| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Start and stop time was incomplete for the documented fire drills of April and July. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Deficiency: Fire drill records for April and July did not include complete start and stop times.
Immediate Correction: The Program Director reviewed the April and July fire drill records. Future fire drill records will include the date, start and stop time, evacuation time, exit route, problems encountered, and whether the fire alarm/smoke detector was operational. We have updated our forms (see attached our fire drill form and indicated AM or PM, as well as whether a sleep or A wake is selected)
Who/ Responsible Person: Program Director
When/ Completion Date: September 17, 2026
How: Record Review: A review of 100% of fire drill records has been completed to identify and correct any additional documentation deficiencies.
Staff Training: Staff responsible for fire drills have been trained on the required documentation
Validation: PVHC will provide a completed fire drill record using the new documentation process and staff training documentation. |
09/18/2026
| Implemented |
| 6400.112(e) | The Fire Drill records for April and July did not accurately list the time as am or pm had not been documented for the start and stop time of drill. | A fire drill shall be held during sleeping hours at least every 6 months. | Deficiency: Fire drill records for April and July did not include complete start and stop times.
Immediate Correction:
WHAT: The Program Director reviewed the April and July fire drill records. Future fire drill records will include the date, start and stop time, evacuation time, exit route, problems encountered, and whether the fire alarm/smoke detector was operational. We have updated our forms (see attached our fire drill form and indicated AM or PM, as well as whether a sleep or A wake is selected). A fire drill shall be held during sleeping hours at least every 6 months.
Who/ Responsible Person: Program Director
When/ Completion Date: September 14, 2026
How: Record Review: A review of 100% of fire drill records has been completed to identify and correct any additional documentation deficiencies.
Prevention: Staff responsible for conducting fire drills will use a standardized fire drill form and will be required to complete all fields immediately following each drill.
Staff Training: Staff responsible for fire drills have been trained on the required documentation
Validation: PVHC will provide a completed fire drill record using the new documentation process and staff training documentation. |
09/18/2026
| Implemented |
| 6400.32(v) | The rights in Individual One's file are the outdated rights from prior to 2018. The rights need to be updated to the current rights listed in the code and bulletin. | An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | Corrective Action:
Pleasant Vine Home Care LLC has updated the Individual Rights documents ( see attached exhibit 2) and will replace the outdated rights document in Individual One's record with the current Individual Rights document applicable under the current Pennsylvania regulations and ODP requirements.
The Program Director will review the updated rights with Individual One and/or the individual's designated representative, as applicable, get them to sign and file.
WHAT: The provider will also review the rights documentation for all individuals served at all locations to ensure that current rights information is being used.
WHO/ Responsible Person: Program Manager Manager
WHEN/ Completion Date: Within 30 days and ongoing.
Monitoring: The Program Director or designee will review individual records monthly for six months to verify that current Individual Rights documentation is present and that any rights modification is properly documented.
Staff Training
All staff responsible for conducting fire drills, completing fire drill documentation, and reviewing individual rights documentation have received training on the applicable requirements (see exhibit 1 and 2) respectively.
Training includes:
·Current Individual Rights requirements and updated document referencing REG 6400
Documentation of training will be maintained by the provider.
Monitoring: The Program Director or designee will review individual records monthly for six months to verify that current Individual Rights documentation is present and that any rights modification is properly documented
Quality Assurance
The Program Director will monitor compliance through routine review of fire drill records and individual records.
Any identified deficiency will result in prompt corrective action and additional staff training when necessary.
The provider will maintain documentation of all corrective actions, staff training, monitoring, and follow-up reviews. |
09/18/2026
| Implemented |