| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff Person #7 has a hire date of 4/27/2025. A background check was not on file. | 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.
| The Program Specialist reviewed the personnel records for Staff Persons #1 and confirmed that the Pennsylvania Criminal History Record Check was not completed within the required timeframe or was missing from the personnel file. The HR Coordinator submitted the required background checks for any staff whose documentation was out of compliance and ensured that the results were placed in the employee personnel files. Additionally, the Program Specialist and HR conducted a comprehensive review of all employee records for staff working in the residential homes to verify that criminal background checks were obtained in accordance with regulatory requirements. |
02/13/2026
| Implemented |
| 6400.62(a) | There were unlocked poisonous cleaning supplies stored underneath the sink in the half bathroom. Individual #2's ISP states that cleaning supplies should be locked up as a precaution. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The cleaning products were immediately removed by staff during the inspection. Following the inspection, the Program Director inspected all storage areas in the home to ensure all poisons are relocated to designated locked storage area that is inaccessible to individuals and separate from food preparation areas. The Program Specialist conducted an additional environmental safety review to ensure that all hazardous materials were stored appropriately. |
02/11/2026
| Implemented |
| 6400.64(a) | The top of the refrigerator was very dirty and grimy.
The second kitchen drawer to the right of the sink was dirty. | Clean and sanitary conditions shall be maintained in the home. | Direct Support Professionals immediately cleaned the areas identified during the inspection. Following the inspection, the Program Director conducted a full review of the residence and completed a deep cleaning to ensure the home met clean and sanitary standards throughout. |
02/11/2026
| Implemented |
| 6400.66 | The main kitchen light was out. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The Program Director submitted a work order, and the light bulb was replaced to restore adequate lighting in the kitchen area. After the replacement was completed, the Program Director verified that the lighting fixture was functioning properly and providing adequate illumination for safe use of the kitchen. |
02/13/2026
| Implemented |
| 6400.68(a) | The water pressure of the kitchen sink was very low. | A home shall have hot and cold running water under pressure. | Program Director submitted a work order to maintenance personnel regarding the low water pressure at the kitchen sink. Maintenance inspected the plumbing fixtures and water supply lines to determine the cause of the low pressure. The plumbing fixture was adjusted to restore proper water flow.
After the repair was completed, the House Manager tested the kitchen sink to verify that hot and cold running water was functioning properly and that adequate water pressure had been restored. |
02/20/2026
| Implemented |
| 6400.68(b) | The kitchen sink temperature was measured at 126.5°F.
The half bathroom sink water temperature was measured at 124.8°F.
The second-floor bathroom bathtub water temperature measured at 136°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | : Immediately following the inspection, Maintenance adjusted the hot water heater thermostat to ensure that water temperatures at all sinks, bathtubs, and showers do not exceed 120°F, consistent with residential safety standards.
After adjustments were made, the House Manager tested water temperatures at all sinks, bathtubs, and showers throughout the home using a thermometer to verify that temperatures were within safe limits. |
02/13/2026
| Implemented |
| 6400.80(a) | The landing outside of the side door was covered with ice. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | staff immediately removed the snow from the back porch step and patio area to eliminate the potential hazard. The House Manager subsequently inspected all exterior walkways, steps, and entry areas of the home to ensure that they were clear of snow, ice, or other obstructions. Any remaining snow or debris was removed to ensure safe access to and from the residence. |
02/13/2026
| Implemented |
| 6400.82(f) | The second-floor bathroom had no paper or cloth towels. | 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. | The Direct Support Professional on duty immediately restocked the bathrooms with the required supplies. The Program Director verified that all bathrooms contained the required items including soap, toilet paper, towels, mirrors, and trash receptacles. |
02/11/2026
| Implemented |
| 6400.110(a) | There was no smoke detector in the basement. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Immediately following Inspections, A new automatic smoke detector was purchased and installed in the basement to ensure that each floor of the home, including the basement, is equipped with an operable smoke detector as required by §6400.110(a). |
02/13/2026
| Implemented |
| 6400.166(a)(11) | The MAR for individual #2 did not include the diagnosis or purpose for the medications Lacosamide, Prazosin and Topiramate. | 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. | Following the inspection, the Program Specialist and agency nurse reviewed the Medication Administration Record for Individual #2 and confirmed that the diagnosis or purpose for the medications Lacosamide, Prazosin, and Topiramate was not documented. The nurse obtained the appropriate diagnosis and medication purpose information from the prescribing physician and updated the MAR to include the required information.
The Program Specialist and nurse then reviewed all medication records for individuals residing in the home to determine whether any additional MAR documentation was incomplete. Any missing medication information identified during the review was corrected. |
02/14/2026
| Implemented |
| 6400.167(a)(1) | The 02/09/26 8 AM dose of Lacosamide 100 mg for individual #2 was missing from the blister pack; however, the MAR states that the dose was missed (not administered).
The controlled Drug Count Record shows that thirty 8 AM doses of the drug were received on 02/09/26 and 2 doses of that allotment were administered on 02/10/26 and 02/11/26. Therefore, it appears that the person who administered the drug started at the incorrect date of 02/09/26 on the blister pack instead of 02/10/26 as stated on the count sheet. | Medication errors include the following: Failure to administer a medication. | Following the inspection, the Program Specialist and agency nurse reviewed the medication administration records, blister pack, and controlled drug count documentation related to the medication Lacosamide for Individual #2. The review confirmed that the medication administration began on the incorrect date on the blister pack, resulting in a documentation discrepancy and medication error. A medication Erroe EIM was entered into HCSIS immediately.
The prescribing physician was notified of the medication error in accordance with medication administration protocols. Staff involved in medication administration were counseled and re-educated by the agency nurse regarding proper medication administration procedures, including verifying blister pack dates, accurate documentation on the MAR, and correct completion of controlled substance count sheets.
The Program Specialist and nurse conducted a review of medication administration practices and medication documentation for all individuals residing in the home to ensure there were no additional medication administration errors. |
02/14/2026
| Implemented |