Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290983 Renewal 06/16/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)On 6/17/26 at 9:45am there was no hand soap located in the downstairs bathroom of the home.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. FreePath Solutions conducted a review of the circumstances surrounding this finding and determined that the organization maintained a process for ordering and replenishing household supplies through an electronic purchasing request system and routine staff walkthroughs. However, the process did not include a standardized point-of-use verification to ensure that required hygiene supplies remained available in bathrooms throughout the day. The organization also recognized that this residence supports an individual with a history of self-harm, requiring staff to balance environmental safety considerations with ensuring required hygiene items remain accessible. Although routine walkthroughs were completed, the absence of a designated verification for required bathroom supplies allowed the missing hand soap dispenser to go unnoticed prior to the licensing inspection. During the licensing inspection, a hand soap dispenser was placed in the downstairs bathroom. Prior to submission of this Plan of Correction, the Operations Manager will inspect every licensed residential location to verify that each bathroom contains all required items, including a functioning sink, wall mirror, hand soap, toilet paper, individual paper or cloth towels, and a trash receptacle. Any deficiencies identified during this review will be corrected immediately. 09/30/2026 Implemented
6400.101On 6/17/26 at 10:14 am the "coal storage area" located in the basement had a hook and eye lock with no swinging hinged door for an exit, causing a blocked egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. FreePath Solutions conducted a review of the circumstances surrounding this finding and determined that the former coal storage room was no longer utilized for program operations and had historically remained an unused building area. The entrance to the former coal room was secured with a hook-and-eye latch to keep the unused space closed and, because the area was not considered an occupiable space, staff did not identify the door hardware as a potential life safety concern during routine environmental inspections. Leadership determined that the organization's environmental review process did not include a structured evaluation of unused building areas and associated door hardware from a life safety and regulatory compliance perspective. Immediately following the licensing inspection, FreePath Solutions evaluated the former coal storage area and determined that the space was not utilized for residential operations and served no programmatic purpose. Because the area does not provide the required clearance to accommodate a code-compliant swinging hinged exit door, the organization elected to permanently eliminate access to the former coal storage area from within the residence. The interior entrance was permanently sealed, eliminating access to the area and removing the cited condition. Leadership also completed a review of all licensed residences and verified that no similar conditions existed elsewhere within the organization. 09/30/2026 Implemented
6400.111(f)On 6/17/26 at 10:13am the fire extinguisher located in the basement of the home was most recently inspected on 2/2025. This exceeds the annual requirement. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. FreePath Solutions conducted a process analysis and determined that, although annual fire extinguisher inspections were assigned to a contracted fire safety vendor and maintained within an internal tracking spreadsheet, the organization did not have an asset-specific inventory identifying the location and inspection status of each individual fire extinguisher. In addition, supervisory verification of inspection due dates was not incorporated into an ongoing environmental safety review process. These process gaps reduced the organization's ability to proactively identify overdue inspections prior to the licensing inspection. Immediately following the licensing inspection, the identified fire extinguisher was replaced with a currently inspected fire extinguisher. Prior to submission of this Plan of Correction, the Operations Manager will conduct a comprehensive inspection of all licensed residential locations to verify that all required fire extinguishers are present, properly located, and display current annual inspection tags. Any deficiencies identified during this review will be corrected immediately. 09/30/2026 Implemented
6400.142(g)Individual #1's assessment completed on 6/18/25 indicates the individual's "hygiene needs more prompting than before." Individual #1 had a dentist appointment on 4/14/26 that indicates the individual needs cleaning every three months due to ongoing gingivitis and poor oral hygiene. The individual had no dental hygiene plan.A dental hygiene plan shall be rewritten at least annually. FreePath Solutions conducted a review of its clinical documentation process and determined that information obtained during medical and dental appointments was appropriately documented within the individual's medical record; however, the organization did not have a standardized clinical follow-up process to ensure that significant provider recommendations were consistently evaluated for required updates to supporting documentation, including Dental Hygiene Plans. Responsibilities for documenting appointments, maintaining medical records, and updating assessments were assigned to different positions, but the process did not include a formal review to ensure clinically significant recommendations were communicated to the Program Specialist for incorporation into the individual's assessment. Leadership also identified that several employees were newly assigned to their positions and required additional role-specific training regarding interdisciplinary communication and documentation responsibilities. Immediately following the licensing inspection, the individual's dental records, assessment, and provider recommendations were reviewed. A Dental Hygiene Plan was developed to address the individual's current support needs, including increased staff prompting and the dentist's recommendation for professional cleanings every three months due to ongoing gingivitis and poor oral hygiene. The Program Specialist completed an addendum to the individual's assessment to ensure it accurately reflected the individual's current dental support needs. 09/30/2026 Implemented
