| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #3, date of hire 10/6/2025, had an application for a Pennsylvania criminal history record check submitted to the State Police on 1/6/2026. | 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.
| Upon receipt of the deficiency notice, BrightPath Human Services conducted a comprehensive audit of all active employees to verify that each staff member had the criminal background checks required by Regulation 6400.21(a). This audit was completed on June 10, 2026, and confirmed that all active employees possessed the required background clearances. |
06/12/2026
| Implemented |
| 6400.62(a) | Individual #1's support plan, last updated 5/12/2026, states "[Individual #1] is aware of and can recognize poisonous substances. [They] would not ingest such substances if left unattended with them. They are locked in [their] home due to concerns [they] would use them to assault staff." At 12:46 PM on 5/28/2026, the following poisonous substances, all with instructions to contact either Poison Control or a physician if ingested, were observed unlocked and accessible in the cabinet under the sink in the basement level bathroom: a 24-fluid ounce bottle of Clorox Toilet Bowel Cleaner with Bleach, a 25-ounce spray can of Scrubbing Bubbles Bathroom Grime Fighter, a 32-fluid ounce bottle of Lysol Advanced Power Clinging Gel Toilet Bowel Cleaner, a 32-fluid ounce bottle of Great Value Bathroom Cleaner with Bleach, and a 24-fluid ounce bottle of Great Value Toilet Bowel Cleaner. On 5/28/2026 at 12:51 PM, the following poisonous substances, all with instructions to contact either Poison Control or a physician if ingested, were observed unlocked and accessible on the windowsill to the right of the dryer in the basement level laundry room: a 166.5-fluid ounce bottle of Arm and Hammer plus Oxi Clean Stain Fighters Laundry Detergent and a 66-ounce container of Tide Power Pods with Oxi Boost. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Upon receipt of the deficiency notice, BrightPath Human Services immediately removed all poisonous materials from the living areas of the home and placed them within the locked closet in the office. This was completed on 5/28/2026. |
06/12/2026
| Implemented |
| 6400.141(c)(3) | Individual #1's most current tetanus, diphtheria, and pertussis vaccination was administered on 4/22/2016. The United States Public Health Service, Center for Disease Control recommends adults to receive the tetanus, diphtheria, and pertussis vaccination every ten years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Upon receipt of the deficiency notice, BrightPath Human Services obtained Individual #1's historical DTaP immunization record. The record has been placed in the individual's medical file and documented with the annual physical information. A call to the physicians office to make an appointment to obtain the DTAP immunization was made. This will occur on 6/13/2026, bringing the record into compliance with Regulation 6400.141(c)(3). |
06/13/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's initial assessment, completed by Program Specialist #1 on 10/31/2025, did not include the preferences of the individual. This section of the assessment was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Upon receipt of deficiency, the Program Specialist added the Functional Strengths, needs and preferences of individual #1. This was completed on 6/11/2026. Additionally, a full audit of all individuals receiving services by BrightPath Human Services in regards to 6400.181(e)(1) will occur and be completed by 6/30/2026. Any issues of non-compliance will be fixed. The Clinical Manager is responsible for the completion and oversight of this task. |
06/12/2026
| Implemented |
| 6400.51(b)(3) | Direct Service Worker #2, date of hire 12/29/2025, did not complete training on individual rights during orientation. Direct Service Worker #3, date of hire 10/6/2025, did not complete training on individual rights during orientation. | The orientation must encompass the following areas: Individual rights. | Upon receipt of the deficiency notice, the Clinical Manager conducted a comprehensive review of all active employee Relias training transcripts to verify compliance with Regulation 6400.51(b)(3). The review identified one staff member who had not completed the required training. The staff member completed the required training on 06/9/2026, bringing the organization into compliance with Regulation 6400.51(b)(3). |
06/12/2026
| Implemented |
| 6400.163(h) | Individual #1 is prescribed Ketorolac Sol 0.4% Op with instructions to "Instill 1 drop in both eyes four times daily as needed for itching." At 12:25 PM on 5/28/2026, this medication had an expiration date of 12/2025. The expired medication had not been removed from the residential home and destroyed in a safe manner. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Upon receipt of the deficiency notice, all expired medications were immediately removed from the home and destroyed in accordance with BrightPath Human Services policies and procedures. This corrective action was completed on May 28, 2026, bringing the home into compliance with Regulation 6400.163(h). |
06/12/2026
| Implemented |
| 6400.213(8) | Individual #1's record did not include a psychological evaluation. | Each individual's record must include the following information: Copies of psychological evaluations, if applicable. | Upon receipt of the deficiency notice, BrightPath Human Services contacted Individual #1's guardian and obtained a copy of the individual's most recent psychological evaluation. The evaluation was received and added to Individual #1's record on May 27, 2026, bringing the file into compliance with Regulation 6400.213(8). |
06/12/2026
| Implemented |