Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00207185 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 4/5/22 at 3PM did not include the exit route/egress used as this section on the form was left blank.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. UCCH provider reviewed the fire drill forms, the exit route was not documented. The residential supervisor shall make sure all fire drills forms are completed thoroughly. The exit route shall be documented on all fire drill forms completed per regulation 6400.112(c). 02/10/2023 Implemented
6400.141(a)An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #2 had a physical examination on 5/11/21 and the Physician noted on the form exam 5/11/21 and signed the form with the date 10/27/21. Individual #2's next physical examination was dated 6/6/22 but the Doctor didn't date the form until 6/13/22. This exceeds the requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The PCP does not complete form the same day the individual was seen rather completes the form when the doctor's gets the chance to do so. The CEO followed up and proceeded to let them know the corrections that needed to be made moving forward, which was to make sure the physician sign and date the form the same day the individual was seen at the provider's office. 02/10/2023 Implemented
SIN-00197759 Renewal 02/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Individual #1's bathroom contained a bottle that was labeled in handwriting, JoJo Siwa shampoo and conditioner. This shampoo and conditioner was not stored in it's original, labeled container.Poisonous materials shall be stored in their original, labeled containers. The bottle containing Jojo Siwa shampoo and conditioner that was labeled with ink by staff has been removed from the individual's bathroom and thrown away immediately. Staff has been trained on this area; they shall leave all contents in its original container which will have the original label that can be read with instructions. 02/08/2022 Implemented
6400.64(a)The vent in Individual #1's bathroom and the vent in the living room were covered in a significant layer of dust.Clean and sanitary conditions shall be maintained in the home. The vent in the individual's bathroom and the vent in the living area was cleaned immediately by residential staff. The house supervisor shall make sure that the house cleaning checklist is completed on all shifts which includes the sanitary conditions of the home. The apartment management team has been notified and will be reminded of the monthly cleaning of all the vents in the home. 02/08/2022 Implemented
6400.67(b)The closet in Individual #2's bedroom contained sliding glass doors that were removed from the individual's shower. The sliding glass doors were propped in the closet to be stored, presenting a hazard if they were to fall or to be pulled out by the individual. Floors, walls, ceilings and other surfaces shall be free of hazards.Individual has 2 closet spaces. Individual shower sliding glass door is stored in one of his closets. In order to prevent a hazard, A key lock was purchased immediately, and the closet door shall remain locked at all times and made inaccessible to the individual to ensure his safety. The Walkin closet (2nd closet space) will be unlocked and shall be accessible to the individual. 02/08/2022 Implemented
6400.144Individual #1 is prescribed Abreva 10% cream, apply 1 appl. Topically to lip as needed. This medication is documented on the Medication Administration Record, however the medication is not available in the home.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. Individual was prescribed Abreva 10% cream to be applied topically to the lip and the same Abreva 10% was prescribed to be applied topically to the mouth by the same physician. The program specialist followed up with the pharmacy to obtained Abreva 10% cream to be applied topically to the lip as stated in the MAR, pharmacy stated no refills on the ointment. PCP discontinued both and prescribed Abreva 10%, apply on affected area as needed. DSPs shall do their medication checks at the start of their shift and report any medication/documentation errors to their direct supervisor. Cycle medications shall continue to be checked by management on-call before it goes into the homes. 02/24/2022 Implemented
SIN-00187562 Unannounced Monitoring 04/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186Individual #1 ISP reflects she does not require a restricted diet, however she does require assistance in choosing healthy options for meals. The ISP reflects that Individual #1 and her staff will work on meal planning, shopping and prepping together. Healthy meal and snack options will be presented to individual and the importance of nutrition will be explained. The staff will ensure that her portion sizes are appropriate and that she is not eating too much too often. With the admittance of the overnight staff #1 (SQ) he would allow individual #1 out after her bedtime to have drinks and snacks which would be candy at times, therefore not following the individual's support plan as written.The home shall implement the individual plan, including revisions.Individual create weekly meal plan with partial guidance from staff. Staff gives the individual options of healthy meals to choose from as well as educating them during the process. It was founded that Staff SQ bring candies from home and offers to individual when she wakes up in the middle of the night in order to get her back to bed. Staff SQ has been re-trained on the process of what actions to conduct when an individual wakes up in the middle of the night asking for unhealthy food, this includes reviewing the individual meal plan with the individual and appropriate times for snacks, also review the effective practices to utilized in order to help the individual go back to bed. Staff SQ was also instructed to completed a Nutritional training from HCQU (online). Program director also emphasized consistence among staff in order to support the individual appropriately according to their meal plan. 05/27/2021 Implemented
SIN-00183661 Renewal 02/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff 1's date of hire was November 1,2020. Staff 1 did not have a Pennsylvania State Police Criminal background check completed within 5 working days of hire. The Pennsylvania State Police Criminal background check was not completed until January 31, 2021.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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.UCCH got her first individual on 8/17/2021, all focus was on this individual. UCCH completed FBI Fingerprint Check on staff. UCCH thought employees who does FBI Fingerprint clearance would not need to complete PA police criminal background check. UCCH re-read the 6400 regulations and the agency policies regarding Criminal background checks with the assistance of the CEO, and all employees PA police criminal background check were completed on 1/31/2021. 04/19/2021 Implemented
