Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225507 Unannounced Monitoring 05/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 3/20/2023 at 01:10 PM inspector Lic: #504104/504104/504. The invoice dated 3/20/2023 stated the inspector spot treated bedframes, box springs, head/foot board, baseboards, two couches and 1 recliner throughout two bedrooms and 1 living room as able/needed on today's service. two slow moving adults and one fast moving nymph found on box spring in bedroom at tips of stairs to the left on today's service. Follow up inspection is recommended in 10-14 days due to today's activity. The follow-up recommendation did not occur. Per ODP direction, individual #1 did return to the home on 5/3/2023 and no activity was found at time of service. Throughout the interview process, bed bugs were reported by witnesses to be in the Bigler AVE home. It was also reported that the individuals #1 and #2 had suffered physical injury due to the infestation. Per ODP direction, both individuals #1 and #2 were seen on 5/3/2023 and their physicians; both of which could not conclude if the rash/and or scars on their bodies were due to bed bugs or not.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Life Changing Support Services, Inc. (LCSS) has created a policy to address this situation if it was to ever occur again. The policy states: If bed bugs are suspected, please utilize the following steps: 1. Limit access to the room where they are suspected or found. 2. All individuals in the house are to be immediately removed to the following hotel: The Quality Inn Ebensburg, PA 15931 (814) 472- 3. Immediately notify the office about the suspected bed bugs. They will contract a Pest Control Agency to come and treat the affected areas. If a suspected bed bug is found, try to isolate the bed bug in a container with a lid for later identification by Pest Control. 4. All clothing, bedding, curtains, towels, wash cloths, etc, should be removed in plastic bags and laundered at the laundromat and dried with high heat drying for at least 30 minutes minimum. 5. Inspect and vacuum all items thoroughly (throwing away vacuum bag and/or replacing filter). Vacuum mattresses, box springs, floors, sofas and cushions, etc. 6. All personal belongings should be inspected before being placed back in the Individual¿s room. 7. Examine individuals for bites. Seek Medical attention if needed. 07/10/2023 Implemented
6400.43(b)(3)On 2/24/2023, Chief executive officer, staff #1, failed to investigate the cause of injury to individual #1's face. The injury was a large bruise covering the left side of his face and ear.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. LCSS has implemented a protocol that if and when a physical restraint has been implemented, a visual check of the individual will occur within 24 hours by someone within LCSS administration. Documentation of this check will be completed and submitted to the Program Director along with a body chart. If at any time injury has occurred, medical treatment will be immediately provided, and an investigation will be started. Administrative staff have been trained on this protocol and completed one has also been sent for review. 07/10/2023 Implemented
6400.141(c)(3)Individual #1 Td/Tdap was not on his current physical 11/2/2022.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. All current physical for individual's that reside with LCSS has been reviewed to ensure all information has been carried over to the individual's physicals and any information that was not transposed was sent back to the appropriate physician's and was corrected. 07/10/2023 Implemented
6400.50(a)Documentation of the agency wide Incident management training conducted October 18, 2022, retains the record of training only including the staff's name, their signature, and date.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.All training forms have been updated to include the training sources, content, the date, length of time, and name of staff being trained. We have also included that a signature is required, plus also printed name, so that it is able to be read more clearly. 07/10/2023 Implemented
SIN-00191360 Allocated Unannounced Monitoring 07/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The door in basement did not open at the time of the inspection. Screens, windows and doors shall be in good repair. A companywide review was completed of all houses. A companywide training was conducted on 8/24/21 which included 6400.72(b). The maintenance department was notified VIA maintenance request and was fixed on August 12th. (The proper size door had to be ordered). Per previous corrective action house team leaders are to do weekly house inspections and the compliance manager and CEO review house checks and submit maintenance request forms to maintenance on a weekly basis. The compliance manager will do a house check once a month making sure to check each house and verify that cleaning and maintenance are being completed. To add another check and balance, we have added another house check at least monthly from office staff that we perform at the same time. Once the checks are completed, we meet back at the office and discuss the findings. If there are problem areas office staff are scheduled within the next couple days to recheck the houses with the problem areas to ensure the tasks have been completed. These checks can occur at any time of the day or night. If night checks are completed the individuals are not disturbed. The forms for the house check have been updated to include key focus areas that have historically been found to need extra attention. House team leads have been encouraged to get their house staff involved in the house checks to ensure their knowledge of the regulations and what is required of them. The house team leads were trained on the new form on 08-24-2021. Two separate calendars have been created one for the team leads and one for the office/compliance on when inspections are to occur. Supplemental checks will be scheduled as needed. Maintenance is also to send the CEO pictures of completed maintenance projects to document completion of maintenance tasks. Team leaders, office staff, compliance, and maintenance will have binders with all their checks, pictures, and recommendations included. CEO and/or Compliance Manager will review all documentation. 08/27/2021 Implemented
6400.181(d)Program Specialist did not sign and date individual #1's assessment 4/6/2021.The program specialist shall sign and date the assessment. A companywide review was completed. A companywide training was conducted on 8/24/21 which included 6400.181(d), the CEO will also re-train the Head program specialist, program specialist and behavior specialist on this regulation & the CEO will review the Program Specialist¿s work to make sure that every assessment has a signature and is dated by either the Program Specialist or the CEO. 08/27/2021 Implemented
6400.216(a)All individual program books were unlocked in the office for individual #1 and individual #2. The office door did not have a lock on it. The top drawer contained unlocked, unfiled meal planning menus from June 2021 and medical documentation for individual #1. An individual's records shall be kept locked when unattended. A companywide review was completed. A companywide training was conducted on 8/24/21 which included 6400.216(a) so that the staff received training on this regulation. The maintenance department received a maintenance request and during the inspection, immediately placed a lock on the door. All the weekly/monthly inspection documentation has been updated to note specific focus areas, and this regulation was added to the focus area section to ensure compliance. Per previous corrective action house team leaders are to do weekly house inspections and the compliance manager and CEO review house checks and submit maintenance request forms to maintenance on a weekly basis. The compliance manager will do a house check once a month making sure to check each house and verify that cleaning and maintenance are being completed. To add another check and balance, we have added another house check at least monthly from office staff that we perform at the same time. Once the checks are completed, we meet back at the office and discuss the findings. If there are problem areas office staff are scheduled within the next couple days to recheck the houses with the problem areas to ensure the tasks have been completed. These checks can occur at any time of the day or night. If night checks are completed the individuals are not disturbed. The forms for the house check have been updated to include key focus areas that have historically been found to need extra attention. This regulation was added to the key focus area list. House team leads have been encouraged to get their house staff involved in the house checks to ensure their knowledge of the regulations and what is required of them. The house team leads were trained on the new form on 08-24-2021. Two separate calendars have been created one for the team leads and one for the office/compliance on when inspections are to occur. Supplemental checks will be scheduled as needed. Maintenance is also to send the CEO pictures of completed maintenance projects to document completion of maintenance tasks. Team leaders, office staff, compliance, and maintenance will have binders with all their checks, pictures, and recommendations included. CEO and/or Compliance Manager will review all documentation. 08/27/2021 Implemented
6400.186Sharps must be locked in the home per individual #1 and #2 Individual plan. Bottom drawer, right side of the bathroom sink, was a small wall hanging unit found with a sharp rusted half inch point. There was a hammer with a blue handle, a yellow screwdriver, steel pointed thermometer, a broken pair of black scissors, staples, two staple removers, all found in the drawers of the desk in the staff office. The bottom drawer of the black filing cabinet contained an old, dusty light fixture with wires, and a box of Brinks single cylinder door locks. The office was unlocked.The home shall implement the individual plan, including revisions.A companywide training was conducted on 8/24/21 which included 6400.186 and during this training, staff were educated on what a potential sharp could be and were instructed to contact their team leads / management when they come into contact with any potential sharps to help identify them. The agency purchased additional lock boxes to place sharps in and are kept locked under the sink at each location. This will help prevent future occurrence of sharps being unlocked. Per previous corrective action house team leaders are to do weekly house inspections and the compliance manager and CEO review house checks and submit maintenance request forms to maintenance on a weekly basis. The compliance manager will do a house check once a month making sure to check each house and verify that cleaning and maintenance are being completed. To add another check and balance, we have added another house check at least monthly from office staff that we perform at the same time. Once the checks are completed, we meet back at the office and discuss the findings. If there are problem areas office staff are scheduled within the next couple days to recheck the houses with the problem areas to ensure the tasks have been completed. These checks can occur at any time of the day or night. If night checks are completed the individuals are not disturbed. The forms for the house check have been updated to include key focus areas that have historically been found to need extra attention. This regulation was added to the key focus area list. House team leads have been encouraged to get their house staff involved in the house checks to ensure their knowledge of the regulations and what is required of them. The house team leads were trained on the new form on 08-24-2021. Two separate calendars have been created one for the team leads and one for the office/compliance on when inspections are to occur. Supplemental checks will be scheduled as needed. Maintenance is also to send the CEO pictures of completed maintenance projects to document completion of maintenance tasks. Team leaders, office staff, compliance, and maintenance will have binders with all their checks, pictures, and recommendations included. CEO and/or Compliance Manager will review all documentation. 08/27/2021 Implemented
SIN-00188595 Unannounced Monitoring 05/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At the time of the inspection, Flame Glo Charcoal Lighter Fluid which stated "contact poison control if ingested" was sitting out in the open in the back room off the kitchen. Individual #1 has a restrictive plan which includes poisons must be locked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. The Lighter fluid was put in the locked poisons closet. A companywide review was completed at all houses to make sure all poisons are locked that are supposed to be according to ISPs and BSPs. Training on this regulation was completed on 06-23-2021. The compliance manager will complete unannounced inspections monthly of all houses and will report to the CEO the findings. House team leaders will do weekly unannounced physical site checks and report to the compliance manager the findings. House inspection documentation has been created for the house team leaders. Along with checks by the compliance manager and house team leaders, maintenance requests will be submitted by both and given to the CEO. The CEO will then give to the maintenance person to be completed with a timeframe work is to be completed. As the work is completed it will be checked by the compliance manager. Both inspections, from the house team leaders and compliance manager, will be given to the CEO for review. 07/07/2021 Implemented
6400.82(f)At the time of the inspection, there was no soap, hand towels or paper towels to dry your hands in the upstairs 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. A companywide review was completed at all houses. Training on this regulation was completed on 06-23-2021. House Team leaders were contacted to determine whether they had paper towels on site or needed purchase and paper towels were put into all bathrooms that were missing them. The house team leader will do weekly unannounced inspections of the houses and will document the findings. This will help to ensure that all bathrooms have nontoxic hand soap and paper towels. Compliance manager will do monthly house checks at all the houses to ensure this regulation is being followed. House inspection documentation has been created for the house team leaders. Both inspections, from the house team leaders and compliance manager, will be given to the CEO for review. 07/07/2021 Implemented
SIN-00175902 Renewal 08/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Staff # 1 verbally reported on 08/25/20 that the agency did not complete the required self-assessments until 08/17/20. Self Assessments should have been completed 3-6 months prior to their license expiration date of January 2020.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The date of the self-assessment will be added to the google office calendar. The CEO will complete them according to the regulation. CEO reviewed the regulations with the office staff and the President will sign off that the assessment was done in the recommended time period. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/25/2020 Implemented
6400.43(b)(1)The agency's Abuse Reporting Policy is found in the document; "Reporting Suspected Abuse" (Effective date 12/2011). The policy reads: "A report of Abuse form must be completed within 24 hours by the staff person reporting the allegation of abuse. The form will be submitted to the Program Specialist. Both the reporting staff as well as the Program Specialist will date and sign the completed form upon receipt." An Incident Report was filed in EIM on 08/21/19 alleging abuse by a staff person towards Individual # 1. The staff person was terminated after an agency investigation and the police were notified for substantiated abuse. An agency "Report of Abuse" form was not filled out or submitted to the Program Specialist for the 08/21/19 incident. The CEO verbally reported to the licensing representatives that they could not locate the Report of Abuse form during the on-site inspection which occurred on 08/26/20. Additional EIM reports of abuse were submitted on 12/27/19, 12/23/19, 04/25/19 and 01/28/19. Agency "Report of Abuse" forms were not located by the CEO during the on-site inspection for these alleged incidents of abuse. The CEO failed to ensure the implementation of their own Policy regarding Abuse Reporting.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. An official report of abuse form was created. A memo was sent out on 9-2-2020 that included the policy, the new form and training materials for the employees to review. A company wide meeting was held on 09-15-2020 that also covered this cite. A company wide review was completed. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/15/2020 Implemented
