Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232945 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace in the home was inspected and cleaned on 08/11/23, but no other documentation of another cleaning and inspection was provided to be able to measure compliance with the regulation.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. Provider has entered a contract with Fazio Heating and Cooling to provide annual furnace inspections to maintain compliance. 10/27/2023 Implemented
6400.112(h)The fire drills completed for October of 2022 through September 2023 did not list the designated meeting place for the individuals to evacuate to as required by this regulation. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Provider's fire drill form has been revised to include a designated meeting place on the form. The form indicates that a location needs to be circled as mailbox or end of driveway depending on the protocol for each location. 10/27/2023 Implemented
SIN-00213558 Renewal 10/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Cleaning products were unlocked and accessible in the cabinet under the kitchen sink. Individual #1's individual plan last updated, 5/26/22, states that cleaning products are kept locked.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials were locked up and or made inaccessible to individuals in the 284 Bruceton site. Residential House Managers and Program Specialists will review ISP and Assessments to ensure correlation. They will sign off that they have read both ISP and Assessments once every three months. Program Specialists will attend an Assessment Training with the Program Director on 11/9/2022. The Assessment meeting and training will cover the following PROGRAM SPECIALIST ASSESSMENT MEETING AGENDA DATE OF MEETING: 11/9/22 ¿ BIG IDEA BEHIND THE ASSESSMENTS o WHO THEY ARE FOR: ¿ PARTICIPANTS ¿ STAFF ¿ SC ¿ FAMILIES AND OTHER TEAM MEMBERS o WHY THEY ARE DONE ¿ GOALS ¿ SUPPORTS THAT ARE REQUIRED/ RECOMMENDED o WHEN THEY ARE DONE ¿ WHO SHOULD BE INVOLVED ¿ PROVIDING COPIES o RECOMMENDATIONS ¿ AUDITS o CHECKING FOR ACCURACY The Programs Specialists will complete an ISP training through ODP by 11/15/2022. 11/18/2022 Implemented
6400.66The light outside the basement exit underneath the back deck of the home is inoperable. There was no other source of lighting in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Residential House Manager was able to submit a maintenance ticket for the light fixture to be fixed. The light fixture was fixed. 11/11/2022 Implemented
6400.112(c)The written fire drill records for the fire drills conducted on 7/24/2022 and 8/22/2022 did not document the amount of time it took for evacuation. [Repeat Violation, 11/19/2021]A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Program Specialists have been appointed the point people for Fire Drills. The Program Specialists will ensure fire drills are conducted and the paperwork is completed in it's entirety. In total we will conduct at least four fire drills within this POC (12/15/2022) to ensure the residents are aware of what to do at this site. The Program Specialists will check the paperwork from the drill within 48 hours to ensure details of the fire drill are being documented. Quality and Compliance Coordinator will attend the 284 Bruceton House meeting on 11/8/2022 at 4:30pm and review the regulation (a) An unannounced fire drill shall be held at least once a month. (b) Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. (c) A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. (d) 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 employee 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. (e) A fire drill shall be held during sleeping hours at least every 6 months. (f) Alternate exit routes shall be used during fire drills. (g) Fire drills shall be held on different days of the week and at different times of the day and night. (h) Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. (i) A fire alarm or smoke detector shall be set off during each fire drill. 55 Pa. Code § 6400.112 All staff will sign off on this at the meeting on 11/8/2022 at 4:30pm. 12/22/2022 Implemented
6400.181(e)(12)Individual #1's assessment, completed on 1/7/22 did not include recommendations.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program Director and Assistant will assist the Program Specialists in completing the initial Assessment by 12/1/2022 this Program Specialists will be retrained on Assessments on 11/9/2022. The assessment training will cover the following.... PROGRAM SPECIALIST ASSESSMENT MEETING AGENDA DATE OF MEETING: 11/9/22 ¿ BIG IDEA BEHIND THE ASSESSMENTS o WHO THEY ARE FOR: ¿ PARTICIPANTS ¿ STAFF ¿ SC ¿ FAMILIES AND OTHER TEAM MEMBERS o WHY THEY ARE DONE ¿ GOALS ¿ SUPPORTS THAT ARE REQUIRED/ RECOMMENDED o WHEN THEY ARE DONE ¿ WHO SHOULD BE INVOLVED ¿ PROVIDING COPIES o RECOMMENDATIONS ¿ AUDITS o CHECKING FOR ACCURACY 12/01/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 4.29/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Old versions of the self-assessment tool were shredded and discarded. Staff were asked to complete the self-assessment on the correct version this will be completed by 11/22/2022 The correct version of the Self Assessment Tool was sought out by new Quality and Compliance Coordinator and supplied by inspector. All expired versions of the Self Assessment Tools were erased off the internal databases by Quality and Compliance Coordinator. Updated version was placed on internal site by direction of IT. 11/22/2022 Implemented