6400.112(d)Individual 1 did not evacuate the home in 2.5 minutes or less as required during fire drills. During the November 11, 2020 fire drill, Individual 1 took 2 min 45 sec to evacuate the home; during the December 12, 2020 fire drill, Individual 1 took 3 minutes to evacuate the home; during the December 16, 2020 fire drill, Individual 1 refused to evacuate the home; December 20, 2020 fire drill, Individual 1 refused to evacuate after 3min 30sec. During the January 3, 2021 fire drill, Individual 1 took 3 min 20 sec. to evacuate the home; during the January 13, 2021 fire drill, Individual 1 refused to evacuate the home; during the January 19, 20201, Individual 1 took 3 minutes to evacuate the home; January 26, 2021 fire drill, Individual 1 took 3 minutes to evacuate the home. During all drills, verbal and physical prompts were utilized. Individual 1 has a desensitization plan to address his refusal to evacuate during fire drills. Individual 1 did evacuate the home during the allotted 2 min 30 sec on October 25, 2020, November 27, 2020 and February 15, 2021.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.UCCH behavioral specialist was able to develop a desensitization plan to address individual's refusal to evacuate his residence during fire drills. Staff go over educational plan developed by the BS, play fire safety videos to educate individual on the importance of fire drills. Individuals gets trained on this process weekly. In case of actual fire, fire department has been contacted and given appropriate information regarding the said Individual. Staff has also been trained on how to use his wheelchair for evacuation during an actual fire incase the individual refuses to evacuate. 04/19/2021 Implemented
6400.15(b)LII was completed on 8/31/2020 on an old document that does not include all components of the Chapter 6400 regulations.(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.The self assessment of the home has been completed on the current department's licensing inspection form. The program specialist made sure that the agency has the correct and current version of the Department's licensing inspection instrument and completes a self-assessment 3 to 6 months before the expiration date of the agency's COC. 04/19/2021 Implemented
6400.32(r)(4)Individual 1 has a lock on his bedroom door, however the lock can only be opened through a pinhole with a device such as a paperclip small enough to place in the pinhole. Individual 1 does not have the ability to unlock this type of lock from outside of his bedroom. This type of lock would not be able to be opened quickly in the event of an emergency.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.The lock on the individual bedroom door has been changed to allow easy and immediate access by the individual and the staff person in case of an emergency. 02/27/2021 Implemented
6400.34(a)Individual 1 signed his rights statement on 10/25/20. Individual Rights have not been updated to reflect the current Chapter 6400 regulations. The missing rights include: 32k, 32p, 32q, 32s and 32t.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.UCCH has updated the individual rights to meet the 6400 regulations. The missing rights 32k, 32p,32q,32s and 32t has been included in order to be complaint and also have the home inform and explain the full individual rights to the individual. The program specialist will be responsible to make sure that the individual rights meets all requirements in the 6400 regulations. The update individual rights has been read to the individual and signed for as well. 04/19/2021 Implemented
6400.51(b)(3)Staff 1 completed Individual Rights training on November 13, 2020 during her orientation training. Individual Rights have not been updated to reflect the current Chapter 6400 regulations. The missing rights include: 32k, 32p, 32q, 32s and 32t.The orientation must encompass the following areas: Individual rights.UCCH has updated the individual rights to meet the 6400 regulations. The missing rights 32k, 32p,32q,32s and 32t has been included in order to be complaint and also have the home inform and explain the full individual rights to the individual. The program specialist will be responsible to make sure that the individual rights meets all requirements in the 6400 regulations. The program specialist will train the staff on Individual rights. 04/19/2021 Implemented
SIN-00174948 Initial review 09/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature measured 128.6 degrees Fahrenheit in the bathroom located off the bedroom on the right side of the apartment. The provider contacted the apartment complex maintenance department and the water temperature was turned down to 115.0 degrees Fahrenheit at the time of inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. A new water heater was installed in the apartment (a new building in the apartment complex) the apartment maintenance department did not know the maximum allowable water temperature, and this was not checked prior to inspection. On September 10, 2020, during the inspection, UCCH provider contacted the apartment complex maintenance department, all faucets were drained and water temperature was turned down to 115 degree Fahrenheit. House Managers and Real Property staff shall conduct random water temperature checks to ensure it does not exceed 120 degrees every month. All United Care Community Homes must have thermometer for checking water temperature in the homes. 09/10/2020 Implemented
6400.111(c)The fire extinguisher located in the kitchen, which also serves as the extinguisher for the one-floor apartment, did not meet the minimum rating required by regulation: the fire extinguisher was rated 1A-10BC. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). UCCH staff was misinformed and got 1A-10-B:C fire extinguisher which was less than the minimum rating required by regulation. On 9/10/20, after the inspection, UCCH provider purchase and certified 3-A:40-B:C from Kistler O'Brien. Each month, on a rotation basis (set up by the House Manager) staff will conduct fire drills in all UCCH homes and all fire extinguishers in all UCCH homes will be checked. Every 12 months (annually), Fire extinguishers shall be inspected and maintained by Kistler O'Brien and the date of inspection shall be on the fire extinguisher, this shall be supervised by the House Managers to make sure it functioning and meets regulation requirements at all times. Photos of fire extinguisher sent vis email to KF. 09/10/2020 Implemented
SIN-00235585 Renewal 01/17/2024 Compliant - Finalized