| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff Member #2 was hired effective 10/3/25, but a criminal history background check was not completed until 10/22/25. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| A review of personnel records identified that Staff Member #2 was hired effective 10/3/2025, however the criminal history background check was completed on 10/22/2025. Notification of the opportunity was communicated to all hiring managers and a retraining session for correct hiring practices was held on 12/16/2025.. |
01/07/2026
| Implemented |
| 6400.67(a) | The kitchen drawer located to the right of the dishwasher was missing a handle. | Floors, walls, ceilings and other surfaces shall be in good repair. | The handle on the kitchen drawer located to the right of the dishwasher was replaced on 12/15/2025. |
12/15/2025
| Implemented |
| 6400.70 | Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were not posted on or near the home's telephone. The telephone was located in the individual's bedroom, and the telephone numbers were located in the home kitchen/living room area. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Telephone numbers for the nearest hospital, police department, fire department, ambulance service, and poison control center were relocated to the individual's bedroom by the telephone on 12/15/2025. |
12/15/2025
| Implemented |
| 6400.77(b) | The home's First Aid Kit was not equipped with tweezers, and none could be located 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. | The missing tweezers were purchased and placed on-site in the home's first aid kit on December 15, 2025. The first aid kit was reviewed at that time to confirm it was fully stocked and compliant with required first aid supply standards, and staff were notified of the update to ensure the supplies remain available and accessible for use as needed. |
12/15/2025
| Implemented |
| 6400.80(a) | Snow had not been cleared from the rear exit of the home which also serves as a means of egress. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The sidewalk and stairs were cleared of snow on 12/15/2025. |
12/15/2025
| Implemented |
| 6400.112(e) | The home became occupied 3/26/25. A sleep drill was conducted in April and not again until December 2025. | A fire drill shall be held during sleeping hours at least every 6 months. | LVC C Class Realty LLC has developed a fire drill schedule to ensure that all required fire drills, including those conducted during sleeping hours, are completed promptly and in accordance with regulatory requirements. The schedule is designed to track quarterly fire drills and biannual sleeping-hours drills, verify completion, and support ongoing compliance. |
12/15/2025
| Implemented |
| 6400.144 | Individual #1 is prescribed Acetaminophen 5ml (as needed), and the medication was not present in the home during inspection. | 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.
| The medication refill was immediately ordered from the pharmacy on December 15, 2025. The medication was delivered promptly and placed in the participant's secured medication cabinet in accordance with medication storage requirements. |
12/15/2025
| Implemented |
| 6400.34(a) | The full listing of rights has not been presented to Individual #1 for understanding and acknowledgment. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | LVC C Class Realty LLC has reviewed and updated its Individual Rights Policy to ensure it fully incorporates all requirements outlined in 55 Pa. Code Chapter 6400 related to individual rights on 12/15/2025. The updated policy clearly defines and protects the rights of individuals receiving services, including dignity, privacy, choice, freedom from abuse and neglect, access to personal property, communication, and participation in decision-making. The revised policy will be reviewed with all participants by 12/15/2025. |
12/15/2025
| Implemented |
| 6400.34(b) | Individual #1 was admitted to the agency on 03/26/2025. There is no statement on record signed by the individual acknowledging receipt of the information on individual rights. The documentation on record was signed only by the CEO and dated 03/27/2025. The Individual's ISP does not specify that Individual signature or mark cannot be obtained. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The participant's ISP will be updated to indicate that they are unable to sign documents. The following statement will be incorporated into all participant forms to document that the form and/or policy has been reviewed with the participant in a manner appropriate to their level of understanding, using support and accommodations as needed.
Participant Signature Accommodation - Participant Unable to Sign:
The participant is unable to provide a written signature due to disability-related and/or communication limitations. The information was reviewed and explained in a manner appropriate to the participant's level of understanding, using necessary support and accommodations. The participant's participation and acknowledgment have been verified as indicated below.
Verified By (check one):
Staff Witness
Authorized Representative / Guardian
Printed Name: _______________________________________ Date ____________
Signature: ________________________________ Relationship: ________________ |
12/15/2025
| Implemented |