| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment form that was completed did not include a date of completion and multiple items on the form were left blank on the form and not indicated that they were reviewed by the agency. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the termination of 3 site managers, & the resignation of a Program Specialist; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements
regarding the assigned home. |
11/18/2025
| Implemented |
| 6400.21(a) | Criminal background check for Staff Person#8 completed 4/2/2025 despite hire date of 2/4/2025 | 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.
| To ensure compliance with new hire background checks, 6400.21(a), Human Resources will develop an
internal auditing tracking system to sustain ongoing adherence to 6400,21(a). A monthly compliance report,
submitted by Human Resources, will be reviewed by Complete Comforts' Quality Improvement Committee. |
11/18/2025
| Implemented |
| 6400.64(a) | The cabinet above the stove and the vent area above the stove were sticky to the touch with residue that appeared to be cooking grease. | Clean and sanitary conditions shall be maintained in the home. | CCiD has acquired a one time contract with a cleaning agency to ensure a sanitary environment within the home. The agency has scheduled to conduct a deep sanitation on 12/01/2025. |
11/17/2025
| Implemented |
| 6400.65 | The bathroom adjacent to Individual #6's bedroom did not have a working exhaust fan. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Facilities will adjust the exhaust as needed to ensure there ae no pre-existing blockages, dust mites present/build up to present such blockages or occurrences in the office area location by 11/24/25. A video or picture and LETTER of the fans function will be sent to the Lead Inspector via email for the plan of correction supporting documentation. |
11/20/2025
| Implemented |
| 6400.76(a) | A chair on the balcony had visible burn holes through the seat pad from cigarettes and where the ashtray has burned through. This is an area where the agency reports an individual in the home goes out to smoke.
The toilet paper holder in Individual #5' bathroom was broken and the toilet paper roll was sitting on the sink. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Facilities will remove the chair by 12/01/25. |
11/17/2025
| Implemented |
| 6400.82(f) | The bathroom adjacent to Individual #5' bathroom did not have soap or hand towels available. | 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. | Paper towels, safe/non-poisonous hand soap has been placed in the bathroom adjacent from
Individual#1's bedroom. |
11/17/2025
| Implemented |
| 6400.104 | There was no notification to the fire department on file for the residents of this home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Notifications to the Fire Department were sent on 10/01/2025 for Individual #1 and Individual #2.
Supporting documentation was provided during licensing inspection date 10/15/25 by 8pm. Documentation will be resent via email by
11/24/25. |
11/17/2025
| Implemented |
| 6400.112(a) | There was no recorded fire drill for November 2024 or August 2025. | An unannounced fire drill shall be held at least once a month. | House Managers & Program Specialists for their assigned homes and caseloads will be responsible for
ensuring compliance with monthly fire drills. |
11/17/2025
| Implemented |
| 6400.112(c) | Fire drills dated 10/16/2024 and 09/01/2025 do not state if any problems were encountered during the drill. The Fire drill dated 07/01/2025 does not indicate if the fire alarm or smoke detector system was operable at the time. The fire drill dated 09/01/2025 does not indicate the exit used. | 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. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(c). |
11/17/2025
| Implemented |
| 6400.112(d) | The fire drill dated 10/16/2024 had an evacuation time of 2:47. The fire drill dated 02/20/2025 had an evacuation time of 2:32. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(d). |
11/17/2025
| Implemented |
| 6400.112(e) | Fire drills completed during sleeping hours occurred in December 2024 and July 2025. (02/20/2025 at 09:56pm is not a sleep drill. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(e). |
11/17/2025
| Implemented |
| 6400.112(i) | The fire drills dated 07/01/2025 and 09/01/2025 did not utilize a smoke detector during the drill. | A fire alarm or smoke detector shall be set off during each fire drill. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(i). |
11/17/2025
| Implemented |
| 6400.113(a) | There is record the Individual received Fire Safety Training on 10/13/2025. There is no record fire safety training was completed upon admission. Therefore, fire safety training for 2025 should have been completed 3/2025 for Individual #5 as individual was admitted 3/2024. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.141(c)(7) | There is no record for Individual #5 receiving a GYN exam in 2025 | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | CCiD will develop a desensitization plan for Individual #5 due to refusal' of OBGYN service. |
11/17/2025
| Implemented |
| 6400.142(a) | There is no record of Individual #5 receiving an examination by a dentist in 2025. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A Dental examination will be scheduled by the program nurse. Once scheduled and confirmed a follow up email of summary will be sent to lead inspector. |
11/17/2025
| Implemented |
| 6400.142(c) | Per the two most recent ISP, Individual #5 had a dental exam on 4/30/2024. No dental form was provided that includes the procedures performed or recommendations for future care. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | A Dental examination will be scheduled by the program nurse. Once scheduled and confirmed a follow up email of summary will be sent to lead inspector. |
11/17/2025
| Implemented |
| 6400.142(g) | There is no dental hygiene plan on file for 2024 or 2025 for Individual #5. | A dental hygiene plan shall be rewritten at least annually. | A dental Hygiene plan will be completed by 12/01/25 for Individual #3. |
11/17/2025
| Implemented |
| 6400.143(a) | Per two most recent ISP, Individual #5 refused an appointment on 4/16/2024. There is no other documentation of refusal or attempt to reschedule. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | CCiD'Program nurse will evaluate the individual's refusal and complete a necessary refusal with the individual for record keeping. |
11/17/2025
| Implemented |
| 6400.151(a) | No annual physical found on file for pre-admission or subsequently. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff Person will have a physical completed by 12/15/25. Human Resources will be required to develop
an auditing tool regarding all regulatory hiring requirements relating to staff physicals, training, &
background checks. |
11/17/2025
| Implemented |
| 6400.151(c)(3) | Physical dated 6/17/2025 does not include a signed statement if staff is free from communicable diseases (151 c-3) for Staff Person #7. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Human Resources will audit the internal employee audit form to ensure inclusion of the free from communicable disease clause is present on the document. |
11/17/2025
| Implemented |
| 6400.181(a) | There is one assessment on file dated 8/30/2024 for Individual #5. An assessment should have been completed by 5/20/2024 as Individual was admitted 3/20/2024. There should be an additional assessment on file ranging from 3/21/2025 through 8/30/2025. It could not be found | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring
structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.216(a) | A medication log individual #6 was out on the counter in the kitchen area and not locked. Meds were not actively being given. | An individual's records shall be kept locked when unattended.
| To ensure compliance with 6400.216(a) the Program Nurse will be responsible for ensuring med admin trained staff are informed and trained that Individual MARS must be locked and stored away when not in use. |
11/17/2025
| Implemented |
| 6400.46(b) | There is no record Staff Person #7 was trained in general fire safety. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking
system to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will
be reviewed by Complete Comforts' Quality Improvement Committee. |
11/17/2025
| Implemented |
| 6400.181(f) | There is no record the assessment was sent to the Individual Plan Team 30 days prior to the ISP meeting for 2024 or 2025 for Individual #5. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring
structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.183(b) | Per two most recent ISP -- Annual ISP, the last annual ISP meeting was completed on 8/19/2024 for Individual #5. The ISP captures the attendees as the individual, Keyana Persons and Supports Coordinator. The plan team must include at least three members as described in 6400.183 (a) excluding the individual being served. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational
staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability
disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.183(c) | There is no record of meetings or attendees for the 2025 ISP meeting for Individual #5. | The list of persons who participated in the individual plan meeting shall be kept. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability
disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.213(1)(i) | Record missing Identifying marks and religious affiliation per 213(1)(ii) for Individual #5. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |