| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | At the time of the 6/22/23 inspection, the lower section of the screen was not attached to the door frame on the back door of the screened-in porch. | Screens, windows and doors shall be in good repair. | A handy man was contacted and is scheduled to come out the week of 7/31/23 to reattach the screen to the door frame. On 7/13/23 staff were retrained on the importance of having Screens, windows and doors shall be in good repair. Management staff including the lead staff and the director were retrained on providing oversight to the home regarding upkeep and repairs. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance. |
08/02/2023
| Implemented |
| 6400.101 | At the time of the 6/22/23 inspection, the door leading from the garage to the side of the home was blocked by the company vehicle. The vehicle was pulled to the front of the garage, cutting off the egress passageway to the door. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| As of 7/25/23 the company vehicle was moved to allow access to the exit from the garage that leads to the side of the home. On 7/13/23 the staff were trained on the importance of Stairways, halls, doorways, passageways, and exits from rooms and from the building shall be unobstructed. Management staff including the lead staff and the director were retrained on providing oversight to the home regarding blocked egresses/exits and correcting the issue ASAP. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance ad unobstructed exits. |
08/02/2023
| Implemented |
| 6400.103 | During the 6/21/23 inspection, the agency produced an Emergency Evacuation Policy for the Department. This policy did not include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation.
The home produced an Emergency Evacuation and Temporary Placement plan. This plan did not include the individual's responsibilities or applicable staff responsibilities. This plan states staff on shift are to contact a program coordinator for directions and the process of evacuation, can contact an on-call point person, and is to take further direction for delivery of medications, supplies, and notification of family members by the program coordinator or program specialist. The agency, Case Sense Living LLC., did not provide the Department with any staff member that holds the title of a program coordinator for the direct support staff to know who to contact for further instructions.
Both plans were missing components of the requirements defined in 55 Pa. Code § 6400.103. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| On 7/13/23 Staff person were updated on the updated emergency evacuation and temporary Placement protocol. The emergency evacuation and temporary Placement protocol were updated to reflect the missing components and they now include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation. The Emergency Evacuation and Temporary Placement plan now includes the individual's responsibilities or applicable staff responsibilities. This plan has been updated who the staff and family members should contact in an emergency. Both plans updated to reflect all components of the requirements defined in 55 Pa. Code § 6400.103. |
07/13/2023
| Implemented |
| 6400.106 | The home was unable to produce records that the furnace of the home was cleaned and inspected annually by a professional furnace cleaning company. At the time of the 6/21/23 inspection, the records produced stated the furnace was inspected in 6/6/2023 but was unable to produce any inspection and cleaning records of the furnace in 2022. | 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.
| On 7/13/23 staff were retrained on the importance of ensuring that 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. |
07/13/2023
| Implemented |
| 6400.110(a) | At the time of the 6/22/23 inspection, the smoke detectors on the first floor and basement that are interconnected were not operable. When attempting to activate the detectors, the detectors said, "Ready to connect, follow quick start installation, ready to connect to four detectors." The home is equipped with 8 smoke detectors. After a few minutes and multiple attempts at connecting and reactivating the detectors, the interconnected devices activated, but only when using one particular detector. The only smoke detector in the common area outside Individual #1's bedroom was very faint when attempting to activate the device. The smoke detector from a bedroom had to be reset to activate the smoke detector in the common area outside the individual's bedroom. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 0n 6/23/23 the smoked detectors were fixed/updated and were in working order. on 7/13/23 staff were retrained on the importance of having a A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Management staff including the lead staff and the director were retrained on providing oversight to the home regarding smoke detectors and then being in proper working order. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance ad unobstructed exits. |
08/04/2023
| Not Implemented |
| 6400.111(f) | During the 6/21/23 inspection, the home was unable to produce records that the fire extinguishers in the home were inspected and approved annually by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | On 7/13/23 staff were retrained on the importance of ensuring that all fire extinguishers shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Management staff including the lead staff, the director were retrained on providing oversight to the home regarding fire extinguishers and proper inspection and maintenance. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance . |
08/04/2023
| Not Implemented |
| 6400.112(c) | The electronic fire drill records produced during the 6/21/23 inspection, were completed by a staff who was not present during 9 out of the 12 fire drills held at the home over the previous year. The electronic fire drill records produced for drills held from January 2023 to June 2023, do not record the same information that the paper fire drill records do for drills held from January 2023 to June 2023. The home reported during the inspection that the paper records are discarded after completion by the staff person who is conducting the drill and recording the information. Due to this, the information documented on the electronic fire drill records for the previous year is unknown if it's accurate information for all requirements defined in 55 Pa Code 6400.112(c).
