| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The home contained unlocked cleaning supplies including bleach in the closet of the upstairs middle room in the home | Poisonous materials shall be kept locked or made inaccessible to individuals. | Upon identification of the deficiency, the cleaning supplies were immediately secured in a locked cabinet to prevent access by individuals receiving services. All hazardous cleaning products in the home were reviewed to ensure they are stored in a locked location. Staff were reminded of the requirement to store all hazardous materials, including cleaning supplies, in a locked cabinet or secured area when not in use. The Program Director reviewed safe storage procedures with staff to reinforce compliance with 55 Pa. Code |
02/09/2026
| Implemented |
| 6400.67(a) | There were several areas in the home of disrepair. Those areas are as follows:
- Several walls had large holes in them, largely as a result of the individual who resides in the home. Some of the holes had sections of drywall or plywood covering the holes. A more permanent fix needs to be implemented.
- There was evidence of water damage on the first floor ceiling resulting from an overflowing bath tub.
- There were several holes pierced into the ceiling of the individual's bedroom.
- The toilet in the upstairs bathroom did not have a cover in the tank, and it was reported that it was broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Program Director assessed the areas of damage within the home and arranged for necessary repairs to restore the environment to a safe and functional condition. Any damaged items or fixtures that posed a potential safety concern were either repaired or removed and replaced as appropriate. Staff have been reminded to promptly report any damage to the home environment so repairs can be scheduled as soon as possible. The team will also review the individual's support strategies to help reduce incidents that may result in property damage. |
02/09/2026
| Implemented |
| 6400.67(b) | There were several areas in the home of potentially hazardous disrepair. Those areas are as follows:
- The top stair of the home has a metal threshold that is bent and kinked presenting a possible tripping hazard.
- There was a light fixture in the basement that had a bulb that was broken but still illuminating (This was fixed the day of the inspection)
- The Front door knob was loose and difficult to use (This was fixed the day of the inspection)
- The ceiling of the center room upstairs was beginning to slump and needs to be addressed.
- The backrest of the chair in the dining room was broken. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Program Director assessed the areas of damage within the home and arranged for necessary repairs to restore the environment to a safe and functional condition. Any damaged items or fixtures that posed a potential safety concern were either repaired or removed and replaced as appropriate. Staff have been reminded to promptly report any damage to the home environment so repairs can be scheduled as soon as possible. The team will also review the individual's support strategies to help reduce incidents that may result in property damage. |
02/09/2026
| Implemented |
| 6400.72(b) | The home contained several broken doors and windows.
- The front window of the home was broken and covered with a wooden board.
- The window in the middle room on the second story was broken and covered with a large sheet of plywood.
- The door leading from the first floor to the basement was broken in half and kicked in.
- The bedroom door of the individual who lives in the home was off of the hinges.
