| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | At the time of inspection, the water temperature in the bathroom of the home was 133°. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water temperature in the home was immediately adjusted by the maintenance department upon discovery of the concern. In addition, hot water temperatures are set and regulated by an external plumbing and heating company as an added measure to help ensure temperatures remain within acceptable ranges (see attached documentation). Ongoing monitoring will continue to ensure compliance with 55 Pa. Code §6400.68(b). The water temperature was adjusted on 05/16/2026Please see attachment #1. |
05/13/2026
| Implemented |
| 6400.70 | There was no telephone in the home at time of inspection. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| At the time of inspection, Individual #9 was incarcerated. Prior to incarceration, the individual damaged the home's landline telephone. Each agency home is equipped with both a landline telephone and a shared cellular device connected to the corporate network. The shared cellular phone remained available for use by all individuals and staff. The landline has since been addressed to ensure continued compliance with 55 Pa. Code §6400.70. The land line was replaced on April 30, 2026. Please see attachment #2. |
04/30/2026
| Implemented |
| 6400.104 | The notification to the local fire department submitted was dated 12/2/25. Individual #9 was admitted into the home on 11/16/25. The notification was not kept current due to the delay in notification from 11/16/25 to 12/2/25.
Previous fire drills indicate that Individual #10 moved from the home between 10/20/25 and 11/16/25. There was no documentation to support that notification of their departure was made to the local fire department. | 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.
| The agency's understanding of the notification requirements to the local fire department differed from the clarification provided during the annual inspection and exit interview. Upon clarification, an updated notification letter reflecting the current individuals residing in the home was submitted to the local fire department to ensure compliance with 55 Pa. Code §6400.104 on 05/08/2026. Please see attachment #3. |
05/08/2026
| Implemented |
| 6400.112(i) | Documentation of the fire drill completed on 11/16/25 indicates that the smoke detectors were not working at the time of the drill and therefore not set off as required. | A fire alarm or smoke detector shall be set off during each fire drill. | At the time of the fire drill, the staff person conducting the drill was unfamiliar with the testing procedure for the newly installed smoke detector model. Staff have since been educated (by our maintenance department) on the proper testing procedures for the updated system. Additionally, the agency maintains a policy requiring 15-minute hazard and risk surveillance checks in the event smoke detectors are non-functional to ensure the continued safety of individuals served and staff. Additionally, when Individual #9 returned from incarceration an additional supporter was present to ensure all alarms were functioning properly. |
02/24/2026
| Implemented |
| 6400.141(b) | The admitting physical dated 11/22/24 for Individual #9 was not dated by the physician as required. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The admitting physical dated 11/22/24 was completed by the individual's previous provider prior to admission. Although the physician's signature was present at the bottom of the physical, the document was not dated by the physician's name as required. There is a date at the top of the physical form. The previous medical provider declined to add a date next to the signature line. Please see attachment #4 |
05/10/2026
| Implemented |
| 6400.141(c)(1) | The admitting physical dated 11/22/24 for Individual #9 did not include information on their medical history as required. The section to provide the information noted "See attached summary." There were no attachments. | The physical examination shall include: A review of previous medical history. | The admitting physical dated 11/22/24 was submitted by the individual's previous provider as Individual #9 transitioned from a children's program into an adult 6400 residential program. The physical referenced an attached medical history summary; however, the attachment was not included in the records received. The previous medical provider was contacted and declined to provide additional documentation regarding the individual's medical history. The agency will continue efforts to obtain complete medical documentation and will review all admission records for completeness upon receipt to ensure compliance with 55 Pa. Code §6400.141(c)(1). |
03/10/2026
| Implemented |
| 6400.141(c)(11) | The admitting physical dated 11/22/24 for Individual #9 did not include information on medication regimen as required. The section for the information noted "See attached MAR." There were no attachments. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The admitting physical dated 11/22/24 was submitted by the individual's previous provider as Individual #9 transitioned from a children's program into an adult 6400 residential program. The physical referenced an attached medical history summary; however, the attachment was not included in the records received. The previous medical provider was contacted and declined to provide additional documentation regarding the individual's medical history. The agency will continue efforts to obtain complete medical documentation and will review all admission records for completeness upon receipt to ensure compliance with 55 Pa. Code §6400.141(c)(11). A MAR was able to be obtain prior to admission. |
