| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #3, date of hire 4/25/2024, provided a copy of a Pennsylvania criminal history record check to with a requested date of 4/23/2024 to the provider agency. The printing on the paper form was not the standard printing, there was no seal on the form and there was no dissemination date. The provider agency requested a new background check on 12/22/2025 that was held for control with pending results. Direct Service Worker #3 began working with individuals on 5/1/2024. | 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.
| Agency Reran the employees PA Crimial record immediately and recieved it back a week late from the state directly. No Criminal record was found. We printed it out and placed in the emplyees file. |
03/06/2026
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination, completed 10/14/2025, does not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | The agency has developed a new Annual Physical Form and has implemented it immediately for all individuals. |
03/06/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 10/14/2025, does not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The agency has developed a new Annual Physical Form and has implemented it immediately for all individuals. |
03/06/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 10/14/2025, does not include medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency has developed a new Annual Physical Form and has implemented it immediately for all individuals. |
03/06/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 9/30/2025, does not include preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment has been updated to include a separate section for preferences. Preferences have been updated for each individual. |
01/15/2026
| Implemented |
| 6400.181(e)(5) | Individual #2's assessment, completed 6/28/2025, states that Individual #1 is able to independently administer medications and categorizes it as a strength in lieu of a need. Staff interviews revealed that Individual #2 often does not self-administer medications and is still working on full independence with this skill. | The assessment must include the following information: The individual's ability to self-administer medications. | This area for assessment was reviewed and the individual #2 is able to self-administer medications though she often choses not to because she may not feel like it, or her medical conditions are bothering her that day. |
01/15/2026
| Implemented |
| 6400.181(e)(8) | Individual #2's assessment, completed 6/28/2025, states that Individual #2 is able to independently evacuate the home in the event of a fire. The provider agency sent a notification letter to the local fire department on 2/19/2025 stating, "[Individual #2] would need full assistance to exit the apartment." Staff interviews revealed that Individual #2 needs full physical assistance to get out of bed and into a wheelchair to exit the home. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Program Specialist updated the assessment for individual #2 to actuarially reflect the need of assistance . |
01/15/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 9/30/2025, does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The HRST will be printed and attached to all individuals assessements. |
01/15/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 9/30/2025, does not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | this area of the assessment was reviewed and updated. |
03/06/2026
| Implemented |
| 6400.46(a) | Program Specialist #1, date of hire 11/25/2019, was trained in general fire safety via an online training on 2/25/2025. This training did not include site-specific in-person training. Direct Service Worker #2, date of hire 11/15/2024, was trained in general fire safety via an online training on 3/14/2025. This training did not include site-specific in-person training. Direct Service Worker #3, date of hire 4/25/2024, was trained in general fire safety via an online training on 3/10/2025. This training did not include site-specific in-person training. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The Director retrained all staff for site specific fire saftey information |
03/06/2026
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #2, date of hire 11/15/2024, completed orientation training on 3/16/2025. This training did not include site-specific training on job-related knowledge and skills. Direct Service Worker #3, date of hire 4/25/2024, completed orientation training on 3/17/2025. This training did not include site-specific training on job-related knowledge and skills. | The orientation must encompass the following areas: Job-related knowledge and skills. | The agemcy retrained all staff on each individuals Icurrent SP's and noted on the Training record. |
03/06/2026
| Implemented |
| 6400.166(a)(4) | Individual #2's December 2025 Medication Administration Record did not include the names of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(5) | Individual #2's December 2025 Medication Administration Record did not include the strength of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(6) | Individual #2's December 2025 Medication Administration Record did not include the dosage form of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(7) | Individual #2's December 2025 Medication Administration Record did not include the dose of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(8) | Individual #2's December 2025 Medication Administration Record did not include the route of administration of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(9) | Individual #2's December 2025 Medication Administration Record did not include the frequency of administration of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(10) | Individual #2's December 2025 Medication Administration Record did not include the administration times of Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(11) | Individual #2's December 2025 Medication Administration Record did not include the diagnosis or purpose for Fluticasone and Nystatin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Sumatriptan 100MG with special instructions to, "not exceed four tablets in 24 hours." Individual #1's December 2025 Medication Administration Record instructs to, "not exceed two tablets in 24 hours." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The director has reviewed and ensured all medications including PRNS for all individuals are on the MARS. |
12/30/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 9/30/2025, states that Individual #1 is able to self-administer medications. Individual #1's service plan, last updated 5/12/2025, reads, "Individual #1 requires staff to administer [their] medications to [them]." The plan also lists each medication and states that Individual #1 does not self-administer. Staff interviews revealed that Individual #1 has the ability to self-administer medications but frequently chooses not to and medications are administered by staff and documented on a Medication Administration Record. Individual #2's assessment, completed 6/28/2025, states the Individual #2 is independent financially. Individual #2's service plan, last updated 11/5/2025, reads, "[Individual #2] requires support to ensure that [Individual #2] is not being taken advantage of by friends seeking gifts/money. [Individual #2] cannot manage money without assistance but can calculate how much access money [Individual #2] has remaining in [their] account. [Individual #2] understands the price of things but would overspend on things [they] wanted if provided the opportunity. [Individual #2] is not able to manage [their] own finances. [Individual #2] will at times attempt to spend [their] money on others and has in the past obtained a credit card to purchase items on impulse. [Individual #2] will work with [their] rep payee and will work along with staff to help manage [their] money and pay [their] bills. This is listed as a priority on the sis assessment. [Individual #2] needs assistance to remain within a budget when shopping to ensure [Individual #2] has enough money for other activities." Individual #2's assessment, completed 6/28/2025, states that Individual #2 is able to independently self-administer medication. Individual #2's service plan, last updated 11/5/2025, reads, "[Individual #2] is learning to become self-medicating. [Individual #2] knows the medications and [Individual #2] is working on identifying the purpose of each and the exact time of day to take them." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individuals assessment has been updated and ISPs have been reviewed. The SCs will be notified of the changes that need to made in the ISPs. |
03/13/2026
| Implemented |