6400.64(a)REPEAT (05/30/19)- Lint was located in a dryer lint trap approximately the size of a golf ball creating a fire hazard.Clean and sanitary conditions shall be maintained in the home. Staff were retrained in fire safety and the importance of cleaning appropriately. Cleaning the lint trap was added to the daily cleaning list which must be filled out and initialed by staff. Also, a memo was sent to each house to reiterate the importance of cleaning the lint trap which had to be signed and returned to the office. A walkthrough of each home will be completed by management quarterly to assure compliance. 09/21/2020 Implemented
6400.101The basement egress door was stuck to the door jamb, at the bottom right portion of the door causing an emergency exit hazard.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Monthly checks are to be completed by supervisors and they are to report any hazards. If the house does not have a supervisor an office staff will do the check. A memo was sent to the supervisors and office staff stating this. They will use the house inspection tool to complete the check. Management will conduct a quarterly walkthrough of each home to assure compliance. 09/25/2020 Implemented
6400.151(a)151a Staff # 2 was hired on 01/23/20. He did not receive a physical exam until 01/27/20. Physical Examinations of staff are to be completed within 12 months prior to the date of hire. Staff # 1 received a physical examination on 06/12/19. The previous physical examination contained in the record was dated 08/24/15. Staff physical examinations are due every two years. 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. The administrative assistant will ensure that anyone that comes in to obtain employment will have the proper documentation. A check list was created to ensure all subjects are covered before an official hire date is offered. A companywide review has been completed. All office staff have been retrained in this area. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/14/2020 Implemented
6400.18(a)(1)Individual #1 received emergency medical treatment at the emergency room on 12/18/19 at 1:30 pm due to blood in his stool during a bowel movement identified at 9:13 AM while at his day program. An incident report was not created in the Department Information Management system until 12/19/19 at 5:47 pm. Incidents must be reported to the Department Information Management system within 24 hours of discovery by a staff personThe home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: DeathProgram Specialist and medical director were retrained in the requirements of entering incidents in the specified time frame according to the regulation. Documentation is to be submitted immediately after the emergency visit or incident to the medical and the program specialist. If ER or incident occur after normal business hours, the Program Specialist and Medical director are to be contacted via phone and the report must be at the office at open of the next business day. If incident occurs over the weekend the management person on call will go to get the documentation and it will be entered. A company wide review was completed. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/14/2020 Implemented
6400.20(b)A three-month trend analysis of incidents and conduct was not completed for this home.The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.The program Specialist has been trained on this regulation. She will make sure that a reminder for the trend analysis is put on the office google calendar. Also, office management meetings have been reintroduced. These meetings were cancelled since March 2020 due to COvid-19. These meetings include training and to over see job duties are being completed efficiently. A company wide review was completed. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/14/2020 Implemented
6400.32(k)Individual # 1 had a Restrictive Procedure Review meeting on 04/24/19. The agency form which is Titled "Consent to Implement" was not signed by the individual to demonstrate that he was involved in a review of the Restrictive Procedure Plan. The space was left blank. Similarly, Individual # 1 had a Restrictive Procedure Review meeting on 02/26/20. The agency form which is Titled "Consent to Implement" was not signed by the individual to demonstrate that he was involved in a review of the Restrictive Procedure Plan. The space was left blank.An individual has the right to participate in the development and implementation of the individual plan.The Program Specialist is responsible for completing this documentation. After each restrictive review, documentation will be submitted to the CEO for review. A line has been added to the documentation to verify that the paperwork was reviewed. There was a company wide review. Office staff has been trained in this area. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/14/2020 Implemented
6400.169(a)Staff # 3 completed her annual Medication Administration Practicum on 01/03/20. Her previous completed Medication Administration Practicum was not dated as completed. The annual practicum document indicates a MAR review on 12/18 and a Med Observation on 09/18.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Vice President Sarah Stiles was in charge of this area. She was abruptly suspended in April 2020. The medical director, Wendy Keith, is now responsible for medication training. Medical director will complete quarterly checks to ensure compliance with this regulation. A company wide review was completed. Anyone that is not in compliance is being retrained. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/25/2020 Implemented
6400.181(f)Individual # 1's Annual Assessment was signed by Individual # 1 on 04/30/20. The Annual ISP meeting occurred on 02/12/20. The annual assessment should be provided to the Service Coordinator and team members at least 30 days prior to the Annual ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.LCSS program Specialist will send assessment when completed annually, then again with addendum if any changes 30 days prior to the ISP review meeting. A reminder will be placed on the office google calendar of completion date. A company wide review was completed. Office staff have been re trained on this regulation. 09/14/2020. The management team will conduct an audit of the records that will include 25% of the individuals quarterly to assure compliance. 09/14/2020 Implemented
SIN-00155471 Renewal 06/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The window beside the closet in Individual #1's room has an approximate 2- inch by 2- inch hole in the screen and the window was open at time of inspection. Screens, windows and doors shall be in good repair. This regulation is important so that individuals are protected from the outside elements and so that outside pests are kept outside. A hole was found in the screen of the window and the window was open. There isn¿t an obvious reason for the hole. The window was immediately shut to protect the individual. A companywide review was completed to make sure this was not an issue anywhere else. The screen will be replaced with a new screen. Supervisors are required to submit any maintenance issues as soon as they are discovered to the compliance manager. The compliance manager will then contact the President, who will arrange to have the issue fixedThe president will give the compliance manager an estimated time for the problem to be corrected. The compliance manager will then verify the correction. 07/21/2019 Implemented