6400.44(b)(1)Individual #1's assessment, completed 1/7/22, indicates on page 9 that Individual #1 safely uses or avoids poisonous materials independently and on page 10 indicates that Individual #1 requires physical assistance to use and store cleaning products safely and appropriately.The program specialist shall be responsible for the following: Coordinating the completion of assessments.The Program Specialists will create an addendum to the assessment with the correct information after attending an Assessment Training by the Program Director on 11/9/2022. The Program Specialists will also complete a training through ODP on ISP's by 11/15/2022. 11/15/2022 Implemented
6400.165(b)Individual #1's prescribed medication, Calcium Chewable tablets, was not present at the home.A prescription order shall be kept current.The Residential House Manager and Program Director were able to order medication to have on hand at the site on 10/20/2022. 12/19/2022 Implemented
6400.165(g)A psychiatric medication completed 9/15/22 for Individual #1 did not include the need to continue prescribed medications. [Repeat Violation, 11/19/2021]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.The Program Specialist has been in contact with the physician that was able to continue the prescription and order for medication. 12/19/2022 Implemented
6400.166(a)(11)Individual #1's October 2022 Medication Administration Record does not include the diagnosis or purpose for Kurvelo, Calcium tablets and Vitamin D3 tablets.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.The MAR has been corrected by the Residential House Manager on the date of the inspection 10/20/2022. 12/19/2022 Implemented
6400.166(b)Individual #1 is prescribed Clonzaepam 1mg Tab with instructions to take 1 tablet by mouth twice daily. This medication was not initialed as administered on 10/5/2022 at 9PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The controlled count was checked by the Residential House Manager and Program Director. It was deemed the medication was given and not signed for. This is a medication documentation error that will be addressed in a full medication training. All direct care staff, residential House Manager, Assistant Program Director and Program Specialists will be retrained in Medication Administration by 12/19/2022. 12/19/2022 Implemented
SIN-00180328 Renewal 12/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned by a professional cleaning company on 8/24/18 and then again on 11/27/19.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 Facilities Director is responsible for coordinating all annual inspections. He indicated that due to COVID restrictions it was difficult to get the company to complete them. A checklist system is in place so that the Quality and Compliance Coordinator will send a notice at least three months in advance to the Facilities Director to have the inspections scheduled. The Quality and Compliance Coordinator will also send a two month and one month warning. All updated inspections were completed on January 11, 2021 and January 12, 2021. Copies will be emailed as proof. The Facilities Director and the Senior Residential Homes Coordinators were trained by the Quality and Compliance Coordinator about the regulation and the new tracking system. 01/12/2021 Implemented
6400.166(a)(7)Individual #1's December 2020 medication administration record did not include the dose of the medication for Aubagio, (teriflunomide).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The staff, Residential Homes Manager and Program Specialists were retrained, by the Quality and Compliance Coordinator, on the MAR and what it needs to contain. The MAR for December was corrected that day and the current MAR for January 2021 contains all of the necessary information including dose of medication, route, frequency, diagnosis or purpose. A copy of the January 2021 MAR indicating the correction will be sent. [At least monthly, a designated staff person certified to administer medication shall audit all individuals' medication administration records, medications with labels and physicians' orders to ensure all individuals are administered medications as prescribed and medication administration are documented as required and medications administration records are accurate with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/21)] 01/14/2021 Implemented
6400.166(a)(8)Individual #1's December 2020 medication administration record did not include the route of the medication for Aubagio, (teriflunomide).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The staff, Residential Homes Manager and Program Specialists were retrained, by the Quality and Compliance Coordinator, on the MAR and what it needs to contain. The MAR for December was corrected that day and the current MAR for January 2021 contains all of the necessary information including dose of medication, route, frequency, diagnosis or purpose. A copy of the January 2021 MAR indicating the correction will be sent.[At least monthly, a designated staff person certified to administer medication shall audit all individuals' medication administration records, medications with labels and physicians' orders to ensure all individuals are administered medications as prescribed and medication administration are documented as required and medications administration records are accurate with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/21)] 01/14/2021 Implemented
