| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | The provider does not have a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | In accordance with 55 PA Code Chapter 6400.22(d)(1), the CEO has updated the agency's current individual funds and property policy to include the counseling of individuals concerning the use of funds and property, as well as a section addressing how agency funds will be documented for individuals that do not receive personal funds of their own. The policy has also been updated to include a standard expense log form to be used by staff whenever $15 or more are spent on behalf of individuals in the program. |
06/05/2026
| Implemented |
| 6400.22(d)(1) | The provider is not currently keeping an up-to-date financial record for Individual #1 detailing personal possessions and funds received by or deposited with the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | In accordance with 55 PA Code Chapter 6400.22(d)(1), the CEO has updated the agency's current individual funds and property policy to include the counseling of individuals concerning the use of funds and property, as well as a section addressing how agency funds will be documented for individuals that do not receive personal funds of their own. The policy will also be updated to include a standard expense log form to be used by staff whenever $15 or more are spent on behalf of individuals in the program. |
06/05/2026
| Implemented |
| 6400.22(d)(2) | The provider is not currently keeping an up-to-date financial record for Individual #1 detailing disbursements made to or for the individual. | (2) Disbursements made to or for the individual.
| In accordance with 55 PA Code Chapter 6400.22(d)(2), the CEO has updated the agency's current individual funds and property policy to include the counseling of individuals concerning the use of funds and property, as well as a section addressing how agency funds will be documented for individuals that do not receive personal funds of their own. The policy has also been updated to include a standard expense log form to be used by staff whenever $15 or more are spent on behalf of individuals in the program. |
06/05/2026
| Implemented |
| 6400.22(e)(3) | Actual receipts or expense records for the last three (3) months were requested for Individual #1. While numerous receipts were provided, many reflected program-covered expenses such as general groceries and household goods. Limited receipts were provided to support each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | In accordance with 55 PA Code Chapter 6400.22(e)(3), the CEO has updated the agency's current individual funds and property policy to include the counseling of individuals concerning the use of funds and property, as well as a section addressing how agency funds will be documented for individuals that do not receive personal funds of their own. The policy has also been updated to include a standard expense log form to be used by staff whenever $15 or more are spent on behalf of individuals in the program. |
06/05/2026
| Implemented |
| 6400.62(a) | Cleaning products and disinfectants were found unlocked in the bathroom above the toilet, and underneath the bathroom sink. Additionally, poisonous hand sanitizer was left on top of the medication storage cabinet. The IEP for Individual #1 notes enhanced supports due to limited cognition, and the ISP for Individual #2 states these items should be locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | In accordance with 55 PA Code Chapter 6400.62(a), the maintenance manager has installed locks on the bathroom sink cabinet, and signs will be posted in the home of where cleaning supplies and other possibly poisonous substances should be stored. The CFO has retrained staff on the necessity of keeping poisonous materials inaccessible to individuals as of 6/5/26 |
06/05/2026
| Implemented |
| 6400.67(a) | The toilet seat was visibly discolored in areas where the white topcoat was worn through. | Floors, walls, ceilings and other surfaces shall be in good repair. | In accordance with 55 PA Code Chapter 6400.67(a), the maintenance manager hired a contractor to replace the discolored toilet seat |
06/15/2026
| Implemented |
| 6400.76(c) | The back of the chair at the dining room table was bent, not allowing for back support while sitting down. | Furniture shall be comfortable and home-like. | In accordance with 55 PA Code Chapter 6400.76(c), the maintenance manager will replace the bent chair. |
06/15/2026
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain scissors, and staff was not aware if scissors were available in the home. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | In accordance with 55 PA Code Chapter 6400.77(b), the Program Specialist will replace the missing scissors to the first aid kit. The program specialist will train staff on the contents of the first aid kit in accordance with this section of the chapter to ensure understanding of having all necessary component present at all times. |
06/15/2026
| Implemented |
| 6400.81(k)(3) | Individual #1 did not have a pillow in his bedroom, and one was not observed to be available in the home. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | In accordance with 55 PA Code Chapter 6400.81(k)(3), the program specialist will ensure that individual #1's pillow is replaced. |
06/15/2026
| Implemented |
| 6400.82(f) | The home bathroom was not equipped with toilet paper, and none was available in the home. The Provider CFO brought a roll of tissue to the home at the time of inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | In accordance with 55 PA Code Chapter 6400.82(f), the program specialist will ensure toilet paper is present in the home at all times. The program specialist will add supply inventory checks as a shift duty for all overnight staff |
06/15/2026
| Implemented |
| 6400.111(a) | The charge needle on the fire extinguisher at the front door was in the red; indicating the unit was "empty". | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | In accordance with 55 PA Code Chapter 6400.111(a), the program specialist will replace the "empty" fire extinguisher. |
06/15/2026
| Implemented |
| 6400.216(a) | The Medication Administration Records for both individuals living in the home, were found unlocked in the living room while not in use. | An individual's records shall be kept locked when unattended.