SIN-00132611 Renewal 05/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(d)Individual #1's assessment dated 4/6/18 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment. A company wide review was completed and all errors were corrected on0/08/2018 The assessment in question was fixed immediately. Program Specialist's were trained in this area on 05/16/2018. This issue will be added to the quarterly record review as a specific bullet point. 05/16/2018 Implemented
SIN-00116413 Unannounced Monitoring 06/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual #1's bedroom did not contain a mirror.In bedrooms, each individual shall have the following: A mirror. A company-wide review to ensure compliance. For any individual that is not able to have sharps in possession a non-breakable mirror will be provided. ISP/BSP will be reviewed and updated as needed to include specific items that may be considered harmful to the individual. These issues will also be addressed at the company-wide training being held on July 19. 21. Attachment Training sign sheet 22. Attachment Receipt for mirrors 07/14/2017 Implemented
SIN-00107289 Renewal 03/08/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff #1 had fire safety training on 12/1/15 and not again until 12/26/16.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Administrative Assistant was replaced and new administrative assistant is starting on 5/1/2017. New AA will be trained in all regulations. Administrative assistant is required to send training logs weekly to the quality compliance manager to ensure all trainings are being completed on time. CEO will complete monthly checks of 25%( random) of employee records to ensure compliance is being met. 05/01/2017 Implemented
6400.62(a)Individuals #2 and #3 were assessed to be unsafe around poisonous materials. An antibiotic cream and alcohol preparation pads with labels indicating to contact poison control center if injested were left unlocked and accessible in the first aid kit. A gallon of paint with a label indicating to contact poison control center if injested was left unlocked and accessible in the basement.Poisonous materials shall be kept locked or made inaccessible to individuals.The first aid kit was immediately put in the cabinet that was able to be locked. There is a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all regulation issues. The first aid check list will also include a section that includes if sharps and poisons are to be locked the first aid kit is to be in an area that is locked. The check list will also contain the location of the first aid kit. The first aid checklist is to be completed on a monthly basis and reviewed by the administrative assistant. A companywide review of the location of first aid kits was completed. An updated maintenance form was created and it reminds maintenance personnel to make sure any dangerous substance is taken out of or stored correctly. The Supervisors are then to check the houses after maintenance has left to ensure nothing dangerous was left behind. Attachment # 71 first aid checklist Attachment #72 previous maintenance request form Attachment # 73 updated maintenance request form 05/08/2017 Implemented
6400.67(a)The shelves on the inside of the refrigerator door were missing the plastic guards that prevented food items from falling off the shelves. The bottom kitchen cabinet drawer to the left of the sink was broken. The carpet on the back porch contained many rips and holes. The kitchen focet was leaking from the pipes under the sink. Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance request was submitted to the head of maintenance. House Supervisors will do weekly maintenance reports and will submit the list to the Head of maintenance who will then assign a maintenance person to complete the work. The Head of maintenance will ensure all repairs are made in a timely manner The QCM will check status¿s during monthly house check. If something is emergent the repair will be completed as soon as possible. A companywide review was performed and any issues were resolved. There is also a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all inspection issues. Attachment #68 maintenance request Attachment #69 Supervisor weekly maintenance report Attachment # 70 QCM checklist 05/08/2017 Implemented
6400.72(b)The front door had approximately a 4 inch hole in the middle of the door. Screens, windows and doors shall be in good repair. A maintenance request was submitted to the head of maintenance. House Supervisors will do weekly maintenance reports and will submit the list to the Head of maintenance who will then assign a maintenance person to complete the work. The Head of maintenance will ensure all repairs are made in a timely manner The QCM will check status¿s during monthly house check. If something is emergent the repair will be completed as soon as possible. A companywide review was performed and any issues were resolved. There is also a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all inspection issues. Attachment #65 maintenance request Attachment #66 Supervisor weekly maintenance report Attachment # 67 QCM checklist 05/08/2017 Implemented
6400.103The written emergency evacuation procedure did not contain an emergency shelter location. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The written emergency evacuation procedure had the next closest company house listed as the emergency shelter location. The procedure was updated to include the physical address of the location. The updated policy was given to each supervisor and they supervisor informed their house staff of the change. There is also a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all inspection issues. Policy¿s will be reviewed by QCM and CEO on a quarterly basis to ensure that all policies are correct and up to date. All Emergency evacuation procedures were reviewed and updated accordingly. Attachment # 63 previous procedure (NC) Attachment # 64 Updated procedure (NC) 05/08/2017 Implemented
6400.104REPEAT from 3/10/16 annual inspection: Individual #3 required assistance to evacuate the home during fire drills and the 12/23/16 notification letter to the fire department did not indicated that Individual #3 required assistance during fire drills. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. An updated fire letter was sent to the fire department stating there may be a need for additional assistance. The administrative assistant will review monthly fire drill documentation and if there is additional assistance needed, the QCM will send an updated letter to the local fire department. The President will oversee that all letters are within compliance. Fire drills and fire letters have been reviewed for the entire agency. There is also a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all inspection issues. Attachment # 60 Previous Fire letter with floor plans Attachment # 61 Updated Fire letter with floor plans Attachment # 62 administrative assistant sign off on fire drill 05/08/2017 Implemented
6400.106The written documentation dated 2/24/17 from the furnace inspection company did not indicated if the company completed a furnace inspection, cleaning, and/or filter change on 2/24/17. The last furnace inspection and cleaning was completed on 3/9/16.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 furnace inspection was completed, but the details of what was done to the furnace were not included. The head of maintenance returned the forms to the agency that cleaned the furnace and had them put a detailed description of the maintenance that was completed. The QCM will sign off on all furnace inspections to ensure compliance. The maintenance department will be required to attend the May 5, 2017 training concerning regulation issues. Attachment # 58 Furnace inspection (old) Attachment #59 Furnace inspection (new) 05/08/2017 Implemented