Documentation if all smoke detectors in the home are operable at the time of the monthly fire drills is not documented on the electronic or paper records, nor do the electronic and paper records match with the location and amount of smoke detectors in the home to determine if they're operable. For example, the electronic fire drill records document 6 smoke detectors are operative from July 2022 to June 2023, the paper fire drill records from January to April 2023 and June 2023 document 7 smoke detectors are operative, the paper fire drill records from May 2023 document 8 smoke detectors are operative, and during the 6/22/23 home inspection 8 smoke detectors were found in the home.
The paper fire drill records do not include the year the fire drill held on January 4th references, and the time the fire drill was conducted was not recorded on the paper fire drill records for the drill held on 2/4/23. The electronic fire drill record for the drill held on 2/4/23 included the time the fire drill was held; however, this document was completed by a staff person who was not present for the fire drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All staff were trained on the importance of having a written fire drill record completed, including the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Staff were trained as well on how to complete fire drill documentation. |
08/04/2023
| Implemented |
| 6400.112(h) | The electronic and paper fire drill records from July 2022 to June 2023 do not document if individuals went to the meeting place during the monthly fire drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | On 7/13/23, all staff were trained on the importance of ensuring that they document and ensure that Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. |
08/04/2023
| Not Implemented |
| 6400.112(i) | The electronic and paper fire drill records from July 2022 to June 2023 do not document or report if a smoke detector was activated to simulate the monthly fire drills. | A fire alarm or smoke detector shall be set off during each fire drill. | On 7/13/23 all staff were trained on the importance of ensuring that they document and ensure that a fire alarm or smoke detector shall be set off during each fire drill. |
08/04/2023
| Implemented |
| 6400.113(a) | At the time of the 6/21/23 inspection, the most recent fire safety training offered to Individual #1 was completed on 3/3/22. | 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. | A new fire safety training was conducted by 7/25/23. On 7/13/23 staff were trained on the importance of ensuring that 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. |
07/13/2023
| Implemented |
| 6400.145(1) | During the 6/21/23 inspection, the agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the hospital or source of heath care the individuals in the home are to utilize in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | On 7/13/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency . |
07/13/2023
| Implemented |
| 6400.145(3) | During the 6/21/23 inspection, the agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the emergency staffing plan the home is to utilize in an emergency. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | On 7/13/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency and the staffing plan. |
07/13/2023
| Implemented |
| 6400.172 | At the time of the 6/22/23 inspection, there was very little food present in the home. The agency reported to the Department during the inspection that the home does not have any daily, weekly, or monthly menus prepared for the home or documentation to show that at least three meals were offered and available to Individual #1 daily. The home reports Individual #1 is not involved in any meal or menu planning that affects the food offered to them and available to them in the home.
The home did not produce documents that the individual's physician has ordered any food restrictions or other dietary needs, nor does the individual have a restrictive plan to restrict food. | At least three meals a day shall be available to the individuals.
| Menus were created and the home shops weekly and or biweekly and the individual is a part of those choices. since the inspection food purchases have been made on more than one occasion. Food items were purchased for the home and food is available for the individual consumption.
