| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The fire department was notified by the agency through letter on 4/19/22, that an individual with intellectual disabilities lives in the home. However, the home's fire department notification letter did not include the following: the total capacity of the home, a description of the general layout of the home, and a general description of the mobility needs of the individuals served. [Repeated Violation, 12/5/24, et al] | 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.
| The agency will modify the fire department notification letter to include all regulatory requirements and send out the modified letter. |
11/20/2025
| Implemented |
| 6400.112(e) | According to the written fire drill record, there was no drill held during sleeping hours from December 2024 through May 2025. [Repeated Violation, 12/5/24, et al] | A fire drill shall be held during sleeping hours at least every 6 months. | Management will conduct a fire drill during sleeping hours to ensure there is one for the second half of the year. |
11/20/2025
| Implemented |
| 6400.141(c)(4) | Individual #1 had a vision screening conducted on 7/01/23, and then again 4/10/25. Individual #1 had a hearing screening conducted on 7/01/23, and not again since. [Repeated Violation, 12/5/24, et al] | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Management schedule the individual for a hearing screening. |
11/20/2025
| Implemented |
| 6400.141(c)(7) | Indvidual #1's date-of-admission is 10/17/24. There was no documentation of Individual #1 ever having a gynecological examination, including a breast examination and a Pap test, conducted. [Repeated Violation, 12/5/24, et al] | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Management will obtain documentation for the individual's most current gynecological exam. |
11/20/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, completed on 1/31/25, did not include physical limitations. The corresponding field was left blank. | The physical examination shall include: Physical limitations of the individual. | Management will obtain a corrected copy of the individual's physical to indicate the individual's accurate status of physical limitations. |
11/20/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed on 1/31/25, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The corresponding field was left blank. [Repeated Violation, 12/5/24, et al] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Management will obtain a corrected copy of the individual's physical to indicate the individual's medical information pertinent to diagnosis and treatment in case of emergency. |
11/20/2025
| Implemented |
| 6400.142(g) | Individual #1 last had an applicable dental hygiene plan written on 8/20/24. | A dental hygiene plan shall be rewritten at least annually. | Management will create an updated dental hygiene plan to be included in the individual's file. |
11/20/2025
| Implemented |
| 6400.144 | On 9/25/25, interviews conducted with Chief Executive Officer Designee #1 revealed that Individual #1 was out in the community with Direct Service Provider #2 for breakfast and a therapy appointment. However, Direct Service Provider #2, who had taken Individual #1 out in the community, was not in possession of Individual #1's prescribed pro re nata life-sustaining medication, Ventolin HFA AER, for their asthma diagnosis. In addition, Individual #1 was hospitalized on 3/2/25, with recommendations to follow up with their primary care physician within 3 to 5 days. Individual #1's physical examination, completed on 1/31/25, documented a recommendation to follow up with Individual #1's primary care physician on 6/5/25. Individual #1 was hospitalized on 2/14/25, with recommendations to follow up with therapy on 2/18/25. Individual #1 was hospitalized on 12/17/24, which documented a recommendation to follow up with therapy on 12/31/24. However, Individual #1's content of records did not include documentation of any of the follow-up appointments recommended. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Management will obtain copies of the individual's follow up appointments. |
11/20/2025
| Implemented |
| 6400.151(a) | Direct Service Provider #3 had a physical examination completed on 4/13/23, and not again since. [Repeated Violation, 12/5/24, et al] | 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. | Management will ensure the DSP completes a current physical. |
11/20/2025
| Implemented |
| 6400.181(a) | Individual #1, with a date-of-admission on 10/17/24, had an initial assessment completed on 9/23/25. [Repeated Violation, 12/5/24, et al] | 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. | Management reviewed all individual files to locate the original assessment that fell within the appropriate regulatory timeframe. |
11/20/2025
| Implemented |
| 6400.181(e)(8) | Individual #1's assessment, completed 9/23/25, documented that Individual #1 can evacuate independently in the event of a fire. However, according to the written fire drill record, drills conducted on 1/9/25, 4/15/25, 6/23/25, and 9/5/25 documented that Individual #1 needed verbal prompting to exit. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Management will review the individual's assessment and make any necessary adjustments. |