| In accordance with 55 PA Code Chapter 6400.216(a), the program specialist has posted signs by the medication cabinet reminding medication administration trained staff to store MAR's in the locked cabinet |
06/24/2026
| Implemented |
| 6400.18(b)(2) | On 04/24/2026, the Provider was instructed to enter an incident for Individual #1 in relation to identified medication errors. As of 05/05/26 at 10am, a report had not been entered. | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | In accordance with 55 PA Code Chapter 6400.18(b)(2), the CFO has entered the incident for individual #1 as of 6/29/26 into EIM -9876244 |
06/29/2026
| Implemented |
| 6400.32(h) | The home is equipped with an operable camera in the living room common area. Individual plans for Individual #1 and ISP for Individual #2 did not indicate cameras were acknowledged. Although signed acknowledgements from both individuals were provided, the documents were not dated to show when consent to monitor was given. | An individual has the right to privacy of person and possessions. | In accordance with 55 PA Code Chapter 6400.32(h), the Program Specialist will ensure that signed acknowledgements from individuals are dated to show when consent to monitor was given. |
06/15/2026
| Implemented |
| 6400.32(t) | The home's refrigerator and freezer, and well as the kitchen cabinets containing food, were equipped with childproof locks. The plans for Individual #1 and Individual #2 do not detail any cause for restricted access to food. | An individual has the right to access food at any time. | In accordance with 55 PA Code Chapter 6400.32(t), the maintenance manager has removed the locks from the refrigerator, freezer, and kitchen cabinets containing food. |
06/05/2026
| Implemented |
| 6400.51(b)(1) | There was no record to support that Staff #1 (DOH: 04/07/26) was trained in the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | In accordance with 55 PA Code Chapter 6400.51(b)(1), Staff #1 will complet trainings on the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.. The CEO will update the staff training plan to include that the administrative assistant with do a file audit on all new hires prior to their first day working alone with individuals |
06/15/2026
| Implemented |
| 6400.163(d) | When conducting a physical site inspection, Trulicity 3/0.5 inj was found in the home's refrigerator, unlocked. The medication was prescribed to Individual #3, who reportedly left the program in January '26, and officially discharged from the program in February '26. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | In accordance with 55 PA Code Chapter 6400.163(d), the medication administration trainer has conducted remediation for previously medication administration trained staff on the storage and disposal of medications as of 6/24/26 |
06/24/2026
| Implemented |
| 6400.163(g) | Medication dropper syringes and cups were left in the medication storage cabinet unprotected from contamination. There was no clear policy or protocol for cleaning or storing the items. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | in accordance with 55 PA Code Chapter 6400.163(g), the medication administration trainer will update the medication administration policy to include proper conditions of sanitation and the use of dispoable cups and droppers for liquid medications. |
06/15/2026
| Implemented |
| 6400.163(h) | For Individual #1, the following discontinued medications were kept with actively prescribed medications and were nor properly removed/disposed of: Azelastine Hydrochloride Nasal Spray 0.1%, Ofloxacin Ophthalmic Solution, Aqueous Vitamin D Oral Drops 400 IU/mL, and Earwax Removal Drops. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | In accordance with 55 PA Code Chapter 6400.163(h), the medication administration trainer has conduct ed remediation for previously medication administration trained staff related to discontinuation and disposal of medications as of 6/24/26. The discontinued medication was removed at the time of notification and taken to the agency's pharmacy for disposal. |
06/24/2026
| Implemented |
| 6400.166(a)(11) | For Individual #1, the Medication Administration Record did not include a diagnosis or purpose for the following medications: Vitamin D 3, and Levetiraceta. | 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. | In accordance with 55 PA Code Chapter 6400.166(a)(11), the medication administration trainer will contact the pharmacy to have the preprinted MAR's updated to reflect the diagnosis or purpose for the following medications: Vitamin D 3, and Levetiraceta. |
06/22/2026
| Implemented |
| 6400.167(a)(1) | Per Individual #1's Medication Administration Record, the following prescribed medications were not administered:
- Vitamin D 3 at 8 am: April 3, 4, 5, 7, 9, 10, 12, and 24
- Levetiraceta at 7 am: April 3, 4, 5, 7, 9, 12, and 24
- Levetiraceta at 7 pm: April 3, 4, 8, 9, 11, 13, 19, 20, and 22
- Valporic Acid at 6 am: April 3, 4, 5, 7, 9, 12 and 24
- Valporic Acid at 1 pm: April 4, 11, and 19
- Valporic Acid at 7 pm: April 3, 4, 7, 8, 11, 13, 17, 20, and 22 | Medication errors include the following: Failure to administer a medication. | In accordance with 55 PA Code Chapter 6400.167(a)(1), the CFO has entered the medication error into EIM. DOS found to have been failures to document by medication administration trained staff have had remediations related to documentation conducted by the medication administration trainer as of 6/24/26. |
06/24/2026
| Implemented |
| 6400.169(a) | Staff #2, Staff #3, Staff #4, Staff #5, and Staff #6 administer medications to individuals; however, training records do not show that they have successfully completed a Department-approved medication administration training course, including annual course renewal requirements. | 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). | In accordance with 55 PA Code Chapter 6400.169(a), staff 2,3,4,5, and 6 were discontinued from administering medications, and the CFO contracted with A home health agency as well as an agency LPN TO administer until they had successfully completed the training. the medication administration trainer has conducted a full medication administration course for staff 3,4,5. Staff 2 and 6 are no longer employed with the agency . |
06/24/2026
| Implemented |
| 6400.182(a) | Individual #1 was admitted in late 2025, and an Individual Support Plan (ISP) has not been developed. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | In accordance with 55 PA Code Chapter 6400.182(a), the program specialist will coordinate the development of the ISP with the behavior specialist and individual's IEP team |
06/23/2026
| Implemented |