| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The provider agency completed a self-assessment of the home on 5/16/25. The regulations, .189a through .217, were not addressed on the self-assessment. These items were left blank. [Repeat Violation- 7/9/24 et al] | 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.
| 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. The CEO has retrained the Residential coordinator on the importance of completing the self assessments in it's entirety, |
06/28/2025
| Implemented |
| 6400.21(a) | Direct Service Provider #2, with a date-of-hire of 4/21/25, completed an application for a Pennsylvania criminal history record check on 4/23/25. This record check documented that Direct Service Provider #2 had a criminal record. The provider agency did not provide documentation of a review considering the nature of the crime, the facts surrounding the conviction, the time elapsed since the conviction, the evidence of the individual's rehabilitation, and the nature and requirements of the job. | 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.
| Atlantis¿ administrative staff will now require all perspective employees to submit onboarding documents at least forty-eight hours prior to orientation. This will allow time for the criminal background to be disseminated prior to completion of orientation and permit Admin staff time to review. No staff or potential staff shall be granted the opportunity to shadow or work with individuals prior to receiving the results of the pending criminal background. This will help ensure and Protects individuals from abuse and mistreatment. |
06/27/2025
| Implemented |
| 6400.65 | On 6/11/25 at 12:32 PM, the mechanical ventilation fan in the ceiling of the bathroom in the hallway of the home was inoperable. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Vents are located on top of roof in the entire apartment building the bathrooms. A letter was requested from the property manager to explain how the exhaust fan works. |
06/28/2025
| Implemented |
| 6400.72(b) | On 6/11/25 at 12:46 PM, there was a one-inch by two-inch hole in the screen in the window of the staff office. | Screens, windows and doors shall be in good repair. | Screens windows and doors shall be in good repair. Maintenance request was submitted for screen repairs. a letter stating screens will be fixed in July they had to be ordered from property manager. Letter was sent to licensing inspector via email. |
06/28/2025
| Implemented |
| 6400.106 | The furnace in the home was inspected and cleaned on 5/10/23, and then again on 9/5/24. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Residential Coordinator has created a tracking sheet of the cleaning inspections annual due date. |
06/28/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's admission date is 9/23/24, and they most recently received a Tetanus immunization on 2/26/15. | 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. | As of 6/17/2025 this individual received his tetanus vaccination. Documentation has been obtained and added to the individual's medical records. A full audit of resident immunizations records to ensure compliance with tetanus shot requirements. |
06/17/2025
| Implemented |
| 6400.171 | On 6/11/25 at 12:35 PM, there was an opened, partially used bottle of ketchup with instructions to "refrigerate after opening" in the cabinet above the counter in the kitchen of the home. [Repeat Violation- 7/9/24 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| Instructions on the ketchup bottle states "for best results refrigerate after opening" Ketchup was placed in the refrigerator. |
06/28/2025
| Implemented |
| 6400.214(b) | On 6/11/25 at 1:30 PM, the most recent copy of Individual #1's physical examination was not present in the home. [Repeat Violation- 7/9/24 et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Atlantis Program specialist reviewed resident files in the home and have updated the required documents. Weekly checks will be conducted by the house supervisor to ensure all medical summaries are present in the resident files. Monthly audits will be conducted by the program specialist to ensure the resident binder contains all required documents. |
06/17/2025
| Implemented |
| 6400.32(r)(1) | On 6/11/25 at 1 PM, there was a turn locking mechanism on the inside with a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. Individual #1 was not provided with a key to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | An individual has the right to lock the individual's bedroom door. All individuals locks were updated with key and given to individual. Picture was sent via email to licensing inspector. |
06/28/2025
| Implemented |
| 6400.32(r)(4) | On 6/11/2025 at 1 PM, there was a turn locking mechanism on the inside with a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. The keys that staff possessed for Individual #1's bedroom door was not clearly labeled, thus, preventing easy and immediate access in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. The locks were replaced with new locks with keys and provided a copy to individual. |
06/28/2025
| Implemented |
| 6400.50(a) | Direct Service Provider #2, with a date-of-hire of 4/21/25, reportedly completed orientation training on recognizing and reporting incidents on 4/25/25. The provider agency did not provide the source and content for this training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Conducted an internal audit of all staff files to identify missing orientation and training records. Ensure each file includes training topics, siting the source of the training. |
06/30/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Provider #2, with a date-of-hire of 4/21/25, did not complete orientation training on individual specific job-related knowledge and skills prior to working with individuals. | The orientation must encompass the following areas: Job-related knowledge and skills. | Update the orientation checklist to include job-specific training topics based on role responsibilities (Direct Support Professional, Residential Manager, Program Specialist, Medication Administrator).
