| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | Chief Executive Officer #1 has failed to provide a home for the safety and protection of the individuals. On 5/16/2022, the home was in such a state of uncleanliness and disrepair that the individuals living in the home were not safe to stay in the home and had to be relocated from the home. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | NHCS deep cleaned and sanitized the site on 5/16/22. The toilet was unclogged and cleaned by NHCS administration on 5/16/22. A new stove and microwave were purchased on 5/18/22 by NHCS administration. The bed shaker was plugged into the wall and the part that detects smoke was hung up in the hallway on 5/16/22 by NHCS administration. The obstructions were removed from the egresses as well as were the slipping, tripping and laceration hazards on 5/16/22 by NHCS administration. Staff were trained on the individual¿s rights to have a safe and healthy living environment on 6/16/22 and will be completed by 6/23/22. The staff were also trained on the individual¿s ISP and the importance of adhering to it as it is written on 6/16/22 and will be completed by 6/23/22. |
06/21/2022
| Not Implemented |
| 6400.43(b)(4) | Chief Executive Officer #1 has failed to comply with the Commonwealth of Pennsylvania, Pennsylvania Code, Title 55, Chapter 6400 Regulations. On 5/16/2022, the home was in such a state of uncleanliness and disrepair and unsafe conditions that the individuals living in the home had to be relocated from the home. Chief Executive Officer #1 has failed to ensure compliance with the Chapter including but not limited to regulations related to individual rights, poisonous substance, sanitary conditions, hazardous conditions, adequate lighting, unobstructed egresses, furniture and equipment including inoperable and unsafe cooking equipment. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | On May 16, 2022, the CEO worked with the owners to correct the issues. The home was deep cleaned by NHCS administration and repaired by maintenance by May 20, 2022. The CEO completed a physical site review of the home on May 16, 2022, and May 20, 2022, to ensure compliance. The chemical was locked on May 16, 2022, by NHCS administration. The light bulbs were placed into the sockets on May 16, 2022, by NHCS administration. The obstructed egresses were corrected by maintenance on May 17, 2022. The stove and microwave were replaced by NHCS administration, May 18, 2022. |
06/21/2022
| Not Implemented |
| 6400.62(a) | Individual #1's Individual plan, last updated, 5/20/22 states:"poisonous substances must be kept out of [Individual #1's] reach as he does not understand that they may be harmful to him." On 5/16/22, a bottle of Lysol all-purpose cleaning spray, with a warning label to contact poison control or doctor, was unlocked and accessible on the edge of the sink in the laundry room in the home. This bottle has instructions to contact poison control center or doctor for treatment advice. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 5/16/22 the Lysol was locked in the chemical cabinet by New Horizon Care Services Administration. On 5/16/22 New Horizon Care Services administration walked through the site to ensure all chemicals were locked. Staff were instructed on 5/16/22 that all chemicals must be locked when not in use. |
06/21/2022
| Not Implemented |
| 6400.64(a) | On 5/16/2021, at 11:42AM, the following unsanitary conditions were present in the bathroom on the first floor of the home. The bathmat in the bathtub was covered in rust colored and black substances that appeared to be mold and mildew and soap scum. In addition, the entire bathtub and surrounding bathtubs walls and corners of the bathtub and were stained with dark color substance from what appears to be mold, mildew, and soap scum. The bathtub drain cover was removed and placed on the corner of the bathtub and drain area appeared rusted and black where the bathtub covering had worn off. There were at least three unlabeled pieces of soap and an unlabeled washcloth in the bathtub. There are two individual who share this bathroom. The toilet was clogged with a large mass of toilet paper and feces rendering the toilet unusable. The bathroom had a strong smell of feces. The toilet seat was spattered with feces. The floor vents in the dining room and kitchen of the home were rusting, had areas a green substance and contained cobwebs and other various debris where the paint was chipped and delaminating. The carpeting in the laundry room was saturated with water to the point where wet, muddy footprints were left when stepped on and there was a pungent odor of mildew. In addition, the laundry room had various items strewn throughout the floor including an empty toilet paper