6400.113(a)Individual #1 received fire safety training on 12/20/16 while living at another home within the agency. He/She has since moved to a new residential home with the agency and did not receive fire safety training for his/her current living enviornment at 2604 Bigler Ave, Northern Cambria. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Fire Safety training and a drill was completed on 12/20/16 on 12/23/16 individual was moved to another location. A fire drill was completed on 12/23/16 to accommodate the individuals new address. The general fire training was completed on 12/20/16. Before the drill on 12/23/16 it was explained to the individual the specific house procedure. Additional documentation will be kept to ensure compliance concerning fire safety training. The QCM will review all fire documentation to ensure compliance in this area. There is also a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all inspection issues. Attachment #55 Fire safety training sign sheet Attachment # 56 Fire drill sheet for 12/20/16 Attachment # 57 Fire drill sheet for 12/23/16 05/08/2017 Implemented
6400.151(c)(2)Staff #2's date of hire was 8/16/16 and she did not have a tuberculin skin test completed until 8/18/16. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Administrative Assistant was replaced and new administrative assistant is starting on 5/1/2017. New AA will be trained in all regulations. The physical form was changed to include a section that is filled out by LCSS administrative assistant that includes the hire date. The hire date is to be filled in by the administrative assistant after the physicals have been reviewed by Medical director #1 and then medical director #2. The QCM will review physical to ensure compliance. Attachment # 53 New Physical form Attachment # 54 Previous Physical form 05/08/2017 Implemented
6400.181(e)(2)Individual #1's 1/25/17 assessment did not include his/her dislikes. His/Her other record information included many dislikes however none were captured in his/herassessment. The assessment must include the following information: The likes, dislikes and interest of the individual. Individual #1 does not like to communicate personal information. Program Specialist, supervisors, and QCM were trained in assessment regulations. Supervisors are now required to complete a questionnaire that covers all assessment areas. Supervisors are to submit this documentation 30 days before the assessment due date. Due dates are put on the company Google calendar and program specialist will notify supervisors when questionnaire is due. QCM signs off on all assessments and will then be reviewed by CEO. Attachment # 33 training signature sheet for 181 reg Attachment # 34 updated assessment for Individual #1 Attachment # 35 previous assessment for individual #1 Attachment #36 Supervisors assessment questionnaire 05/08/2017 Implemented
6400.181(e)(4)Individual #1's 1/25/17 assessment did not include his/her need for supervision. The assessment must include the following information: The individual's need for supervision. Program Specialist, supervisors, medical directors, and QCM were trained in assessment regulations. Supervisors are now required to complete a questionnaire that covers all assessment areas. Supervisors are to submit this documentation 30 days before the assessment due date. Due dates are put on the company Google calendar and program specialist will notify supervisors when questionnaire is due. QCM signs off on all assessments and will then be reviewed by CEO. Attachment # 37 training signature sheet for 181 reg Attachment # 38 updated assessment for Individual #1 Attachment # 39 previous assessment for individual #1 Attachment #40 Supervisors assessment questionnaire 05/08/2017 Implemented
6400.181(e)(5)Individual #1's 1/25/17 assessment did not include his/her ability to self-administer medications. His/Her assessment indicated that "he didn't take medications but the agency would assume he could take over the counter medications." The agency did not assess his/her ability to self-administer medications. The assessment must include the following information:  The individual's ability to self-administer medications.Medical directors were trained on the assessment regulations. An assessment tool was created to assess the ability to self-medicate by the medical director. This assessment will be completed for each assessment written and updated. The information will be given to the Program Specialists who will include it in the assessment. The QCM will review the assessment and the CEO will sign off on the assessment. Attachment # 41 training signature sheet for 181 reg Attachment # 42 updated assessment for Individual #1 Attachment # 43 previous assessment for individual #1 Attachment #44 self-medicating assessment 05/08/2017 Implemented
6400.181(e)(12)REPEAT from 3/10/16 annual inspection: Individual #1's 1/25/17 assessment did not include recommendations for specific areas of training, programming and services for Individual #1. The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program Specialist, supervisors, medical directors, and QCM were trained in assessment regulations. Supervisors are now required to complete a questionnaire that covers all assessment areas. Supervisors are to submit this documentation 30 days before the assessment due date. Due dates are put on the company Google calendar and program specialist will notify supervisors when questionnaire is due. QCM signs off on all assessments and will then be reviewed by CEO. Attachment # 45 training signature sheet for 181 reg Attachment # 46 updated assessment for Individual #1 Attachment # 47 previous assessment for individual #1 Attachment # 48 Supervisors assessment questionnaire. 05/08/2017 Implemented
6400.181(e)(14)Individual #1's 1/25/17 assessment did not include his/her ability to swim. The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Program Specialist, supervisors, medical directors, and QCM were trained in assessment regulations. Supervisors are now required to complete a questionnaire that covers all assessment areas. Supervisors are to submit this documentation 30 days before the assessment due date. Due dates are put on the company Google calendar and program specialist will notify supervisors when questionnaire is due. QCM signs off on all assessments and will then be reviewed by CEO. Attachment # 49 training signature sheet for 181 reg Attachment # 50 updated assessment for Individual #1 Attachment # 51 previous assessment for individual #1 Attachment # 52 Supervisors assessment questionnaire. 05/08/2017 Implemented
6400.183(4)Individual #1's Individual Support Plan (ISP) did not include his/her level of supervision. The supervision sections were not included in the ISP and there was no documentation that the agency attempted to send his/her supervision needs to his/her supports coordinator. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. Individual was an emergency placement and emails were sent to SC to complete the ISP. ISP meeting was held on 3/17/2017 and was completed with updated information. Program Specialist are required to put all emails regarding an individual in their books to prove the proper steps have been taken. LCSS asked the SC for an ISP meeting, SC¿s response is included in attachments. An agency wide training is scheduled for May 5, 2017 to address regulatory issues. Attachment # 30 email verification 05/08/2017 Implemented
6400.183(7)(iii)REPEAT from 3/10/16 annual inspection: Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. Individual was an emergency placement and emails were sent to SC to complete the ISP. ISP meeting was held on 3/17/2017 and was completed with updated information. Program Specialist are required to put all emails regarding an individual in their books to prove the proper steps have been taken. LCSS asked the SC for an ISP meeting, SC¿s response is included in attachments. Program Specialist were trained on this regulation. Attachment # 31 email verification Attachment #31b training signature sheet 05/08/2017 Implemented
