| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of inspection, the rear porch light could not be made to function. There was no other lighting in the rear of the home to provide illumination during darkened conditions. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Provider has contacted electrician and will be installing a new light in the rear of the home. Light will provide better illumination for staff and clients. Staff will monitor this light to make sure it is in good working order at all times. |
10/05/2025
| Implemented |
| 6400.112(h) | The fire drills for this location did not note whether all of the individuals residing in the home evacuated to the designated meeting area outside of the home. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program Manager's and DSP's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (h). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. All employees and consumers will be trained on meeting places for their respective sites. |
10/05/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent Physical Examination, dated 04/30/2025, did not contain medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Information was requested from PCP as an addendum to the physical. Staff was trained in the aforementioned regulation to ensure that proper information is collected moving forward. Staff will advocate at appointment to ensure all forms are filled out to meet regulatory requirement. |
10/05/2025
| Implemented |
| 6400.144 | Per Individual #1's September 2025 Medication Administration Record (MAR), the individual was prescribed Pro Re Nata (PRN) Geri-tussin Syrup DM ("Take 2 teaspoonfuls (10ml) by mouth every 6 hours as needed for cough"). This medication could not be located within the home at the time of inspection. As this prescribed medication was unavailable for the individual to use PRN, the provider failed to arrange pharmaceutical services for the individual as required. | 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.
| IHRS contacted PCP for new order and prescription was delivered to the home. |
10/05/2025
| Implemented |
| 6400.46(d) | Staff #1's two most recent training courses in first aid and cardiopulmonary resuscitation occurred on 10/07/2022 and 12/12/2024. These trainings did not occur annually and exceeded the Red Cross' alternative two-year renewal period. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | IHRS had previously issued discipline to the aforementioned staff for not meeting regulatory requirements with training. Training policy was enforced. |
10/05/2025
| Implemented |
| 6400.52(c)(1) | Per the staff training record, Staff #2 did not receive training in the following area(s) during the 2024 training year: application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Training was assigned to staff #2 and completed. |
10/05/2025
| Implemented |
| 6400.52(c)(2) | Per the staff training record, Staff #2 did not receive training in the following area(s) during the 2024 training year: 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. | 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. | Training was assigned to staff #2 and completed. |
10/05/2025
| Implemented |
| 6400.52(c)(4) | Per the staff training record, Staff #2 did not receive training in the following area(s) during the 2024 training year: Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Training was assigned to staff #2 and completed. |
10/05/2025
| Implemented |