| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Provider #2's date-of-hire is 1/28/25. The agency completed a Pennsylvania criminal history check to the State Police on 9/17/25. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Upon noticing the DSP's original criminal history check was missing from their file, the agency completed a PA criminal history check and maintained it in the staff file. |
09/26/2025
| Implemented |
| 6400.67(b) | At 12:49 PM on 9/25/25, there were extensive pools of standing water on the floor in the laundry/ furnace room located in the home's basement. Some areas of water measured one-eighth of an inch in depth. [Repeated Violation-7/1/25, et al] | Floors, walls, ceilings and other surfaces shall be free of hazards. | The basement floor was dried, and a humidifier will be added to lessen water accumulation. A plumber is scheduled to reinspect the area the week of 10/20/2025 to determine the best fix for the water issue. |
11/20/2025
| Implemented |
| 6400.142(f) | Individual #1's date-of-admission is 1/15/25. Their initial/ current assessment, completed on 9/23/25, states that "[Individual #1] can brush [their] teeth independently, but at times, will need prompted to do so." Individual #1's content of records did not include a written plan for dental hygiene. | 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 will maintain a dental hygiene plan in the individual's file. |
11/20/2025
| Implemented |
| 6400.181(a) | Individual #1's date-of-admission is 1/15/25. However, Individual #1's initial assessment was not completed until 9/23/25, by Program Specialist #3. [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)(10) | Individual #1's lifetime medical history was not included with their initial/ current assessment completed on 9/23/25, as this document was not present in Individual #1's content of records. [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)(11) | Individual #1's applicable psychological evaluation was not included with in their initial/ current assessment completed on 9/23/25, and Individual #1's content of records did not include documentation of the agency attempting to obtain one. [Repeated Violation, 12/5/24, et al] | The assessment must include the following information: Psychological evaluations, if applicable. | The program specialist will request the historical documentation of the individual's psychological evaluation. In the event one cannot be located, the agency will arrange for the individual to have a completed evaluation. |
11/20/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's initial/ current assessment, completed on 9/23/25, did not address recommendations for specific areas of training, programming and services relative to Individual #1, as the corresponding field read, "Staff will be trained on [Individual #1's] ISP and RPP." [Repeated Violation, 12/5/24, et al] | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist will review all individual assessments and ensure they include the recommendations for specific areas of training, programming, and services. |
11/20/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's date-of-admission 1/15/25. Individual #1's initial/ current assessment, completed on 9/23/25, did not address their progress or current level of functioning 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 12:54 PM 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 psychological evaluation; refusal documentation of the 7/25/25 dental examination appointment; and an applicable dental hygiene plan. [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 |
| 6400.46(d) | Direct Service Provider #1's date-of-hire is 1/15/25. Direct Service Provider #1 completed a two-year certification training through the National CPR Foundation on 1/14/25 in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. However, according to the National CPR Foundation curriculum, this 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 |
| 6400.51(b)(5) | Direct Service Provider #1's date-of-hire is 1/15/25. Direct Service Provider #1's orientation training included reviews of behavior support plans, restrictive procedure plans, and individual service plans conducted on 1/10/25, 1/11/25, and 1/12/25. However, this training did not specify the individuals whose care plans were reviewed. [Repeated Violation-12/5/24, et al] | The orientation must encompass the following areas: Job-related knowledge and skills. | A sign in sheet has been created to verify staff are trained in the plan specific to the individual they will be working with. All current staff will be retrained on the care plan specific to their house assignment(s). |
11/20/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 7/1/25, contained the following discrepancies between their initial and initial/ current assessment, completed on 9/23/25, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 7/1/25, contained no reference to or language addressing their ability to sense and quickly move away from such heat sources. Individual #1's assessment, completed on 9/23/25, indicated that Individual #1 is able to sense and quickly move away from dangerous heat sources independently; regarding supervision within the home, Individual #1's Individual Service Plan, last updated 7/1/25, explained that Individual #1 receives "24-hour supervision in a single-person home and is required to follow conditions of [their] bond," as Individual #1 is currently on probation. "Staff should be aware of [Individual #1's] whereabouts at all times." In contrast, Individual #1's assessment, completed on 9/23/25, provided that Individual #1 requires 24-hour supervision, that they must be monitored at all times, and that before interacting with females, Individual #1 must be informed by staff of whether the female is of legal age; and regarding supervision within the community, Individual #1's Service Plan, last updated 7/1/25, stated that Individual #1 requires a 1:1 staffing ratio and that they can negotiate traffic as well as cross streets independently. However, Individual #1's assessment, completed on 9/23/25, informed that Individual #1 requires 24-hour supervision when in the community and that they must be supervised at all times, as Individual #1 is currently on house arrest. [Repeated Violation, 12/5/24, et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Management will review the individual's assessment and make any necessary adjustments. |
11/20/2025
| Implemented |