6400.183(7)(iv)REPEAT from 3/10/16 annual inspection: Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive community-integrated employment. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. Individual was an emergency placement and emails were sent to SC to complete the ISP. ISP meeting was held on 3/17/2017 and was completed with updated information. Program Specialist are required to put all emails regarding an individual in their books to prove the proper steps have been taken. LCSS asked the SC for an ISP meeting, SC¿s response is included in attachments. An agency wide training is scheduled for May 5, 2017 to address regulation issues. Attachment # 32 email verification 05/08/2017 Implemented
6400.185(b)Individual #3 required sharp objects to be locked due to his/her behaviors. A pair of scissors and fingernail clippers were unlocked and accessible in the first aid kit in the staff office. Staff indicated to licensing on 3/9/17 that the staff office is never locked. The ISP shall be implemented as written.The first aid kit was immediately put in the cabinet that was able to be locked. There is a companywide meeting scheduled for May 5, 2017 to have a comprehensive training on all regulation issues. The first aid check list will also include a section that includes if sharps and poisons are to be locked the first aid kit is to be in an area that is locked. The checklist will also contain the location of the first aid kit. The first aid checklist is to be completed on a monthly basis and reviewed by the administrative assistant. A company wide review of the location of first aid kits was completed. Attachment # 29 first aid checklist 05/08/2017 Implemented
6400.216(a)Individuals #1-#3 record information was unlocked and accessible in the staff office. Staff inidcated to licensing on 3/9/17 that the staff office, where individual specific information is kept, is never locked. An individual's records shall be kept locked when unattended. Records were not locked that had individuals name on it. Records were immediately put in a cabinet so the records would not be out in the open. A maintenance request was submitted to add locks to the cabinet or purchase a file cabinet that locked. A companywide review was completed. Companywide memo was distributed stating the importance of keeping all individuals records locked when unattended. Memo was distributed on 4/26/17. All employees are to sign the memo after they have read it. Supervisors are to return the memo to the Quality Compliance Manager by 5/3/17 to ensure compliance. Quality Compliance Manager will do monthly house inspections to ensure compliance in this area. The CEO will review QCM checks. Attachment 27 Maintenance request Attachment 28 Memo 05/08/2017 Implemented
SIN-00091752 Renewal 03/10/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.21(a)Staff #1 was hired on 12/14/15 and his criminal history check wasn't completed until 12/14/15. This needs completed before hire date. The legal entity responsible for a facility or agency subject to approval under Article IX of the Public Welfare Code (62 P. S. § § 901¿922) shall submit an application for a certificate of compliance prior to the inspection and issuance of a certificate of compliance by the Department.Criminal histories will be completed before the date of hire. 04/07/2016 Implemented
6400.104The notification letter to the fire department does not inlcude the needs of the individuals to evacuate.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Fire drill documentation will be reviewed by Q/C manager. Changes will be sent to local fire department. 05/05/2016 Implemented
6400.112(h)The fire drills dated 7/22/15 and 6/15/15 did not inlcude if all individuals met at the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Fire drill documentation was changed. Instead of circle yes or no, it is now an open question that a yes or no must be entered along with the number of people at the meeting place. The fire drill documentation will be reviewed by the CEO as well as the Administrative Assistant. Fire drill documentation that is not complete is cause for another fire drill to be completed. 05/05/2016 Implemented
6400.142(g)Individual #1's dental hygiene plan was not updated annually. A dental hygiene plan shall be rewritten at least annually. Plan will be updated annually. There is documentation that exams were performed. The Q/C manager will review documentation on a regular basis to ensure compliance and plans are dated. 05/05/2016 Implemented
6400.181(a)Individual #1's assessment was completed on 4/1/14 and then again on 4/25/15. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. A comprehensive calendar has been created with assessment due days, among other pertinent dates. The Quality/Compliance Manager will send alerts to the PS's 30 days before the assessments are due. 05/05/2016 Implemented
6400.181(e)(3)(iii)Individual #1's assessment did not include current level of performance and progress in personal adjustment. The individual's current level of performance and progress in the following areas: Personal adjustment. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(7)Individual #1's assessment did not include knowledge of the danger of heat sources and ability to sense and move away quickly. 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. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(12)Individual #1's assessment 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. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(13)(i)Individual #1's assessment did not include progress over the last 365 calendar days and current level in health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(13)(ii)Individual #1's assessment did not include progress over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(13)(iii)Individual #1's assessment did not include progress over the last 365 calendar days and current level in activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(13)(iv)Individual #1's assessment did not include progress over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(13)(v)Individual #1's assessment did not include progress over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(e)(13)(vi)Individual #1's assessment did not include progress over the last 365 calendar days and current level in recreation. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. Will continue to use template taken from 6400 regulations with a status section included in each section. The Quality/Compliance manger will review each assessment before it is sent to the appropriate parties to make sure all information is included. The Q/C Manager will sign and date the assessment to note that is was reviewed. 05/05/2016 Implemented
6400.181(f)Individual #1's assessment did not inlcude documentation that it was sent to plan team members. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Program Specialist will print the email for verification that the assessment was provided to plan team members in a timely manner. The email will be included in the individual¿s program book. 05/05/2016 Implemented
6400.183(7)(iii)Individual #1's ISP did not include a assessment of the individuals potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. Program Specialist 1 will review ISP's on a monthly basis to ensure correct and up to date information. If there are changes or corrections an email will be sent to the SC by PS1 to request the ISP change. The email will be printed and put in the individual¿s program book for verification. 05/05/2016 Implemented
6400.186(c)(2)Individual #1's ISP reviews dated 2/8/16, 11/13/15, 8/15/15, and 5/14/15 contained no updates on the outcome. There was no update on the behavioral support plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Content was reviewed but not specific and thorough enough. Changed template to include more detailed information. Program specialist 1 will create ISP review and Program Specialist 2 will review documentation. 05/05/2016 Implemented
6400.186(d)Individual #1's ISP reviews dated 2/8/16, 11/13/15, 8/15/15, and 5/14/15 was not sent to all team members. 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. Option to decline was given to Ganister Station. PS will endure at each ISP meeting declinations are completed by all team members. A checklist of required documentation for ISP meetings will be created by Program Specialist. An email will be sent to verify receipt of documentation and will be printed and put in individual program books for verification. 05/05/2016 Implemented