roll, a window blinds, a towel, various sizes of plastic bags and used dryer sheets and a multitude of dryer lint. | Clean and sanitary conditions shall be maintained in the home. | The bathroom including the toilet, bathtub, bathroom sink, and floors were cleaned on 5/16/22 by NHCS administration. The bathmat was thrown away and replaced with a new one on 5/16/22 by NHCS administration. The bathtub was thoroughly cleaned on 5/16/22 by NHCS administration. The bathtub was replaced on 6/5/22 by a contractor. The bathtub drain cover was discarded on 5/16/by NHCS administration. The unlabeled pieces of soap were discarded on 5/16/22 by NHCS. The toilet was unclogged on 5/16/22 by NHCS administration. The floor vents have been replaced by NHCS administration on 5/17/22. The carpet in the basement was removed and replaced on 5/17/22 by a carpet company. The laundry room was cleaned on 5/18/22 by NHCS administration. |
06/21/2022
| Not Implemented |
| 6400.64(e) | On 5/16/2022, at 12:06PM, the trash receptacles with a height of twenty-four inches in the laundry room and kitchen of the home did not have lids. | Trash receptacles over 18 inches high shall have lids. | The trash was replaced on 5/16/22 by New Horizon Care Services administration. Administration completed a review of the physical site on 5/16/22 to ensure that all trash cans over 18 inches had a lid. |
06/21/2022
| Not Implemented |
| 6400.64(f) | On 5/16/2022, at 10:34AM, the outside trash receptacle on the side of the home was overflowing with garbage bag to be close completely. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | On 5/16/22 New Horizon Care Services administration brought an additional trash receptacle to the house and removed the excess garbage |
06/21/2022
| Not Implemented |
| 6400.66 | On 5/16/2022, at 11:24AM, the exterior lighting fixture next to sliding glass door leading from the dining room did not have a bulb; there is not another source of lighting in this area. At 11:49am, four of the six lighting fixtures above the mirror in the bathroom on the first floor of the home did not contain light bulbs which did not provide sufficient lighting. There were four exposed electrical lighting sockets in the bathroom on the first floor 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.
| The lights bulb in the exterior lighting fixture, and the light bulbs in the bathroom were placed on 5/16/22 by NHCS administration. NHCS administration conducted a physical site review on 5/19/22 to ensure that all areas of the home have adequate lighting and that all fixtures had working light bulbs. |
06/21/2022
| Not Implemented |
| 6400.67(a) | On 5/16/2022, at 11:40AM, there was a jagged edge hole approximately two inches by three inches in the wall above the left side of the vertical blinds mount above the sliding glass door in the dining room of the home. The vertical blinds over the sliding glass door in the dining room of the home were lopsided causing the blinds to bend when hitting the floor and to not open and close properly. | Floors, walls, ceilings and other surfaces shall be in good repair. | The area above the left side of the vertical blinds was repaired on 5/17/22 by maintenance. The vertical blinds were removed by NHCS administration on 5/17/22. A new rod and new curtains were hung in place of the vertical blinds on 5/19/22 by NHCS administration. NHCS administration conducted a physical site review on 5/19/22 to ensure that the walls in the home were in good repair. |
06/21/2022
| Not Implemented |
| 6400.67(b) | On 5/16/2022, at 12:07PM, the door to the bathroom in the basement of the home was not attached with the top hinge leaving two screws were protruding three-inch from the door posing a laceration and puncture hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The door was attached to the hinges on 5/16/22 by NHCS administration. A physical site review was completed by NHCS administration on 5/19/22 to ensure that all doors were on hinges and there were no hazards. |
06/21/2022
| Not Implemented |
| 6400.72(a) | On 5/16/2022, at 12:08PM, the screen for the window facing the street in the basement of the home was too small leaving a half inch gap that was not screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | A new screen to the window facing the street in the basement was purchased and replaced on 5/17/22 by NHCS administration. The agency completed a physical site review on 5/19/22 to ensure that all windows had screens present and that they were in good repair. |
06/21/2022
| Not Implemented |
| 6400.72(b) | On 5/16/2022, at 11:16AM, the sliding glass door from the dining room to the outside deck did not have a screen. The screen was leaning against the door and is too large to fit in the track and was unable to be reinstalled. | Screens, windows and doors shall be in good repair. | The screen was removed on 5/19/22. NHCS administration completed a physical site review on 5/19/22 to ensure that all screens are in good repair. |
