes manager is working with the primary care doctor to get a copy of orders for the bed rails. |
12/31/2024
| Implemented |