6400.186(e)Individual #1's ISP reviews did not inlcude an option to decline. It was not offered to ganister station. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Option to decline was given to Ganister Station. PS will endure at each ISP meeting declinations are completed by all team members. A checklist of required documentation for ISP meetings will be created by Program Specialist. An email will be sent to verify receipt of documentation and will be printed and put in individual program books for verification. 05/05/2016 Implemented
SIN-00085521 Unannounced Monitoring 10/16/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The home needs cleaned. Dusty throughout home; bathroom has urin odor; CB's bedroom has urin odor; bathroom toilet, sink, and tub needs scrubbed. Clean and sanitary conditions shall be maintained in the home. The house sits next to route 219 which experiences heavy amounts of traffic, including coal trucks which produce a lot of dust. The home will be dusted daily. The supervisor will do regular checks to ensure all cleaning is being completed in the proper manner. The cleaning list has been updated and each employee will sign off on what was completed. A new supervisor was put in place in October and has been instructed in house compliance issues. 11/16/2015 Implemented
6400.67(a)Caulking around back wall by kitchen sink is needed; the kitchen sink window sill is wooden and splintered; holes in bathroom walls; caulking needed around tub; new light fixture is needed above bathroom sink; holes in the bathroom window curtain; the bathroom sink is leaking a slow drip of water; soap holder by bathroom sink is rusted; molding around wall behind the toilet needs repaired; bathroom floor is old, worn, and stained; bathroom sink cabinet is worn, door will not shut, and the drawer handles are rusted; JW¿s closet will not shut; areas of CB¿s bedroom floor is torn; CB¿s bedroom door has holes in it; CB¿s short dresser is missing a drawer on the bottom right; CB¿s tall dresser top drawer is missing; small tears in CB¿s ceiling blocks; bathroom radiator is rusted and needs repainted; CB¿s tall dresser handle on second drawer is missing; there is a large tear in the kitchen floor near sink area; the TV stand in the Livingroom has a chunk of wood missing on the left side. Floors, walls, ceilings and other surfaces shall be in good repair. All issues are being addressed, in addition the field manager or assistant field manager will complete one house check per week to ensure compliance is met. They will document anything out of compliance and report to proper departments. The house supervisor will also complete regular checks throughout the week and report to the field manager any non-compliance issues. Regular house checks start the week of 11/6/15. All specific issues will be completed by 12/30/15 12/30/2015 Implemented
6400.67(b)There is water in the basement laying under the active dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.The dryer was put on something to elevate it off of the floor and the water coming into the basement is being addressed by the landlord. 11/06/2015 Implemented
6400.69(a)The temperature read 63.6 degrees F. The indoor temperature may not be less than 65°F during nonsleeping hours while individuals are present in the home. Staff will check house temperature two times per shift and document. Staff will contact the office during normal business hours if the temperature goes below 68F. If it is during non-business hours staff will contact their house supervisor and they will then contact maintenance. 11/16/2015 Implemented
6400.76(a)Indiv JW recliner is broken; it is leaning to the right. Furniture and equipment shall be nonhazardous, clean and sturdy. The old chair is being taken out and a new recliner is being purchased. Staff will be required to do daily checks of the furniture. If there is anything broken a maintenance request will be submitted to the office via fax. If it cannot be fixed or poses an immediate danger the item will be removed immediately and replaced as soon as possible. 11/16/2015 Implemented
6400.82(f)There were no individual clean paper or cloth towels in the bathroom upstairs. 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. Each shift is required to do a bathroom check when they come on shift to make sure all bathroom requirements are met. 11/09/2015 Implemented
6400.106Annual Furnace inspections for all homes were late. Bigler Ave home 3/4/14 and 4/3/14; Carrolltown 2/10/14 and 4/3/15; and Johnstown 2/17/14 and 4/3/15. 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 next furnace inspection will be scheduled 2 months a head of time, then when that inspection occurs the next furnace inspection will be scheduled that day for the next year. 02/01/2016 Implemented
SIN-00075350 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)No medical history available for Indiv #1. The physical examination shall include: A review of previous medical history. The medical director will review the physical examination documentation and if not completed by the doctor shall return to the doctor. The program specialist will also review the documentation as well as the CEO to ensure all information is documented. 02/01/2016 Implemented
6400.142(f)There is no Dental Hygene Plan in place for indiv #1. An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The program specialist shall include a dental hygiene plan for those members that have not achieved independence. The CEO will perform quarterly checks of the program books to ensure all information is provided. 02/01/2015 Implemented
6400.151(a)Staff #2 bi-annual physical was due 6/28/2014 and was not completed until 10/28/2014. 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. A comprehensive list of all employees physical dates will be kept by the administrative assistant. Each employee that is due to complete a physical will be notified in writing one month prior to physical date. If an employee fails to complete physical by due date they face termination. 02/01/2015 Implemented
6400.151(c)(2)Staff #2 bi-annual TB test was due 7/2/2014 and not completed until 10/30/2014. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. A comprehensive list of all employees physical dates will be kept by the administrative assistant. Each employee that is due to complete a physical will be notified in writing one month prior to physical date.In addition the medical director will review all physical forms for completion. If an employee fails to complete physical by due date they face termination. 02/06/2015 Implemented
6400.168(a)Staff #2 Annual Medication Administration training was due 7/23/2014 and not completed until 7/28/2014. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. The administrative assistant will compile a comprehensive list of employee training dates and will review on a monthly basis to ensure all training is completed in a timely manner. Any employee not able to complete the required training will be taken off the schedule until training is completed. 02/01/2015 Implemented
6400.168(b)Staff #3 did not receive diabetes training; indiv #1 is diabetic and takes insulin. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course and who has completed and passed a diabetes patient education program within the past 12 months that meets the National Standards for Diabetes Patient Education Programs of the National Diabetes Advisory Board, 7550 Wisconsin Avenue, Bethesda, Maryland 20205, is permitted to administer insulin injections to an individual who is under the care of a licensed physician who is monitoring the diabetes, if insulin is premeasured by licensed or certified medical personnel. Diabetic training has been included in the training curriculum and will be taken by all employees. The administrative assistant has a list of all employees and training dates to ensure all employees have met requirements. Any employee that has not met these requirements will be unable to work in the house. 02/01/2015 Implemented