11/20/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 9/23/25, did not include a current lifetime medical history, as the information had been last updated on 10/3/23. [Repeated Violation, 12/5/24, et al] | The assessment must include the following information: A lifetime medical history. | Management will assess all current individual files and ensure the implementation of their lifetime medical history document. |
11/20/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment, completed 9/23/25, did not include their current skill level in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Management will review all individuals' files to ensure their level of financial independence is reflected in their assessment. |
11/20/2025
| Implemented |
| 6400.214(b) | At 10:20 AM on 9/25/25, neither hard nor electronic copies of the following regarding Individual #1's most current records were kept at the home: a Service Plan; a hearing screening or examination; a dental examination; an applicable dental hygiene plan; and incident reports. [Repeated Violation, 12/5/24, et al; 5/30/25; 7/1/25, et al; & 8/21/25, et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Management will review all individual house binders to ensure all required documents are included. |
11/20/2025
| Implemented |
| 6400.18(a)(3) | Enterprise Incident Management # 9675090, for a behavioral health crisis event involving a voluntary psychiatric hospitalization, was discovered on 8/10/25 at 8:00 PM and reported on 8/18/25 at 9:47 AM. [Repeated Violation, 12/5/24, et al] | The 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: Inpatient admission to a hospital.
| Management staff will be retrained on Incident Management requirements. |
11/20/2025
| Implemented |
| 6400.32(g) | At 10:22 AM on 9/25/25, the interior door leading to the basement was locked, requiring a key to disengage it, due to Individual #1's medication and records being kept at the desk located on this level of the home. On 9/25/25, the agency stated that one of Individual #1's goals is to complete their own laundry. However, since Individual #1 has to request staff to unlock the interior basement door to provide access to the laundry room located in the home's basement, Individual #1's goal of completing their own laundry is being impeded. | An individual has the right to control the individual's own schedule and activities. | Management will remove the locking doorknob and replace it. |
11/20/2025
| Implemented |
| 6400.46(d) | Direct Service Provider #3 was trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation on 4/07/23, through the National CPR Foundation. However, the National CPR Foundation's curriculum for the aforementioned training did not include an in-person component. [Repeated Violation, 12/5/24, et al] | 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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Management will identify CPR training with an in-person component and retrain current staff to maintain compliance with regulatory requirements. |
11/20/2025
| Implemented |
| 6400.52(c)(5) | Direct Service Provider #3, with a date-of-hire on 3/13/24, had no record of being trained in the safe and appropriate use of behavior supports for the individuals with whom they worked. [Repeated Violation, 12/5/24, et al] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Management will ensure the retraining of DSP staff on the appropriate use of behavior supports for the individuals with whom they work. |
11/20/2025
| Implemented |
| 6400.52(c)(6) | Direct Service Provider #3, with a date-of-hire on 3/13/24, had no record of being trained in the implementation of the individual plans for the individuals with whom they worked. [Repeated Violation, 12/5/24, et al] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Management will ensure the retraining of DSP staff on the implementation of the individual plans for the individuals with whom they work. |
11/20/2025
| Implemented |
| 6400.163(h) | On 9/25/25, the following Individual #1's prescribed pro re nata medications were expired, according to their corresponding medication labels: Anti-Diarrhea Tab. 2 MG---Take 1 tablet by mouth four times a day as needed for diarrhea---with an expiration date of 8/11/25; Ondansetron Tab. 4 MG ODT---Dissolve 1 tablet on the tongue and swallow every eight hours as needed for nausea or vomiting---with an expiration date of 8/11/25; and Ventolin HFA AER---Inhale 2 puffs every four hours as needed for wheezing (Asthma)---with an expiration date of 7/16/25. [Repeated Violation-2/27/25, et al; 5/30/25; 7/1/25, et al; and 8/21/25, et al] | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Management will dispose of the expired PRN medications and ensure the individual has updated medications on site. |
