| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's service plan, last updated 10/21/2025, states, "[Individual #1] has a limited sense of time and money [Individual #1] requires assistance with the price of items, budgeting [their] money." Staff interviews revealed that staff has been assisting Individual #1 with purchases. The provider agency is not keeping a financial ledger of funds received by or deposited with the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Allegiant Human Services has updated its Individual Funds and Property Policy. The updated policy has been reviewed with staff and record of review has been documented. The Director of Operations reviewed and documented each individual's Personal Possessions and Property Record. A Cash and Money Reconciliation Binder has been created for each individual to keep an up-to-date financial ledger of funds received and deposited. In addition, each individual's Financial Management Plan has been reviewed and updated. Residential staff have received training on proper procedures to keep an up-to-date financial ledger of funds received and deposited. The Program Specialist has reviewed all financial areas in each individual's Skills Assessment and sent the assessment to the Supports Coordinator on November 25, 2025. |
11/25/2025
| Implemented |
| 6400.22(d)(2) | Individual #1's service plan, last updated 10/21/2025, states, "[Individual #1] has a limited sense of time and money. Individual #1] requires assistance with the price of items, budgeting [their] money." Staff interviews revealed that staff has been assisting Individual #1 with purchases. The provider agency is not keeping a financial ledger of disbursements made to or for the individual. | (2) Disbursements made to or for the individual.
| Allegiant Human Services has updated its Individual Funds and Property Policy. The updated policy has been reviewed with staff, and a record of review has been documented. The Director of Operations reviewed and documented each individual's Personal Possessions and Property Record. A Cash and Money Reconciliation Binder has been created for each individual to keep an up-to-date financial ledger of funds received and deposited. In addition, each individual's Financial Management Plan has been reviewed and updated. Residential staff have received training on proper procedures to keep an up-to-date financial ledger of funds received and deposited. The Program Specialist has reviewed all financial areas in each individual's Skills Assessment and sent the assessment to the Supports Coordinator on November 25, 2025. |
11/25/2025
| Implemented |
| 6400.72(b) | On 11/12/2025 at 12:33 PM, the screen in the window on the left side of Individual #1's bedroom did not securely fit the window and ripped at the top when touched by staff. | Screens, windows and doors shall be in good repair. | The screen in the bedroom has been replaced in the window at the site on November 26, 2025, by the Director of Operations. All windows were checked to ensure that the screens were securely in place and in good repair by the Programs Coordinator immediately after replacement. A picture of the screen replacement in the individual's bedroom is on file for proof of correction. |
11/26/2025
| Implemented |
| 6400.101 | On 11/12/2025 at 12:40 PM, there was a turn locking mechanism on the outside with a pinhole locking mechanism on the inside of the door in the basement leading to the garage causing an obstructed egress. There is no swing door inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Director of Operations has replaced the doorknob in the basement leading to the garage with a passage doorknob on November 26, 2025. The newly installed doorknob does not have a locking mechanism on either side of the door. The doorway from the basement leading to the garage is unobstructed and ensures that people can escape from the home in the event of a fire or other life-safety emergency. A picture of the passage doorknob is on file for proof of correction. |
11/26/2025
| Implemented |
| 6400.142(f) | Individual #1's assessment completed 9/01/2025 document the individual needs verbal Instruction, which means the individual exhibits behavior given only simple instructions and no other help, in regard to oral care teeth and/or gums. Individual #1 does not have a written plan for dental hygiene. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Allegiant Human Services has developed a Dental Care Policy. The policy has been reviewed with staff, and a record of review has been documented. On November 20, 2025, the Program Specialist reviewed and updated each individual's Dental Hygiene Plan. The Program Specialist has reviewed all areas of oral hygiene and dental care in each individual's Skills Assessment and sent the assessment to the Supports Coordinator. Assessment was set to Supports Coordinator on November 25, 2025. |
11/25/2025