6400.46(b)Direct Service Worker # 2 most recently completely fire safety training on 3/17/25. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).FreePath Solutions conducted a review of its annual training process and determined that required training was assigned through the College of Direct Support learning management system; however, the organization no longer maintained a centralized management tracking process to monitor annual training completion and expiration dates. Leadership determined that while required training assignments remained in place, the removal of the master training tracking system reduced management's ability to proactively identify overdue annual training requirements before expiration. The organization further determined that strengthening leadership oversight of mandatory training compliance would provide a more reliable process for maintaining regulatory requirements. Immediately following the licensing inspection, FreePath Solutions verified the employee's current training status and ensured the required Fire Safety training was completed. Leadership also is working on initiation of the redevelopment of a centralized training compliance tracking system to monitor mandatory annual training requirements, identify upcoming expirations, and provide proactive oversight of staff training compliance. 09/30/2026 Implemented
6400.52(c)(6)Direct Service Worker #1 did not have the required annual Individual Service Training for Individual #1 for the training calendar year dated 1/1/2025 through and including 12/31/2025. Direct Service Training #2 did not have the required annual Individual Service Training for Individual #1 for the training calendar year dated 1/1/2025 through and including 12/31/2025.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.FreePath Solutions reviewed its individual-specific training process and determined that employees received orientation to the individual's ISP upon hire and were expected to review the individual's record prior to providing supports. However, the organization did not maintain a standardized competency verification process documenting that staff had demonstrated understanding of the individual's current ISP, assessment, and support needs following initial orientation or subsequent revisions. Leadership further determined that updates to individual support documentation were not consistently accompanied by a structured communication and competency verification process for employees assigned to provide services. Immediately following the licensing inspection, FreePath Solutions reviewed the employee training records for staff assigned to support Individual #1 and identified those requiring annual individual-specific training. The Program Specialist initiated completion of the required individual-specific training for affected employees and began redevelopment of the agency's individual-specific training process to include documented competency verification and centralized tracking. Leadership also reviewed the current Connecteam training capabilities to support implementation of the revised process. 09/30/2026 Implemented
6400.165(g)Individual #1 had a documented psychotropic medication review on 6/18/25, and then again on 11/12/25. This exceeds the every 3-month requirement.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.FreePath Solutions conducted a review of its medical documentation process and determined that although medical appointments were tracked and staff completed the agency's medical appointment summary following appointments, the organization did not have a standardized process to immediately preserve and verify receipt of physician documentation containing all regulatory requirements for psychotropic medication reviews. The physician documentation associated with the appointment could not be located within the individual's medical record during a records audit. Leadership determined that the organization's document handling process relied upon paper records moving through an internal distribution process before being incorporated into the individual's record, creating the potential for critical clinical documentation to become unavailable. Additionally, the organization recognized the need to strengthen oversight of time-sensitive clinical documentation to ensure required physician documentation is received, maintained, and readily available for review. Immediately upon identifying the missing physician documentation, FreePath Solutions contacted the prescribing physician's office to request replacement documentation and to date still hasn't received requested documentation. The organization was advised that archived medical records were maintained through an external records vendor, resulting in delays in obtaining the requested documentation. While awaiting replacement records, leadership reviewed the agency's document management process and implemented an immediate procedure requiring staff accompanying individuals to medical appointments to electronically scan all provider documentation using Adobe Scan before documents enter the agency's internal distribution process. The Medical Coordinator now reviews all scanned documentation for completeness, combines the physician documentation with the agency's medical appointment summary, and uploads the complete record to the individual's electronic chart. 09/30/2026 Implemented
SIN-00283916 Unannounced Monitoring 02/25/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The patio light was not working during the physical site walk through.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. . WHO is responsible for correcting the problem · Direct Support Professionals (DSPs) and house supervisor: Responsible for reporting any non functioning interior or exterior lighting immediately and submits maintenance work orders · Maintenance Department: Responsible for diagnosing the lighting issue and completing necessary repairs or replacements promptly. b. WHAT will be corrected · The patio light fixture was repaired to restore full illumination to the patio and the exterior doorway. · All exterior lights around the home will be checked to ensure no additional outages exist. c. WHEN & HOW · Immediate Correction Completed: The lightbulb was replaced on the day of the inspection in the light fixture. · Permanent Correction: Retraining on timely maintenance request submissions. Ensuring staff are checking all entrances and exits during all shifts to ensure that the exterior lights are working properly. · Procedure: 1. DSPs complete shift based checks of all exterior lighting. 2. Any outage is reported immediately via maintenance request. 3. Maintenance completes repair in a timely manner. 04/06/2026 Implemented