06/21/2022
| Not Implemented |
| 6400.72(c) | On 5/16/2022, at 11:15AM, the sliding glass door leading from the dining room to the outside deck in the back of the home did not have an operable lock. | Outside doors shall have operable locks. | A new lock was purchased and placed on the sliding glass door on 5/17/22 by NHCS administration. NHCS administration completed a physical site review to ensure that all outside doors have operable locks on 5/19/22. |
06/21/2022
| Not Implemented |
| 6400.76(a) | On 5/16/2022, at 12:04PM, the entire three-foot length cushion of the single side of the sectional couch torn two to four inches exposing the foam padding and other stuffing materials. The back left burner head was lifted away from the stove top rendering it inoperable. The top, sides, inside, outside, handle and door of the oven in the kitchen were coated in grease, drippings and splattering of food substances and particles. The oven door did not fully close leaving the oven always open approximately one to two inches. The microwave in the kitchen of the home had a multitude of food particles and splatters to the inside of the door. The acrylic enamel on the top of the inside of the microwave was melted with food stuck to it. The first-floor bathroom toilet was clogged and backed up with bodily waste and toilet paper. There was also fecal matter on the toilet seat. This bathroom was overcome with acrid fumes from the amount of excrement in the toilet. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The couch was discarded on 5/17/22 by NHCS administration. A new stove was purchased by NHCS administration on 5/16/22 and delivered on 5/17/22. The microwave was replaced with a new one on 5/17/22 by NHCS administration. The toilet was unclogged on 5/16/22 by NHCS administration. The bathroom was cleaned (including toilet seat) on 5/16/22 by NHCS administration. The toilet seat was replaced on 5/25/22 by NHCS administration. NHCS administration completed a physical site review on 5/19/22 to ensure that furniture is nonhazardous, clean, and sturdy. |
06/21/2022
| Not Implemented |
| 6400.80(a) | One of the wooden planks of the exterior deck directly outside of the sliding glass door egress from the dining room was lifting approximately one inch, posing a tripping and falling hazard. In addition, twigs, leaves, and other outside debris were collecting around the protruding board posing a tripping and slipping hazard. The gutter in the rear of the house, was reportedly damaged by a fallen tree thus creating a stream of water running down the side of the house on to the landing of the outside stairs causing an accumulation of moss and water creating a wet slick surface posing a slipping and falling hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The wooden plank that was lifted on the deck was repaired on 5/17/22 by an outside company. The twigs, leaves and other debris were removed on 5/17/22 by NHCS administration. The gutter in the rear of the home was repaired on 5/17/22 by an outside company. The area where the moss was located was cleaned and nonskid strips were placed on 5/17/22 by an outside company. |
06/21/2022
| Not Implemented |
| 6400.82(d) | On 5/16/2022, at 12:07PM, the door to the bathroom in the basement of the home was askew and attached only by the lower hinge. | Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. | The door to the basement bathroom was attached to the hinge on 5/16/22 by NHCS administration. A physical site review was completed on 5/19/22 by NHCS administration to ensure that the individuals have privacy while using the bathroom. |
06/21/2022
| Not Implemented |
| 6400.82(f) | On 5/16/2022, at 11:48AM, the bathroom on the first floor of the home was observed to not have clean paper or cloth towels. | 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. | Paper towels and a paper towel holder were placed in the bathroom on 5/16/22. NHCS completed a physical site review on 5/19/22 to ensure that both bathrooms at the home had paper towels present. |
06/21/2022
| Not Implemented |
| 6400.83(a) | The back left burner head was lifted away from the stove top rendering it inoperable. The oven door did not fully close leaving the oven always open approximately one to two inches rendering unsafe to use. The acrylic enamel on the top of the inside of the microwave was melted, pealing and delaminating rendering unsafe to use. | A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. | A new stove and microwave were purchased by NHCS administration on 5/16/22 and it was delivered on 5/17/22.NHCS administration completed a physical site review on 5/19/22 to ensure that the home had clean, operable cooking equipment. |