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment completed 9/01/2025 documents that he needs assistance with identifying his medications. Individual #1's individual support plan, last updated 10/21/2025, documents "[The individual] takes his medication in the morning and needs reminders to take it as prescribed." Individual #1 is self-administering medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Allegiant Human Services has updated its Individual Assessment Policy. The updated policy has been reviewed with staff, and a record of review has been documented. Allegiant Human Services has evaluated the individual's ability to self-administer medications. The Program Specialist has reviewed the knowledge of the individual's ability to self-administer medications in each individual's Skills Assessment on November 24, 2025. The updated assessment was sent to the Supports Coordinator on November 25, 2025. The individual is self-administering of medications. Both the skills assessment and individual support plan have corresponding information on each individual's ability to self-administer medications. |
11/25/2025
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment completed 9/01/2025 document the individual needs verbal Instruction, which means the individual exhibits behavior given only simple instructions and no other help, in regard to using or avoiding poisonous materials. Individual #1's individual support plan, last updated 10/21/2025, documents, "[The individual] would not ingest a poisonous substance if unattended. [The individual] utilizes cleaning materials safely at his competitive job.' | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Allegiant Human Services has evaluated each individual's ability to safely use or avoid poisonous materials when in the presence of poisonous materials. The Program Specialist has reviewed all areas of poison safety and the ability to safely use poisonous materials in each individual's Skills Assessment on November 24, 2025. The updated assessment was sent to the Supports Coordinator on November 25, 2025. Both the skills assessment and individual support plan have corresponding information on each individual's ability to safely use or avoid poisonous materials when in the presence of poisonous materials. |
11/25/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, completed 9/01/2025, did not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Allegiant Human Services will maintain a record of a psychological evaluation for each individual. If a psychological evaluation is unavailable, proof of attempt to obtain shall be kept on file. Psychological evaluations will be used in the development of the individual's skills assessments. The Program Specialist will provide the skills assessment, lifetime medical history, and psychological evaluation to the individual plan team. The Director of Operations has reached out to each individual's Supports Coordinator to request a copy of the psychological evaluation. Request for psychological evaluations has been documented. |
11/20/2025
| Implemented |
| 6400.44(b)(2) | Individual #1 had an annual individual support plan meeting 12/09/2024 and Program Specialist #1 did not attend the meeting. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | Allegiant Human Services has developed a Residential Program Specialist Policy. The policy has been reviewed with the Program Specialist, and a record of review has been documented. The Program Specialist will participate in the individual plan process, development, team reviews, and implementation in accordance with 55 PA Code Chapter 6400. The Program Specialist will attend and participate in all Individual Support Plan meetings for all individuals receiving residential supports. |
11/24/2025
| Implemented |
| 6400.163(h) | On 11/12/2025 at 12:20 PM, a tube of Neosporin Pain Relief Cream with an expiration date of 3/2023 and a tube of Extra Strength Benadryl Itch Stopping Cream with an expiration date of 4/2023 were in the first aid kit. At 12:39 PM, a bottle of Visine with an expiration date of 7/2023, a tube of Terbinafine Hydrochloride Cream with an expiration date of 4/2024, an aerosol spray can of Lotrimin Antifungal with an expiration date of 10/2020, an aerosol spray can of TopCare Medicated Athlete's Food Powder Spray with an expiration of 11/2023, and an aerosol spray can of Antifungal Athlete's Food Powder Spray, with an expiration date of 5/2024, were inside the medicine cabinet above the sink in the bathroom of the first floor of the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Allegiant Human Services has developed a Medications and First Aid Kit Inspection and Disposal of Medications Policy. The policy has been reviewed with staff, and a record of review has been documented. The Director of Operations checked each site for expired or discontinued medications, including the contents of the first aid kits. Expired items in the first aid kit were replaced with new products. On November 21, 2025, the Program Specialist properly disposed of all expired and/ or discontinued medications. |
11/21/2025
| Implemented |