| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(a) | Individual #1 had annual physicals documented as occurring on 5/8/25 and 5/26/26. This extends beyond the annual timeframe and additional grace period. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | RBL will incorporate more safeguards to ensure all consumers complete a physical within the required timeframe. |
07/07/2026
| Implemented |
| 2380.113(c)(3) | Staff #1 had a physical dated 2/15/26. The section assigned to indicate that Staff #1 was free from communicable disease was blank with the Yes/No boxes not checked. A signed statement that the person is free of serious communicable diseases is required. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | The HR department at RBL will implement a process to ensure that all pre-hire documentation is completed in full before employees work alone with consumers. |
07/07/2026
| Implemented |
| 2380.153(b)(1) | Attempts to be made in order to anticipate and de-escalate the behavior using methods of intervention less intrusive than a restrictive procedure were not outlined in the plan dated 5/15/26 for Individual #1. Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than a restrictive procedure for each incident requiring a restrictive procedure. | For each incident requiring a restrictive procedure: Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than a restrictive procedure. | RBL will implement a more thorough and compliant approach to ensure all staff are trained in de-escalation methods that are less intrusive than restrictive procedures. |
07/07/2026
| Implemented |
| 2380.171(b)(2) | The emergency information record for Individuals #1, #2, #3, #4, #5 were lacking complete information for the name, address and telephone number of the individual's physician or source of health care. Individual #1 had no address for the physician or source of health care. Individual #2 had no address and telephone number of the individual's physician or source of health care.
Individual #3 had no address and telephone number of the individual's physician or source of health care. Individual #4 had no address for the physician or source of health care. Individual #5 had no address and telephone number of the individual's physician or source of health care. The name, address and telephone number of the individual's physician or source of health care shall be included in the Individual's emergency information. | Emergency information for each individual shall include: The name, address and telephone number of the individual¿s physician or source of health care. | RBL will collect, document, and update all required information from the consumer and their caretakers to comply with 55 PA Code Chapter 2380.171. |
07/07/2026
| Implemented |
| 2380.181(e)(3)(iv) | Individual #3 assessment dated 1/6/26 and the Individual #4 assessment dated 4/30/26 did not include the progress and growth over the past year for the Individuals in Socialization. The section did not address the progress or growth made by the individual over the past year as required. (REPEAT VIOLATION 8/28/25) | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | The Program Specialist will use daily and monthly notes to compare progress in Socialization. Their documentation will include key phrases such as progress in the area of Socialization, regression, or no change, based on observations, documentation, and the previous year's assessment. |
07/07/2026
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1 assessment dated 11/14/25 and the Individual #4 assessment dated 4/30/26 did not include the progress and growth over the past year for the Individuals in personal adjustment. The section did not address the progress or growth made by the individual over the past year as required. (REPEAT VIOLATION 8/28/25) | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The Program Specialist will use daily and monthly notes to compare progress in personal adjustment. Their documentation will include key phrases such as progress in the area of personal adjustment, regression, or no change, based on observations, documentation, and the previous year's assessment. |
07/07/2026
| Implemented |
| 2380.181(e)(13)(v) | Individual #1 assessment dated 11/14/25, Individual #3 assessment dated 1/6/26, and Individual #4 assessment dated 4/30/26 did not include the progress and growth over the past year for the Individuals in Recreation. The section did not address the progress or growth made by the individual over the past year as required. (REPEAT VIOLATION 8/28/25) | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | The Program Specialist will use daily and monthly notes to compare progress in Recreation. In addition to their observations, the program specialist will document any progress, regression, or no change from the previous year's assessment. |
07/07/2026
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1 assessment dated 11/14/25, Individual #3 assessment dated 1/6/26, and Individual #4 assessment dated 4/30/26 did not include the progress and growth over the past year for the Individuals in Community-integration. The section did not address the progress or growth made by the individual over the past year as required. (REPEAT VIOLATION 8/28/25) | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Program Specialist will use daily and monthly notes to compare progress in Community-integration. In addition to their observations, the program specialist will document any progress, regression, or no change from the previous year's assessment. |
07/07/2026
| Implemented |
| 2380.155(a) | In the Restrictive Procedure Plan dated 6/8/26 for Individual #5 the following areas are missing from the plan: (c) The behavior support component of the individual plan shall include: (1) The specific behavior to be addressed. (2) An assessment of the behavior, including the suspected reason for the behavior. (3) The outcome desired.
(5) Methods for facilitating positive behaviors such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, recognizing and treating physical and behavior health conditions, voluntary physical exercise, redirection, praise, modeling, conflict resolution, de-escalation and teaching skills. (7) The amount of time the restrictive procedure may be applied. (8) The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. At time of inspection on 6/18/26 the 6/8/26 restrictive procedure plan for Individual #5 had been reviewed by a Human Rights Committee but had not been implemented. Prior to implementation of the restrictive procedure plan all required components of the plan as outlined above must be included in the written plan. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 2380.154 (relating to human rights team), prior to use of a restrictive procedure. | RBL will ensure that all Restrictive Procedure Plans include, at a minimum, the eight components specified in 55 PA Code Chapter 2380.155(c). RBL will ensure that the Human Rights Committee has reviewed and approved the plan, per 2380.154. Once the RPP is complete, with all information included in the written plan, and the HRC has approved the plan, RBL will ensure that the staff working with the consumer is trained specifically on the restrictive procedure and its contents. No implementation of a restrictive procedure can take place until all previous steps are completed and documentation has been collected. |
07/07/2026
| Implemented |
| 2380.167(f) | In the Restrictive Procedure Plan dated 6/8/26 for Individual #5 the rational for restriction section notes that "Staff continued the hold for 45 minutes." The stated 45 minutes is beyond the 30 cumulative minutes allowed per regulation. Holds may not be used for more than 30 cumulative minutes within a 2-hour period. | A physical restraint may not be used for more than 30 cumulative minutes within a 2-hour period. | RBL shall designate trained staff in Safe Crisis Management to administer timely physical restraints and provide appropriate consultation. Additionally, RBL shall inform the caretaker of a consumer who has been physically restrained for a cumulative duration of fifteen minutes to arrange for the individual's pickup and removal from the Day Program. |
07/07/2026
| Implemented |