SIN-00270295 Renewal 07/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Program Specialist #1 had a physical examination conducted on 10/18/22 and then again on 12/09/24. This exceeds the every 2-year requirement. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 6400.151(a) - A staff person who comes into direct contact with the individuals or who prepares or serves food for more than 5 days in a 6-month period, including temporary, substitute, and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. This regulation ensures that all staff, regardless of work arrangements, are medically fit to support individuals in licensed settings. Physical exams serve as a safeguard¿identifying health conditions that could impact staff safety, service quality, or the well-being of those they serve. During inspection, it was identified that a Program Specialist¿s physical examination exceeded the required two-year timeframe, resulting in a violation of § 6400.151(a). A root cause analysis revealed that the Program Specialist previously worked there as residential staff and then came back to work in a remote scheduling position, and the team erroneously assumed that the physical exam requirement applied primarily to in-person staff. This oversight led to the lapse in file compliance as the Specialist did not get the next physical until they returned to in person work. All remote employees will be notified to schedule a physical exam. All managers will be retrained on the requirements of § 6400.151(a), including the mandate that all staff¿remote or on-site¿must maintain up-to-date physical examinations. This plan of correction will be implemented by August 31, 2025. 08/31/2025 Implemented
SIN-00249492 Renewal 08/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Support Professional #1, date of hire 06/24/24, had a Pennsylvania State Police criminal background check completed on 08/06/24. This exceeds within 5 working days after the person's date of hire.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. This plan ensures immediate correction of the onboarding issue and establishes procedures to prevent future occurrences through updated practices, staff training, and regular monitoring. Compliance will be maintained by implementing and adhering to the new process for criminal background checks. 09/02/2024 Implemented
6400.165(g)Individual #1 is prescribed psychiatric medications to treat symptoms of mental illness. A psychiatric medication review was completed on 11/01/23 and then again on 03/05/24. There have not been any other psychiatric medication reviews since 03/05/24. This exceeds the at least every 3-month requirement.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.This plan ensures that medication reviews are conducted as required and establishes procedures to prevent future non-compliance through updated practices, staff training, and regular monitoring. 09/13/2024 Implemented
SIN-00237303 Unannounced Monitoring 01/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 11:43AM, the unoccupied bedroom on the second floor of the home had a multitude of items strewn throughout the floor. The items included but were not limited to piles of clothing, blankets, shoes, loose DVDs, and DVD cases, babydolls, a laundry basket and clothes hamper overflowing with what appeared to be soiled linens and soiled clothing, and an empty and a third full gallon containers of tea. At 11:45AM, upon entering Individual #1's bedroom there was a strong, overwhelming smell of urine. In addition, in Individual #1's bedroom, there was a multitude of items strewn throughout the floor. The items included but were not limited to piles of clothing, shoes, a plastic bottle containing a red liquid, an unsealed partially eaten bag of pepperoni, a partially used bottle of honey mustard, open boxes of Kodiak Crunchy and Nature Valley granola bars and an unsealed, partially eaten bag of Pepperidge Farm Goldfish crackers. Also, in Individual #1's bedroom, there were two plastic cups with lids and straws atop the dresser, the transparent pink cup contained a dark liquid with layer of an unidentifiable substance floating on top of the liquid.Clean and sanitary conditions shall be maintained in the home. 1. A plan to fix the immediate problem a. WHO: QLS Management and Staff b. WHAT: QLS staff will be responsible for ensuring the cleanliness and sanitation of the homes in which they work in. QLS management will be responsible for weekly home inspections. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 01/08/2024 Implemented
6400.77(b)At 11:32AM, the first aid kit in the kitchen of the home did not contain scissors or tweezers. 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. 1. A plan to fix the immediate problem a. WHO: QLS Management and Staff b. WHAT: QLS staff will be responsible for ensuring that all first aid kits are equipped and well maintained with the appropriate items. QLS management will be responsible for weekly home inspections, including a comprehensive inventory check of the first aid kits. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 01/08/2024 Implemented
6400.81(k)(2)At 11:45AM, the bed in Individual #1's bedroom did not have a solid foundation. The mattress was on top of a box spring that was directly on the floor.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. 1. A plan to fix the immediate problem a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring that all individuals beds remain clean, comfortable and sanitary as will as the foundation remains in good repair. QLS management will be responsible for weekly home inspections, including an inspection of the beds and mattresses for the individuals. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. QLS Maintenance will replace any mattresses that are stained, damaged, or no longer providing a comfortable sleeping surface. QLS Maintenance will repair or replace any foundations that are unstable or damaged. b. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections and reported to maintenance any repairs or replacements that are needed 01/08/2024 Implemented
SIN-00229826 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 9/06/2023, there was no lighting in the dining room.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. ¿ A plan to fix the immediate problem o WHO: QLS maintenance o WHAT: This room was originally lit with a lamp, QLS maintenance will install a lighting fixture in this room to ensure compliance. o WHEN and HOW: By 10/1/23 QLS maintenance will have installed a light fixture in the room that cannot be removed. 09/21/2023 Implemented
SIN-00292488 Unannounced Monitoring 07/22/2026 Compliant - Finalized
SIN-00211317 Renewal 09/13/2022 Compliant - Finalized
SIN-00195270 Renewal 10/21/2021 Compliant - Finalized
SIN-00178065 Renewal 10/21/2020 Compliant - Finalized
SIN-00158134 Renewal 06/27/2019 Compliant - Finalized