03/10/2026
| Implemented |
| 6400.141(c)(14) | The admitting physical dated 11/22/24 for Individual #9 did not include medical information pertinent to diagnosis and treatment in case of an emergency as required. The section for the information on the physical form was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The admitting physical dated 11/22/24 was submitted by the individual's previous provider as Individual #9 transitioned from a children's program into an adult 6400 residential program. The physical referenced an attached medical history summary; however, the attachment was not included in the records received. The previous medical provider was contacted and declined to provide additional documentation regarding the individual's medical history. The agency will continue efforts to obtain complete medical documentation and will review all admission records for completeness upon receipt to ensure compliance with 55 Pa. Code §6400.141(c)(14). |
03/10/2026
| Implemented |
| 6400.141(c)(15) | The admitting physical dated 11/22/24 for Individual #9 did not include information on the Individual's diet. The section assigned for the information was blank. | The physical examination shall include:Special instructions for the individual's diet. | The admitting physical dated 11/22/24 was submitted by the individual's previous provider as Individual #9 transitioned from a children's program into an adult 6400 residential program. The physical referenced an attached medical history summary; however, the attachment was not included in the records received. The previous medical provider was contacted and declined to provide additional documentation regarding the individual's medical history. The agency will continue efforts to obtain complete medical documentation and will review all admission records for completeness upon receipt to ensure compliance with 55 Pa. Code §6400.141(c)(15). |
03/10/2026
| Implemented |
| 6400.181(a) | Individual #9 was admitted to the program on 11/16/25. As of 4/7/26 there was no evidence to illustrate that an assessment had been completed within 1 year prior to or 60 calendar days after admission to the residential home as required. | 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. | It was the agency's understanding that an assessment could not be completed due to the limited amount of time Individual #9 resided in the program, approximately 2.5 weeks prior to incarceration. The clarification and education provided during the annual licensing inspection and exit interview assisted the agency in better understanding the assessment requirements under 55 Pa. Code §6400.181(a). The agency will ensure assessments are completed within the required timeframe regardless of length of stay or other circumstances impacting service delivery. An assessment was completed. |
04/27/2026
| Implemented |
| 6400.34(a) | Documentation that the rights for Individual #9 were reviewed was dated 11/16/25, the Individual's admission date. The dated signature sheet indicated that the rights were reviewed but did not note the rights that were reviewed as required. Documentation of the exact rights reviewed was requested and not received. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | In an effort to reduce paper usage and waste, the agency implemented a process allowing individuals to sign acknowledgment that their rights were reviewed, explained, and provided to them rather than signing duplicate copies of the rights document. During the inspection, the rights reviewed with Individual #9 were present and available for review; however, the rights document was maintained separately and not physically attached to the signature acknowledgment page. The agency will revise its documentation practices to ensure the signed acknowledgment is maintained together with the specific rights reviewed to ensure compliance with 55 Pa. Code §6400.34(a). |
05/08/2026
| Implemented |
| 6400.213(1)(i) | The record for Individual #9 did not include the individual's eye or hair color as required. | Each individual's record must include the following information: Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | The record for Individual #9 has been updated to include the individual's eye and hair color as required. Please see the attached updated face sheet. Please see attachment 7 |
06/01/2026
| Implemented |
| 6400.213(1)(i) | The record for Individual #9 did not include the religious affiliation of the Individual. | Each individual's record must include the following information: Personal information, including: (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. | The record for Individual #9 has been updated to include the individual's religious affiliation as required. Please see the attached updated face sheet. Please see attachment 7 |
06/01/2026
| Implemented |