Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234372 Renewal 11/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There were areas of disrepair in the home: - There was water damage under the bathroom sink from an apparent leak. - A knob was missing from the dresser in the individual's bedroom, - The handle on the freezer was broken off.Floors, walls, ceilings and other surfaces shall be in good repair. The dresser knob, freezer handle and and bathroom sink leakage were all replaced and repaired. 11/11/2023 Implemented
6400.113(c)Annual Fire Safety was not located in Individual 1's binder. Documentation was requested but not received during inspection. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.Person Centered Services will ensure all staff are trained on fire-safety and ensure we are in compliance with the 24 hour annual training requirement and new employee orientation. 11/15/2023 Implemented
6400.141(c)(4)For Individual 1, No vision screening and hearing screening was performed on annual physical dated 10/27/23.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The insurance company of individual 1 would not approve another physical until the 2024. We have however, notified individual 1's PCP of this violation. The PCP acknowledged the oversight and promised to complete annual physicals that meets the regulations compliance, going forward. 11/15/2023 Implemented
6400.141(c)(6)On Individual 1's annual physical dated 10/27/23, TB exam was dated for 10/27/23, but results were not listed as read negative anywhere else in binder.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The insurance company of individual 1 would not approve another physical until the 2024. We have however, notified individual 1's PCP of this violation. The PCP acknowledged the oversight and promised to complete annual physicals that meets the regulations compliance, going forward 11/15/2023 Implemented
6400.141(c)(10)On Individual 1's annual physical dated 10/27/23, Free from communicable diseases was not checked.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The insurance company of individual 1 would not approve another physical until the 2024. We have however, notified individual 1's PCP of this violation. The PCP acknowledged the oversight and promised to complete annual physicals that meets the regulations compliance, going forward 11/15/2023 Implemented
6400.24The controlled substances in the home were not being counted accurately. For individual 1 there were 22 Clonazepam tablets listed on the count, however 44 were present in the home.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The additional counts of Clonazepam tablets were returned to the pharmacy for disposal. 11/11/2023 Implemented
6400.52(a)(1)The training hours for Staff 1 were less than the required 24hrs, based on the reported calendar training year (2022 being assessed).The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.In the next training circle, PCS Inc. will ensure full compliance with the Regulations for a 24 hour training hours for all employee per their functions. 11/20/2023 Implemented
6400.163(h)Individual 1's Divalproex 500MG was discontinued however the blister packs containing the medication were still present in the medication box.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.PCS returned the discontinued medication to the pharmacy 11/20/2023 Implemented
6400.165(c)The dose on the individual 1's Quetiapine dose did not match between the blister pack and the medication administration log. The MAR stated to take one 100MG tablet twice a day, however the MAR stated to take one and a half of those tablets.A prescription medication shall be administered as prescribed.Our RN contacted our pharmacy and the error on the MAR was since corrected, per the PCP instructions. 02/16/2024 Implemented
6400.165(g)Individual 1 was admitted on 12/18/22, however, the psychotropic med reviews on file were for 11/1/23 and for 10/23/23. We need to see at least quarterly reviews with psychiatrist signature assessing levels when taking psychotropic meds. There were several copies of 8/8/22, however that was from 14 months prior.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.Due to intense behavior issues, appointments of Individual 1 kept being pushed forward and thus the violation. Individual one has since calmed a little bit. Appointments with physicians are much manageable now. 11/20/2023 Implemented
6400.166(b)For individual 1, The PRN medications that were present in the medication box and reported as active by the staff were not listed on the MAR. Those PRN medications were: - Docusate Sodium 100 MG cap -- Take one capsule by mouth once daily as needed. - Meloxicam 15 MG -- Take one tablet by mouth once daily as needed - MAPAP Arthritis ER 650 MG -- Take one tablet by mouth every 6 hours as needed for mild pain, moderate pain, or headaches for up to 10 days.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All PRN medications not reauthorized by the PCP were returned to the Pharmacy. We have since constituted a check to ensured actual medication are in agreement with the MAR 11/20/2023 Implemented
SIN-00214058 Renewal 11/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)The physical exam for Staff #1 dated 10/10/22 does not include if the staff member is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff # 1 annual physical was corrected by his physician to reflect no communicable disease. 11/20/2022 Implemented
6400.151(c)(3)The physical exam for Staff #2 dated 10/6/22 did not include if the staff member is free of communicable diseases-it was left blank. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff # 2 annual physical was corrected by his physician to reflect no communicable disease. 11/20/2022 Implemented
SIN-00179169 Renewal 10/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)At inspection, staff member#1's first aid training was not completed within the required annual time frame to be completed timely, although certifications expire in two years, the previous first aid training was conducted 2/22/17, then again 3/30/2019.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Going forward, Person Centered Services will ensure all staff are trained within our training calendar year. We have contracted with a certified First aid/CRP trainer to met our need that compliance. Our CEO, Patrick Turry is responsible compliance. 10/25/2020 Implemented
6400.151(a)The last physical exam completed for staff member#1 was completed 7/20/2017, no current physical exam provided during inspection. 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. Person Centered Service will ensure all staff members have a completed physical report that is within compliance. The staff in question has since completed a new physical. Our tickler system that monitors timely renewal date of staff documentation was updated to ensure this oversight doesn't occur again. Going forward, our HR personnel will on a quarterly basis check and update the tickler for necessary updates. 10/25/2020 Implemented
6400.32(d)The Thermostat control located in the living room was locked and there was no access by the individual and staff persons to operate the device.An individual shall be treated with dignity and respect.The lock cover was removed the same day as the inspection. Person Centered Services would no longer cover up thermostats. A teleconferenced meeting was held with all staff to enforced the importance of keeping the temperature at a reasonable level for the health and safety of the people we support as the reason for the cover was to prevent heat strokes and the potential of educing seizure episodes in individuals with seizure disorder. 10/20/2020 Implemented
6400.32(e)Individual#1 does not have pillows on his bed which he has a right to possess. Behavior plan is vague at best detailing why the pillows were taken off of the bed.An individual has the right to make choices and accept risks.A pillow was place in the individuals room as instructed by the code and the inspector the next day. During the individual's ISP meeting held on 12/7/2020, the team discussed and agreed to update his ISP with clear language indicating that his bed doesn't need a pillow as it posses a health risk to himself. The individual has a history of plugging his ears with fillers in his pillow. 10/21/2020 Implemented
6400.52(a)(3)It could not be determined at inspection if staff member #1 completed 24 hours of annual training, no documentation found in record, requested but not provided at inspection.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.Person Centered Service will ensure all staff meets training compliance each year. The staff in question has since completed all of his trainings. Our tickler system that monitors timely renewal date of staff documentation was updated to ensure this oversight doesn't occur again. Going forward, our HR personnel will on a quarterly basis check and update the tickler for necessary updates. 10/25/2020 Implemented
SIN-00150210 Renewal 02/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit was missing tweezers A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit has since been completed with a tweezer. Going forward, managers, nurses, and all staff charged with replacing/replenishing first aid kits are guided by 55 PA code chapter 6400.77(b) to ensure compliance. Our quarterly QA inspection would look for compliance as well. 02/16/2019 Implemented
6400.101The front door is equipped with two lock mechanism that require key and manipulation to open causing a delayed egress in the event of a fire emergencyStairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Due to serious elopement issues, the individual's team agreed to install child safety-like devices during his transition phrase to mitigate elopement. Only one device required a key. However, in compliance with 55 PA code chapter 6400.101, both devices were uninstalled. Going forward, Person Centered Services would evoke the code at meetings with support teams in matters regarding elopement and measures allowed per the code. 02/16/2019 Implemented