Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224340 Unannounced Monitoring 05/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There is a three-foot in diameter pool of water, on the floor near the furnace in the basement of the home, from what appears to be a leak from the furnace, posing a slipping and falling hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Heating and Cooling company was called immediately and air conditioner was repaired on May 16, 2023. Residential Manager will review the Inspection tool with the Team Leads to ensure their understanding of the Regulations, and Inspection Tool. 05/31/2023 Implemented
SIN-00215610 Renewal 11/17/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Individual #1's financial record as of 11/18/22 indicated a ledger balance of $80. On 11/18/22 at 10:45 AM, Individual #1's cash-on-hand totaled $30. Individual #'1's financial record was absent of any documentation to account for the difference. The agency receives funds from Individual #1's representative payee to use on Individual #1's behalf. Individual #1's assessment, completed 3/18/22 indicates Individual #1 is unable to manage finances. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Residential Manager went through all receipts and documented all deposits and expenses, that were not documented in the ledger. After all documentation was reviewed, a difference of $5.00 was found. KZL Agency reimbursed Individual #1 for the missing funds. 12/16/2022 Implemented
6400.62(a)At 10:03AM on 11/18/2022, the home's cleaners products were unlocked and accessible underneath the kitchen sink. Individual #1's 9/1/22 individual plan explains they require physical and verbal assistance when using cleaning products and states, "[a]ll cleaning products are locked... in the home." Individual #1's assessment, completed 3/18/22 indicates they require verbal prompting to safely identify and use poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous materials were immediately locked in an area where they are now inaccessible to Individual #1. All individuals' assessments were reviewed and all poisonous materials were immediately locked in an area, inaccessible to any individuals as needed. 12/16/2022 Not Implemented
6400.66There is not a light source outside the basement exit.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light outside the basement exit was repaired. All rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes lights were repaired as needed. to assure safety and to avoid accidents. 12/16/2022 Not Implemented
6400.68(b)At 10:23AM on 11/18/2022, the hot water temperature measured 130°F at the bathtub in the bathroom in the home. [Repeat Violation, 12/2/2022] Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water tank was immediately turned down. Water temperature was tested for the next three days to ensure hot water temperatures in bathtubs and showers did not exceed 120°F. 12/16/2022 Not Implemented
6400.82(f)There is not a trash receptacle inside the bathroom.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. New trash receptacles were purchased and placed in each bathroom. 12/16/2022 Implemented
6400.141(a)Individual #1 had a physical examination completed on 1/25/2021 and then again on 2/22/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Residential Manager was trained on the above regulation. All individuals' medical files were reviewed and appointments were made as needed to keep in compliance with 55 PA Code Chapter 6400 regulations. 12/05/2022 Implemented
6400.181(e)(4)Individual #1's assessment completed 3/18/22 does not include the individual's need for supervision within the home. The assessment must include the following information: The individual's need for supervision. The assessment has been updated to show supervision requirements on the front page so that staff is able to easily locate the information. (see attached) All assessments will be updated accordingly. Please see attached document. 12/12/2022 Not Implemented
6400.181(e)(13)(viii)Individual #1's assessment, completed 3/18/22 assessment does not include the individual's progress over the last 365 days and current level to manage personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The assessment was updated by adding a comments box at the end of the assessment to allow for Progress to be addressed. Also, added a section to the assessment to list the individuals personal belonging and how well they can take care of the items. (see attached) 12/12/2022 Not Implemented
SIN-00198875 Renewal 12/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1 had a dental examination completed 9/30/2020 and not again since. (Repeated Violation-1/06/2021, et al).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. The Residential Manager has been instructed make a dentist appointment for individual #1, for the first available appointment. Director of Operations has reviewed regulation 6400.142(a), 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, with the Residential Manager to ensure the understanding compliance of the regulation. 02/04/2021 Implemented
6400.144Individual #1's physical examinations completed 8/07/2020 and 9/16/2021 states the individual's hearing was unable to be tested. No documentation was provided on any further hearing examinations or refusals.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. Residential Manager has been instructed to contact Individual #1's PCP to get information regarding on the inability for his hearing to be tested, and to get documentation for further hearing exams. Director of Operations has reviewed Regulation 6400.144 - 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, with the Residential Manager and the importance of Compliance. 02/04/2022 Implemented
6400.181(e)(12)Individual #1's assessment completed 9/20/2021 did not include: Recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. KZL Agency has revised and updated Residential Annual Assessment to ensure all information as noted in Chapter 6440.181(e) is reflected, including specific recommendations for specific areas of training, programming, and services. KZL Agency Residential Program Specialist will begin using this revised assessment immediately, replacing the old assessment. 01/26/2022 Implemented
6400.34(a)Individual #1's most recent signed copy of rights completed 12/16/2020, did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j to voice concerns and 6400.32k to participation in the development and implementation of the individual plan; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home.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.KZL Agency has revised and updated our agency Individual Rights policy to include all rights as noted in Chapter 6400 and Chapter 6100 regulations. KZL Agency has already been following the guidelines in the residential homes but had not updated written policy to reflect these guidelines. KZL Agency will ensure that this updated policy is what is shared with individuals going forward. 12/03/2021 Implemented
6400.163(d)During the on-site inspection conducted 12/03/2021 Equate Stomach Relief 16fl oz and Nyquil 12fl oz were located in the living room, unlocked under a shelf. Individual #1's assessment completed 9/20/2021 states the individual is unable to self-administer medications.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medications that were located in the living room, unlocked under a shelf was immediately placed with the rest of the medications in a locked area. Regulation 6400.163(d) ¿ Prescription medication and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked was reviewed with staff. A house-checklist was put into place to ensure that prescription medication and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. 02/04/2022 Implemented
6400.165(g)Individual #1 had a psychiatric medication review 1/20/2021 and then again 5/05/2021. Individual #1's psychiatric medication reviews completed 1/20/2021, 5/05/2021, and 7/30/2021 did not include the physician's signature and credentials.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.KZL Agency has revised its psychiatric medication review documentation to include the physicians¿ credentials, the reason for prescribing the medication, the need to continue the medication and the necessary dosage 02/01/2022 Implemented
6400.166(a)(9)Individual #1 is prescribed Ibuprofen 200mg tablet, with instructions to take 1 tablet every 4 to 6 hours as needed for minor aches, pain, and fever. Individual #1's December 2021 medication administration record states to take 1 tablet every 6 hours as needed.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Individual#1's MAR was corrected to state take one (1) tablet every 4-6 hours as needed. Do not exceed six (6) tablets in a 24-hour period. All other medications were checked to ensure the instructions on the MAR coordinated with the instructions of the medication prescribed. 02/04/2022 Implemented
SIN-00227983 Renewal 07/18/2023 Compliant - Finalized
SIN-00222785 Unannounced Monitoring 04/17/2023 Compliant - Finalized
SIN-00181208 Renewal 01/06/2021 Compliant - Finalized