11/20/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed Lithium 450mg for Bipolar, Risperidone 3mg for depression, Buspirone 10mg for anxiety, and Venlafaxine for depression. Individual #1 had a psychotropic medication review by a licensed physician completed on 2/19/25, which did not include the reason for prescribing the medication. Individual #1 had a subsequent psychotropic medication review by a licensed physician completed on 4/9/25, which did not include the reason for prescribing and the need to continue the medications. In addition, individual #1, with a date-of-admission on 10/17/2024, had psychotropic medication reviews by a licensed physician completed on 2/19/25, 4/9/25, but not again since. [Repeated Violation, 12/5/24, et al] | 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. | Management will obtain documentation for the individual's medication reviews and ensure their accuracy. |
11/20/2025
| Implemented |
| 6400.166(a)(5) | On 9/25/25, Individual #1's September 2025 Medication Administration Record listed the following prescribed pro re nata medication as "Ventolin HFA AER," and did not include the medication's strength. However, the corresponding medication box read: "Each actuation delivers 108 mcg of albuterol sulfate equivalent to 90 mcg albuterol base from the mouthpiece." [Repeated Violation-12/5/24, et al; 7/1/25, et al and 8/21/25, et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Management will update the individual's MAR to reflect the medication strength. |
11/20/2025
| Implemented |
| 6400.166(a)(9) | On 9/25/25, Individual #1's September 2025 Medication Administration Record listed the following prescribed pro re nata medication as "Ventolin HFA AER---Inhale 2 puffs every four hours as needed for wheezing (Asthma). However, the frequency of this medication differed from what was indicated on its corresponding medication label that read: "Ventolin HFA AER---Inhale 2 puffs every six hours as needed for wheezing (Asthma)." [Repeated Violation-12/5/24, et al; 7/1/25, et al and 8/21/25, et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Management will update the individual's MAR to reflect the medication strength. |
11/20/2025
| Implemented |
| 6400.167(a)(1) | On 9/25/25, Individual #1's prescribed, Pantoprazole 40 MG Tab---Take 1 tablet every morning 1 hour before the first meal of the day for gerd---was not at the home. However, Individual #1's September 2025 Medication Administration Record documented the initials of Direct Service Provider #2 who had reportedly given this medication at 8:00 AM on 9/26/25. An interview conducted with Chief Executive Designee #1 revealed that Direct Service Provider #2, who had reportedly administered the aforementioned medication to Individual #1 at 8:00 AM on 9/25/25, stated that this administration was the last dose disposed from the corresponding blister pack which was, then, thrown in the garbage. However, this particular empty blister was not present in the home on 9/25/25. In order to ascertain if the "disposed" blister pack had enough tablets remaining to have been administered at 8:00 AM on 9/25/25, the Department requested the agency to contact PDC Pharmacy, which had filled this medication, for the last dispense date. However, the agency did not provide the Department with this information. Therefore, since Individual #1's prescribed, Pantoprazole 40 MG Tab., was not present in the home on 9/25/25, and that the last dispense date of this medication was not provided, the administration of this aforementioned medication at 8:00 AM on 9/25/25, cannot be confirmed. [Repeated Violation-2/27/25, et al] | Medication errors include the following: Failure to administer a medication. | Management provided the documentation requested by Department as requested via email on 10/01/2025 |
10/01/2025
| Implemented |
| 6400.169(a) | Direct Service Provider #3 was trained in medication administration on 2/25/25. However, this medication administration practicum did not include completion documentation of the hand washing and gloving, observations and medication administration record reviews. | 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). | Management reviewed staff files to locate the documentation of the DSP's medication administration. Management will retrain all staff missing any regulatory components of their medication administration training. |
11/20/2025
| Implemented |
| 6400.181(f) | There was no documentation of Individual #1's assessment, completed 9/23/25, ever being sent to the plan team prior to an annual individual support plan 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. | Management updated the calendar to ensure that assessments are mailed in the accurate timeframe. |
11/20/2025
| Implemented |
| 6400.183(c) | Individual #1's content of records did not include documentation of the list of persons who participated in Individual #1's last individual support plan meeting. [Repeated Violation, 12/5/24, et al] | The list of persons who participated in the individual plan meeting shall be kept. | Management reached out to the individual's SC to obtain the ISP signature page. |
11/20/2025
| Implemented |