06/21/2022
| Not Implemented |
| 6400.101 | On 5/16/2022, at 10:54AM, there was a wooden bar in the left side track of the sliding glass door leading from the dining room to the outside deck obstructing immediate egress from this exit of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The wooden bar was removed from the window and the home on 5/16/22 by NHCS administration. NHCS completed a physical site review on 5/19/22 to ensure that none of the exits in the home were obstructed. |
06/21/2022
| Not Implemented |
| 6400.110(a) | Individual #1 requires a bed shaker to alert him in the event of a fire as a result of his visual and hearing impairment. The bed shaker was not operable and was not connected to the home's fire alarm system on May 16, 2022; the individual was observed sleeping in his bed at 10:40 AM on that date | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The individual unplugged the bed shaker to charge his iPad. The bed shaker was plugged back into the wall. The part of the bed shaker that detects smoke was removed from the bedroom and placed in the hallway on 5/16/22 by NHCS. The part of the bed shaker that detects smoke was moved to the hallway on 5/16/22 by NHCS administration. The bed shaker was tested on 5/16/22, 5/17/22, and 5/19/2 by NHCS administration to ensure that it was operable. |
06/21/2022
| Not Implemented |
| 6400.171 | On 5/16/2022, at 11:42am, the acrylic enamel on the top of the inside of the microwave was melted causing peeling, and delaminating rendering it unsafe to safely use. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The microwave was discarded, and a new microwave was purchased on 5/17/22 by NHCS administration. The agency completed a physical site review on 5/19/22 to ensure that that food would be protected from contamination. |
06/21/2022
| Not Implemented |
| 6400.32(c) | Individual #1's Individual Plan last updated on 5/20/22 states "Poisons substance must be kept out the [Individual #1]'s reach as he does not understand that they may be harmful to him. He has balance problems because of his vision and auditory deficits, making him prone to falling at times. [Individual #1] does not understand danger. He is visually and hearing impaired." On 5/16/2022, the home had multiple slipping, tripping, falling, laceration, and puncture hazards including loose wiring, wet inside floors, wet and mossy outside steps, wooden decking with protruding boards, obstructed egresses both in the home and on the walkways, lack of handrails, accessible poisonous materials, and inadequate lighting. In addition, Individual #1 would not be alerted in the event of fire, the bed shaker was not operable while individual #1 was sleeping in his bed at 10:40AM and was not connected to the fire alarm system throughout the home. Individual #2's Individual Plan last updated on 5/11/22 states: "He needs supervision and verbal prompts with cooking and cleaning. [Individual #2] needs monitoring and verbal supports from staff when around heat sources. He is never left alone when cooking something with a heat source. [Individual #2] does like helping when in the kitchen but staff are always with him when heat is involved, with verbal and monitoring supports. [Individual #2] does not always understand the dangers of heat sources requires supervision around them. He needs verbal, monitoring, physical support. Physical is for cooking meals but if he wants to assist, he needs reminders of when to turn off heat or monitoring for proper use. [Individual #2] lives in a 24-hour residential home. He is also always monitored. He can be alone in his room or within eyesight on his porches." On 5/16/2022, Direct Service Worker #2 was sitting in the living room on the couch covered up with a blanket scrolling on her cell phone. Individual #2 was unsupervised cooking eggs in the kitchen on the stovetop by himself. There were three occasions where Individual #2 unsupervised when exited the interior of the home and went out on to the front porch while Direct Service Worker #2 remained on the living room couch. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | On 5/16/22 the poison was locked in the chemical cabinet by New Horizon Care Services administration. The home corrected all identified repairs May 16, 2022-May 20, 2022. The part of the bed shaker that was in Individual 1's bedroom that detected smoke was moved to the hallway on May 16, 2022, by New Horizon Care Services administration. The bed shaker was connected to the fire alarm system throughout the home on May 16, 2022, by New Horizon Care Services administration. Staff was trained on Individual #2's ISP plan on 5/17/22 by New Horizon Care Services Program Specialist. All staff working at the site were instructed of the agency cell phone policy, job descriptions, and individual rights on 6/16/22. An investigation has been initiated. Staff identified has been trained on the individual's ISP. |