6400.181(e)(10)No Medical History was documented in indiv #1's Assessment. The assessment must include the following information: A lifetime medical history. The medical director shall document medical history's to be included in each members assessment. A template that follows regulations will be used to create assessments so all information required is presented. 02/06/2015 Implemented
6400.183(5)There is no SEEN Plan in place for indiv #1. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A seen plan will be completed for any member requiring one by the program specialist. The CEO will complete quarterly reviews of the documentation that is to be included in a members program books.A comprehensive list will be made and an index will be included in program books to ensure all documentation that is required is complete and included as stated in regulations. 02/06/2015 Implemented
SIN-00058964 Renewal 12/05/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)The Representative Payee for Individual #1 gave staff $200 to help him with buying clothes. There were two different purchases which occurred with this money on 10/13/13 ad 10/14/13 and it was never put on the ledger for Individual #1. Also, money for glasses ($50) went to staff and it was never put on the ledger.(d) The home shall keep an up-to-date financial and property record for each individual that includes the following: (1) Personal possessions and funds received by or deposited with the home. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Created an individual register for special monies given to the individuals. Also a document was created that staff sign to ensure the money will be used for specific purpose. Staff also agree to return receipt and change within three days, when signing document. 12/09/2013 Implemented
6400.66There was no light out the back exit of the home. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Lights were installed. There will be a two check house inspection process installed. The house will be checked by CEO, and maintenance supervisor, to insure all elements are covered in physical house inspections. 12/16/2013 Implemented
6400.67(a)There needs to be a light fixture in Individual #1¿s bedroom and to the outside light. The light bulbs are just exposed. (a) Floors, walls, ceilings and other surfaces shall be in good repair. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 There will be a two check house inspection process installed. The house will be checked by CEO, and maintenance supervisor, to insure all elements are covered in physical house inspections. 12/16/2013 Implemented
6400.82(f)There was no trash can in the main upstairs bathroom.(f) 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. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Trash can was put into the bathroom. House supervisors will do weekly checks to make sure the proper items are present and in working order according to 6400 regulations. House supervisors and staff were required to review regulations. President will do bi monthly inspections to ensure compliance. 12/10/2013 Implemented
6400.101The exit to the back door (secondary exit) was locked in the inside where you had to use a key to unlock it. The door went into a sunroom/staff office and then there was another door to get to the outside. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 The door was immediately unlocked and a memo was sent to all house to indicate the importance of making sure all exits are accessible to all who occupy the house. Checks will be completed by the President every other month to ensure all regulations are being followed. 12/06/2013 Implemented
6400.141(b)The physical for Individual #1 completed on 10/23/13 did not include a date written by the physician. (b) The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 All physicals will go through two people to be checked to ensure all questions are answered and appropriate signatures and dates are provided. The two people the physical will be checked by are the medical director, and CEO. 01/15/2014 Implemented
6400.151(c)(2)Staff #1 was hired on 6/17/13, but TB test was not read until 6/20/13. The TB testing was not completed prior to hire date. (2) Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Created an offer of employment document with restrictions that states employee will not be officially hired until all documentation is completed and turned into the LCSS administrative offices. 02/03/2014 Implemented
6400.167(a)Staff #2 was initially trained in medication administration on 8/18/12, but her annual practicum which requires 2 MAR reviews and 2 Observations were not completed. (a) Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home. (3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 All staff who were required to complete medication training completed. Heather Hovanis, of LCSS was trained to be an observer. All medication training documentation will be reviewed by medical director upon completion. Administrative assistant will complete monthly checks to ensure all training is current. 12/09/2013 Implemented
6400.181(e)(3)(iv)The assessment for Individual #1 does not include personal assistance needs.(iv) Personal needs with or without assistance from others. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Assessments updated. An assessment template was created to ensure all pertinent information is included in assessments. When assessment is complete it will also be reviewed by the President of LCSS. 02/07/2014 Implemented
6400.181(e)(4)The assessment for Individual #1 does not include his supervision needs.(4) The individual's need for supervision. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW Assessments updated. An assessment template was created to ensure all pertinent information is included in assessments. When assessment is complete it will also be reviewed by the President of LCSS. 02/07/2014 Implemented
6400.181(e)(7)The assessment for Individual #1 does not include his ability to be around heat sources.(7) 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. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Assessments updated. An assessment template was created to ensure all pertinent information is included in assessments. When assessment is complete it will also be reviewed by the President of LCSS. 02/07/2014 Implemented
6400.181(e)(12)The assessment for Individual #1 does not include any recommendations for training and services(12) Recommendations for specific areas of training, programming and services. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Assessments updated. An assessment template was created to ensure all pertinent information is included in assessments. When assessment is complete it will also be reviewed by the President of LCSS. 02/07/2014 Implemented
6400.181(f)The assessment for Individual #1 was not sent to his Support Coordinator or his day program, TLC.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 Assessment was updated and sent to his SC, day program, and TLC. In the future the Program Manager will ensure that the assessment is sent to plan team members at least 40 calendar days prior to an ISP meeting. 35 days prior to an ISP meeting the CEO will check with the program manager to make sure this was completed. 12/15/2014 Implemented
6400.186(c)(2)Individual #1 has an outcome for Household Projects but this is not being documented in his ISP reviews and Life Changing is responsible for this outcome. (2) A review of each section of the ISP specific to the residential home licensed under this chapter. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 2/27/14 There will be a two person check to make sure all sections of the ISP specific to the residential home are being reviewed. The Program Manager will complete the review and then check to make sure all sections are complete. The Program Specialist will then go over the review and make sure all sections are complete and accurate. The ISP's will be reviewed to make sure all information is accurate. 02/10/2014 Implemented
SIN-00227721 Renewal 07/25/2023 Compliant - Finalized
SIN-00076514 Renewal 01/06/2015 Compliant - Finalized