On 7/13/23 staff were retrained on the importance of ensuring that at least three meals a day shall be available to the individuals. The director of residential also set up as of 7/25/23 an online grocery store portal access so all team members have access to see food choices and purchases. |
07/25/2023
| Implemented |
| 6400.32(d) | During the 6/22/23 onsite inspection, an additional non-skid shower mat was located inside Individual #1's bathroom closet. Staff person #2 raised their voice at Individual #1, asked the individual why they removed the non-skid shower mat from the shower and put it in the closet, and told the individual they couldn't remove the non-skid shower mat, all while Individual #1 repeatedly kept saying, "I'm sorry, I'm sorry," in a defeated tone. | An individual shall be treated with dignity and respect. | On 7/13/23 staff were retrained on the individuals plan and behavior plan and best practices as it pertains to creating a therapeutic environment and usage of positive approaches where the individual is treated with dignity and respect. as of 7/13/23- The nonskid shower mat was put in place in the showers for the individuals use. |
07/13/2023
| Implemented |
| 6400.32(t) | At the time of the 6/22/23 inspection, there was very little food present in the home. The agency reported to the Department during the inspection that the home does not have any daily, weekly, or monthly menus prepared for the home or documentation to show that at least three meals were offered and available to Individual #1 daily. The home reports Individual #1 is not involved in any meal or menu planning that affects the food offered to them and available to them in the home.
The home did not produce documents that the individual's physician has ordered any food restrictions or other dietary needs, nor does the individual have a restrictive plan to restrict food. | An individual has the right to access food at any time. | Menus were created and the home shops weekly and or biweekly and the individual is a part of those choices. since the inspection food purchases have been made on more than one occasion. Food items were purchased for the home and food is available for the individual consumption.
On 7/13/23 staff were retrained on the importance of ensuring that at least three meals a day shall be available to the individuals and that an individual has the right to access food at any time. The director of residential also set up as of 7/25/23 an online grocery store portal access so all team members have access to see food choices and purchases. |
07/13/2023
| Implemented |
| 6400.169(a) | Staff person #1 administers medications to Individual #1. Individual #1's Individual Support Plan states the individual is prescribed daily transdermal patches to be applied for hormone replacement. The agency never provided the Department with documentation that Staff person #1 was trained by a medical professional, or a certified medication administration trainer who was trained by a medical professional, in how to administer the medication. | 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). | On 7/13/23 Staff were trained to the importance of only administering items/medication that they are medically trained to administer. A separate mar has been created so that the nurse at the offsite location can sign off on the patch administration since they are certified to do so. |
08/04/2023
| Implemented |
| 6400.186 | Individual #1's 6/12/23 Individual Support Plan (ISP) states that the individual has self-harmed with sharp objects (plastic utensils, credit cards, combs, but not with knives or razor blades), and all medications, sharp knives and cleaning supplies need locked in their home. The ISP also states the individual historically has made comments about ingesting chemicals. At the time of the 6/22/23 inspection, there were multiple poisonous materials that contained a label to contact poison control center if ingested and multiple sharp objects found unlocked and accessible throughout the home These items included: multiple face washes and hygiene supplies in the individual's bathroom, multi-surface cleaner, dawn dish soap, and 2 bags of cascade dishwashing pods under the kitchen sink, and bleach, joint compound, B-gone bug killer in the hallway closet by the laundry machine. A box of sharp construction objects (nails, screw drivers, bits, a hammer) and scissors were unlocked and accessible in the closet in the dining room.
During the 6/22/23 inspection, staff person #2 unlocked the cabinet in the hallway by Individual #1's bedroom to get items out for inspection. Individual #1 was present in the home. Staff person #2 never re-locked the cabinet and left the keys in the doorknob. Individual #1 came over to the open cabinet and staff person #2 guided the individual away from the cabinet but still did not lock the cabinet. Inside this cabinet was cleaning supplies and sharp objects.
Individual #1's ISP states they are on a diet of "no seconds, except fruits and vegetables." The individual does not have a restrictive plan to restrict foods. Very little, if any fruits and vegetables could were present in the home during the 6/22/23 onsite inspection. | The home shall implement the individual plan, including revisions. | On the 13th of July 2023 staff were retrained on the importance of ensuring that the home implements the individual plan, including revisions. On 7/28/23, the homes management team will be meeting to review plans and any revisions needed in order to do a cohesive update per person. As of 6/26/23 knives and poisons were locked away and also fruits and vegetables were purchased for the home for the Indvidual. |
07/28/2023
| Implemented |