06/21/2022
| Not Implemented |
| 6400.32(d) | On 5/16/2022, the home was in such a state of uncleanliness and disrepair that the individuals living in the home had to be relocated from the home. The Individuals in the home did not have an operable toilet, safe and operable equipment to cook and prepare food, a safe and clean bathtub, an operable fire alarm system, unobstructed egresses, and the safe conditions in the home without the risk of slipping, tripping and laceration hazards. | An individual shall be treated with dignity and respect. | The home was deep cleaned and sanitized on 5/16/22 by NHCS administration. The toilet was unclogged and cleaned on 5/16/22 by NHCS administration. The stove and microwave were replaced on 5/17/22. The bathtub was cleaned by NHCS administration on 5/16/22. The obstructions were removed from the egresses by NHCS on 5/16/22. The slipping, tripping and laceration hazards were completed by 5/20/22 by an outside entity. |
06/21/2022
| Not Implemented |
| 6400.186 | Individual #1's Individual Plan last updated on 5/20/22 states "Poisons substance must be kept out the [Individual #1]'s reach as he does not understand that they may be harmful to him. He has balance problems because of his vision and auditory deficits, making him prone to falling at times. [Individual #1] does not understand danger. He is visually and hearing impaired." On 5/16/2022, the home had multiple slipping, tripping, falling, laceration, and puncture hazards including loose wiring, wet inside floors, wet and mossy outside steps, wooden decking with protruding boards, obstructed egresses both in the home and on the walkways, lack of handrails, accessible poisonous materials, and inadequate lighting. In addition, Individual #1 would not be alerted in the event of fire, the bed shaker was not operable while individual #1 was sleeping in his bed at 10:40AM and was not connected to the fire alarm system throughout the home. Individual #2's Individual Plan last updated on 5/11/22 states: "He needs supervision and verbal prompts with cooking and cleaning. [Individual #2] needs monitoring and verbal supports from staff when around heat sources. He is never left alone when cooking something with a heat source. [Individual #2] does like helping when in the kitchen but staff are always with him when heat is involved, with verbal and monitoring supports. [Individual #2] does not always understand the dangers of heat sources requires supervision around them. He needs verbal, monitoring, physical support. Physical is for cooking meals but if he wants to assist, he needs reminders of when to turn off heat or monitoring for proper use. [Individual #2] lives in a 24-hour residential home. He is also always monitored. He can be alone in his room or within eyesight on his porches." On 5/16/2022, Direct Service Worker #2 was sitting in the living room on the couch covered up with a blanket scrolling on her cell phone. Individual #2 was unsupervised cooking eggs in the kitchen on the stovetop by himself. There were three occasions where Individual #2 unsupervised when exited the interior of the home and went out on to the front porch while Direct Service Worker #2 remained on the living room couch. | The home shall implement the individual plan, including revisions. | The home was cleaned and sanitized on 5/16/22 by NHCS administration. The light bulbs were placed in each socket on 5/16/22 by NHCS administration. The tripping hazards were rectified by an outside agency by 5/20/22. This included a wood plank on the deck, non-skids being placed on the deck, the gutter being repaired, and new carpet being installed throughout the home. The smoke detector was plugged in and the part that detects smoke was placed into the hallway. The agency conducted a staff training on 6/1/22. The staff were trained that an individual's ISP must be implemented as written. The staff were instructed that chemicals must be locked at all times. NHCS created the daily household task form which must be completed and documented using the checklist. The training also included checking and documenting the all-household essentials, physical site compliance, and that the individual is supervised according to their ISP. NHCS administration completed a physical site visit on 5/19/22 to ensure that the site was within regulatory compliance. The identified staff has signed off on an in-service that both of the ISPs of the individual was read. |
06/21/2022
| Not Implemented |