- The closet door next to the basement door had a large hole in the bottom center area. | Screens, windows and doors shall be in good repair. | The Program Director assessed the areas of damage within the home and arranged for necessary repairs to restore the environment to a safe and functional condition. Any damaged items or fixtures that posed a potential safety concern were either repaired or removed and replaced as appropriate. Staff have been reminded to promptly report any damage to the home environment so repairs can be scheduled as soon as possible. The team will also review the individual's support strategies to help reduce incidents that may result in property damage. |
02/09/2026
| Implemented |
| 6400.81(i) | There were no blinds or curtains present in the individual's bedroom. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Window Blinds that were damaged or missing were replaced and installed to ensure they are functional and properly fitted to the windows |
02/07/2026
| Implemented |
| 6400.81(k)(4) | There was no dresser or chest of drawers in the individual's bedroom. | In bedrooms, each individual shall have the following: A chest of drawers. | The maintenance team obtained and placed a chest of drawers in the individual's bedroom to ensure the individual has appropriate storage for personal clothing and belongings. |
02/07/2026
| Implemented |
| 6400.81(k)(6) | There was no mirror present in the individual's bedroom. | In bedrooms, each individual shall have the following: A mirror. | The maintenance team obtained and installed a mirror in the individual's bedroom to ensure the individual has access to appropriate personal grooming supports. |
02/07/2026
| Implemented |
| 6400.82(e) | The shower in the upstairs bathroom did not contain a non-slip mat or surface in the shower. | Bathtubs and showers shall have a nonslip surface or mat. | The maintenance team obtained and placed a slip-resistant mat in the shower to reduce the risk of slips and falls and to ensure the bathroom environment is safe for individuals receiving services. |
02/07/2026
| Implemented |
| 6400.101 | The back door which leads out of the lower level of the home was obstructed with debris from recent repairs in the home. (This was removed the day of inspection) | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Upon identification of the deficiency, the debris was removed from the area surrounding the back door to ensure the exit pathway is clear and safe for use. Staff were reminded of the requirement to maintain all entrances, exits, and surrounding areas free of debris or obstructions to ensure a safe environment. |
02/06/2026
| Implemented |
| 6400.111(f) | All fire extinguishers in the home were last inspected in 2024 which is greater than 1 year ago. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | All fire extinguishers in the home were replaced with new extinguishers that meet the required rating standards. Each extinguisher has been properly inspected, tagged, and placed in the appropriate locations throughout the home in accordance with fire safety requirements. The Program Director reviewed fire safety procedures with staff and verified that all required fire safety equipment is present, properly maintained, and accessible throughout the home. |
02/16/2026
| Implemented |
| 6400.163(g) | Many of Individual #1's medications have their blister packs completely punched out and refilled/repackaged with clear tape to keep the pills in place. Many pills are broken or crushed and are not in suitable condition for administration. The resealable bag that contained the AM blister packs had four Lamotrigine tablets loose within the bag. | 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. | Upon discovery, the medication that had been removed from the blister packs was discarded according to medication disposal procedures. The pharmacy was contacted to obtain replacement medications to ensure all medications are maintained in properly labeled blister packaging as provided by the pharmacy. Staff were reminded of the importance of monitoring medication storage and ensuring that medications remain secured and maintained in their original pharmacy packaging. Staff were also instructed to increase supervision during medication administration times to prevent medications from being removed from blister packs by individuals. |
02/09/2026
| Implemented |
| 6400.166(a)(4) | Individual 1's Polyethelene Glycol powder was not found on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The Program Director reviewed the physician's order and pharmacy label for the medication powder and reconciled it with the individual's medication records. The medication was added to the Medication Administration Record (MAR) to accurately reflect the physician's order. All medications present in the home were reviewed to ensure they are properly listed on the MAR. |
02/09/2026
| Submitted |
| 6400.166(a)(13) | Individual #1's Guanfacine 3mg tablets for 8:00am administration have not been initialed on the MAR as given or refused on any date this month. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Program Director reviewed the Medication Administration Record (MAR) and verified the medication administration with the staff member who administered the medication. The MAR was corrected to include the appropriate staff signature verifying administration. All current MARs were reviewed to ensure that medication administrations are properly documented with staff signatures. |
02/09/2026
| Submitted |
| 6400.207(4)(IV) | Individual #1 has received two doses of a PRN psychotropic medication, one on 02/02/2026 and 02/03/2026 -- documentation of required aspects of administration (signature of CEO or designee approving the administration and follow-up monitoring performed by medical professionals) was not provided. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: A specific, time-limited stressful event or situation to assist the individual to control the individual's own behavior. | The Program Director reviewed the Medication Administration Record (MAR) and verified the PRN medication administration with the staff member involved. The MAR was corrected to include the staff signature and the appropriate documentation of monitoring the individual following the administration of the PRN medication. Current MARs were reviewed to ensure all PRN administrations include proper signatures and monitoring documentation. |
02/09/2026
| Submitted |