6400.166(a)(9)Individual #1's December 2020 medication administration record did not include the frequency of administration of the medication for Aubagio, (teriflunomide).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The staff, Residential Homes Manager and Program Specialists were retrained, by the Quality and Compliance Coordinator, on the MAR and what it needs to contain. The MAR for December was corrected that day and the current MAR for January 2021 contains all of the necessary information including dose of medication, route, frequency, diagnosis or purpose. A copy of the January 2021 MAR indicating the correction will be sent.[At least monthly, a designated staff person certified to administer medication shall audit all individuals' medication administration records, medications with labels and physicians' orders to ensure all individuals are administered medications as prescribed and medication administration are documented as required and medications administration records are accurate with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/21)] 01/14/2021 Implemented
6400.166(a)(11)Individual #1's December 2020 mediation administration record did not include the diagnosis or purpose of the medication for Aubagio, (teriflunomide), Omega-3; Vitamin B-2 (Riboflavin)' Vitamin B-12 (cyanocobalamin), Vitamin C (Ascorbic Acid), Vitamin D3 (cholecalciferol) and Melatonin.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.The staff, Residential Homes Manager and Program Specialists were retrained, by the Quality and Compliance Coordinator, on the MAR and what it needs to contain. The MAR for December was corrected that day and the current MAR for January 2021 contains all of the necessary information including dose of medication, route, frequency, diagnosis or purpose. A copy of the January 2021 MAR indicating the correction will be sent.[At least monthly, a designated staff person certified to administer medication shall audit all individuals' medication administration records, medications with labels and physicians' orders to ensure all individuals are administered medications as prescribed and medication administration are documented as required and medications administration records are accurate with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/21)] 01/14/2021 Implemented
SIN-00140422 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(7)Individual #1's assessment, dated 5/1/18, does not assess the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. This section of the assessment states "N/A."The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. The assessment tool will be revised by the Training Coordinator to include heat sources other than water which can be over 120 degrees. The revised tool will be used then by the Program Specialists effective immediately when completing assessments on all individuals served by CLASS. This revised tool will be sent to the licensing office as part of the plan of correction by the Quality Compliance and Privacy Officer. [Immediately, the program specialist(s) shall update individual #1's assessment to include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated and audit all individuals' current assessment and update as needed to include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of all individuals' assessment to ensure all required information is included in individuals' assessments. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] 09/27/2018 Implemented
6400.186(d)The Program Specialist provided Individual #1's ISP review, completed 9/8/17, 12/8/17 and 3/8/18 to the plan team members on 4/30/18. The Program Specialist did not provide Individual #1's ISP review, completed 6/8/18, to the plan team members. [Repeat Violation 9/12/18, et. al.]The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Training Coordinator will retrain both Program Specialists regarding this responsibility as well as the others in this job category. In addition, the Quality Compliance and Privacy Officer will conduct periodic audits (every 6 months) of the individuals' ISP activity and documentation completion. [Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] 10/01/2018 Implemented
SIN-00121260 Renewal 09/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 9/13/17, at 12:30PM, the hot water temperature measured 129°F in the shower in hallway bathroom. (Repeated Violation 9/23/16 et al) Hot water temperatures in bathtubs and showers may not exceed 120°F. The Quality Compliance and Privacy Officer ordered Extech Waterproof Pocket thermometers to be used by CLASS personnel in the measuring of the home(s) water temperature throughout the year to insure compliance of the 120 degree maximum temperature mandate. [The Residential Homes Assistant adjusted the hot water temperature on 9/13/17. On 10/4/17, the Residential Homes Specialist measured the hot water temperature which measured 120°F. At least weekly until the hot water temperature does not exceed 120°F for at least one month and then continuing at least monthly, the hot water temperature at all bathtubs and showers shall be measured to ensure the hot water temperatures in bathtubs and showers does not exceed 120°F. Documentation of all measurements shall be kept. (AS 10/4/17)] 10/20/2017 Implemented