| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Vents in the hallway bathroom and Individual #2's bedroom were visibly covered with dust. This was corrected at the time of the visit. | Clean and sanitary conditions shall be maintained in the home. | Plan of Correction
Regulation: 6400.64(a) -- Clean and sanitary conditions shall be maintained in the home.
Deficiency: During the inspection, the vents in the hallway bathroom and Individual #2's bedroom were visibly covered with dust. This issue was corrected during the visit.
Plan of Correction:
The vents in the hallway, bathroom, and Individual #2's bedroom were cleaned immediately during the inspection to restore clean and sanitary conditions. |
10/13/2025
| Implemented |
| 6400.104 | The fire letter does not indicate the specific locations of individual's bedrooms. | 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.
| Regulation: 6400.104 -- The home shall notify the local fire department, in writing, of the location of each individual's bedroom and the needs of the individuals who reside in the home, at the time of occupancy and annually thereafter.
Deficiency: The fire letter previously sent to the local fire department did not include the specific locations of the individuals' bedrooms.
Plan of Correction:
A corrected fire letter that includes the specific locations of each individual's bedroom and their identified needs has been completed and sent to the local fire department. |
10/10/2025
| Implemented |
| 6400.144 | Individual #3 is prescribed PRN Medihoney gel for wound care, and the medication could not be located in the home.
On 08/12/2025, Individual #3 was prescribed Juven Powder (fruit Punch) twice a day, and the medication could not be located in the home. The MAR indicates "Awaiting insurance clearance." Nursing staff explained that insurance denied coverage and would require out-of-pocket payment. | 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.
| Plan of Correction
Regulation: 55 PA Code §6400.144 -- Health Care
Correction Required:
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.
Deficiency:
Individual #3 is prescribed PRN Medihoney gel for wound care; however, the medication could not be located in the home at the time of inspection. In addition, on August 12, 2025, Individual #3 was prescribed Juven Powder (Fruit Punch flavor) twice daily, and this supplement also could not be located in the home. The Medication Administration Record (MAR) indicated "Awaiting insurance clearance." Nursing staff explained that insurance denied coverage and that the item would require an out-of-pocket payment.
Plan of Correction:
The prescribed Juven supplement for Individual #3 was ordered and delivered to the home on September 16, 2025. Proof of delivery was obtained and placed in the individual's record. The Medihoney gel was verified as discontinued after review. The individual's wound care nurse confirmed the medication was no longer needed, and the PRN medication listed in error on the MAR was reviewed and removed.
Systemic Plan to Prevent Recurrence:
All prescribed medications and supplements will be ordered immediately upon receipt of the physician's order.
In the event of pharmacy or insurance delays, the agency will pay out of pocket to ensure the individual does not go without any necessary medication or supplement |
10/12/2025
| Implemented |
| 6400.181(a) | The 6/28/25 Initial assessment for individual #3 was completed timely, but is missing the following required components:
181(3)(4) The individual's need for supervision at home and in the community;181(e)(5) The individual's ability to self-administer medications; 181(e)(6) The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials;181(e)(7) The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated;181(e)(8) The individual's ability to evacuate in the event of a fire;181(e)(14) The individual's knowledge of water safety and ability to swim. The individual's record indicates that they are their own representative payee, and the assessment does not indicate the assistance necessary to manage their finances, pay bills and complete purchases. | 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. | Plan of Correction
Regulation: 55 PA Code §6400.181(a) -- Individual Assessments
Correction Required:
Each individual shall have an initial assessment completed within 1 year prior to or within 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 the level of skills completed within 6 months prior to admission to the residential home.
Deficiency:
The 6/28/2025 initial assessment for Individual #3 was completed timely; however, it was missing the following required components:
§181(e)(3)(4): The individual's need for supervision at home and in the community.
§181(e)(5): The individual's ability to self-administer medications.
§181(e)(6): The individual's ability to safely use or avoid poisonous materials when present.
§181(e)(7): The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources exceeding 120° F and not insulated.
§181(e)(8): The individual's ability to evacuate in the event of a fire.
§181(e)(14): The individual's knowledge of water safety and ability to swim.
The assessment did not indicate the assistance necessary for managing finances, paying bills, and completing purchases, despite the individual being their own representative payee.
Plan of Correction:
The initial assessment for Individual #3 was reviewed and updated to include all required components, including:
Knowledge of medications and ability to self-administer.
Water safety and swimming ability.
Ability to evacuate in the event of a fire.
Supervision is needed at home and in the community.
Management of finances and purchases as appropriate.
The Program Specialist and RN have verified that the updated assessment is complete and in compliance with 55 PA Code §6400.181(a). |
10/14/2025
| Implemented |
| 6400.15(b) | The agency incorrectly used the self-assessment form for newly opened homes instead of the correct annual self-inspection instrument. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Regulation: 6400.15(b) -- The facility shall complete and maintain an annual self-assessment using the Department's current licensing inspection instrument for the community home.
Deficiency: The self-assessment completed did not use the Department's most current version of the licensing inspection instrument.
Plan of Correction:
The provider has reviewed and verified that the current ODP self-assessment instrument is now being used for all annual self-assessments.
Retraining was completed with all administrative and program management staff on the proper use of the most recent self-assessment form and on verifying version dates prior to completion. |
10/11/2025
| Implemented |
| 6400.165(f) | Individual #3 was admitted on 4/25/25 and is prescribed psychotropic medication. The SEEP plan in the record was not effective until 7/28/25. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Plan of Correction
Regulation: 55 PA Code §6400.165(f) -- Social, Emotional, and Environmental Plan (SEEP)
Correction Required:
If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional, and environmental needs of the individual related to the symptoms of the psychiatric illness.
Deficiency:
Individual #3 was admitted on April 25, 2025, and is prescribed psychotropic medication. The SEEP plan in the record was not effective until July 28, 2025, leaving a gap in the documented plan to address the individual's social, emotional, and environmental needs related to psychiatric symptoms.
Plan of Correction:
The SEEP plan for Individual #3 was updated and made effective immediately following the inspection to ensure it aligns with the individual's current needs and prescribed psychotropic medication. The updated plan includes specific interventions and supports to address the social, emotional, and environmental factors contributing to the individual's psychiatric symptoms. |
10/15/2025
| Implemented |