Include training scenarios and competency checks to confirm staff understanding of their specific duties. |
07/02/2025
| Implemented |
| 6400.52(a)(3) | Program Specialist #1, with a date-of-hire of 4/3/23, did not complete at least twenty-four hours of training during the annual training year, 1/1/24 through 12/31/24. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | The Program Specialist will complete the remaining training hours within 20 days of this plan. training will be directly related to job duties including but not limited to the required ODP trainings. Certificates will be placed in the program specialist employee training file. |
07/10/2025
| Implemented |
| 6400.52(c)(1) | Program Specialist #1's annual trainings for the training year, 1/1/24 through 12/31/24, did not include individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Program Specialist will complete all overdue training hours within thirty days.
Training will include content relevant to job duties such as Persons Centered Practices, Community Integration, Individual Choice and Supporting Individuals to develop and maintain relationships.
All completed training will be documented with the training date, topic, trainer, and certificate or sign-in sheet. There was also a verbal warning issued for this violation. |
07/11/2025
| Implemented |
| 6400.52(c)(2) | Program Specialist #1's annual trainings for the training year, 1/1/24 through 12/31/24, did not include the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The Program Specialist will complete all overdue training to include prevention, Detection, and reporting abuse, suspected abuse and alleged abuse. There was also a verbal warning issued to the program specialist as well. |
07/10/2025
| Implemented |
| 6400.52(c)(4) | Program Specialist #1's annual trainings for the training year, 1/1/24 through 12/31/24, did not include recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The Program Specialist will complete all overdue training to include Recognizing and Reporting Incidents. There was also a verbal warning issued to the program specialist as well. |
07/10/2025
| Implemented |
| 6400.163(a) | On 6/11/25 at 1:01 PM, Individual #1's prescribed, Ketoconazole 2% Shampoo, was not stored in its originally labeled container from the pharmacy. The label was not present in the home. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The improperly stored medication was immediately removed and replaced with medication in the original pharmacy-labeled container. Staff responsible were re-instructed on proper medication storage procedures. All staff involved in medication administration will receive refresher training on medication storage requirements, including the importance of keeping medications in their original labeled containers.
Training will be completed by 07/02/2025, and attendance will be documented. Verbal warning was issued to all staff. |
07/02/2025
| Implemented |
| 6400.163(f) | On 6/11/25 at 12:36 PM, there were two vials of allergy medication wrapped in a folded piece of paper labeled, "[Individual #1] exp. 11/29/2025," that were unlocked and accessible in the compartment in the door of the refrigerator in the kitchen of the home. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | The medications were immediately removed and placed in a locked medication refrigerator or a locked box within the refrigerator. A site-wide inspection was conducted to ensure all refrigerated medications were secured. A lock box was purchased to store medications in the refrigerator. All staff were shown the new setup and procedures for accessing refrigerated medications. |
06/12/2025
| Implemented |
| 6400.165(b) | Individual #1's prescribed medication, Ketoconazole Shampoo 2%, was on the June 2025 Medication Administration Record twice. The first entry included instructions, "use to wash scalp daily until clear for Atopic Dermatitis (After clear use 3 times a week)." This medication was originally prescribed on 10/11/24 and was initialed as administered daily from 6/1/25 through 6/11/25. The second entry included instructions to, "apply topically to scalp and leave on a few minutes and rise 3 times weekly for Seborrheic Dermatitis." This medication was originally prescribed on 4/30/25 and had not been administered from 6/1/25 through 6/11/25. Staff could not ensure which medication was correct, and the physician's orders were not present in the home. [Repeat Violation- 7/9/24 et al] | A prescription order shall be kept current. | The duplicate error on the MAR was identified and corrected /discontinued. The individual's physician was contacted to confirm the correct entry on the MAR. Followed by a phone call to the pharmacy requesting the duplicate entry to be removed from all future MARS. |
07/03/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. The psychiatric medication review completed on 4/2/25 did not include the reason for prescribing the medication. [Repeat Violation- 7/9/24 et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | All Psychiatric reviews will be scheduled to be completed by psychiatric provider. The Psychiatric medication review appointment summary form has been updated to reflect the reasons for prescribing the medication as well as the need to continue the medication and necessary dosage. Files are being audited to ensure compliance and corrections made where necessary. |
07/01/2025
| Implemented |
| 6400.166(b) | Individual #1's prescribed medication, Triamcinolone Cream 0.1%, was not initialed as having been administered at 8 AM on 6/11/25. [Repeat Violation- 7/9/24 et al] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The responsible staff member was immediately retrained on the correct procedure for documenting medication administration. On 6/13/2025 this staff member was retrained on proper Mar documentation procedures including immediate documentation after administration. The use of acceptable documenting codes and steps to follow when a dose is missed, refused or delayed. Staff reviewed the Medication Administration Policy and signed acknowledgment forms. |
06/13/2025
| Implemented |
| 6400.169(d) | Direct Service Provider #2, with a date-of-hire of 4/21/25, completed the online Office of Developmental Programs Standard Student Medication Administration Course on 4/29/25. The required medication administration observations were completed prior to the completion of the course on 4/25/25, 4/26/25, 4/27/25 and 4/28/25. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Employee files were audited to ensure every staff member has a complete and compliant training record. |
07/01/2025
| Implemented |