| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | There were no lids on the outside trash receptacles. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | In accordance with 55 PA Code Chapter 6400.64(f), the executive director will ensure that the maintenance manager is retrained on the agency's "Home Maintenance Checklist" by 2/28/26. The Program Specialist will ensure that the staff is also trained on this section of the 6400 regulation. The agency's "Home Maintenance Checklist" will continue to have checking outside trashcans for lids as a checklist item. |
02/28/2026
| Implemented |
| 6400.67(a) | There was a cracked/broken floor tile leading into the kitchen that has potential to be a tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | In accordance with 55 PA Code Chapter 6400.67(b), the maintenance manager will ensure that contractor replaces the cracked floorboard by 2/28/26. |
02/28/2026
| Implemented |
| 6400.68(b) | The running water returned with a temperature of 151.7F exceeding the allowable threshold of 120F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | IN accordance with 55 PA Code Chapter 6400.68(b), the maintenance manager will ensure that a contractor adjusts the temperature at the water heater at the residence. The executive director will ensure that the maintenance manger is retrained on the "Home Maintenance Checklist" that currently includes checking that water temperatures do not exceed 120F. |
02/28/2026
| Implemented |
| 6400.72(b) | The kitchen window frame is damaged along the lower portion necessary for grasping to open. | Screens, windows and doors shall be in good repair. | In accordance with55 PA Code Chapter 6400.72(b), the maintenance manager will ensure that a contractor replaces and/or repairs the kitchen window frame by 2/28/26. |
02/28/2026
| Implemented |
| 6400.77(b) | There were no tweezers in the first aid kit during inspection. (This was corrected.) | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | in accordance with 55 PA Code Chapter 6400.77(b) this violation was corrected during inspection |
01/23/2026
| Implemented |
| 6400.144 | The following prescribed medications were not available during inspection: -Albuterol HFA Aer -Acetaminophen 325MG Tab -Minerin Cream -Polyeth Glyc Powder 3350NIndividual
Individual #1 is prescribed Benztrapine 0.5MG Tab. The 8am dosage was removed from blister pack on 1/20/26 despite records indicating that the Individual was hospitalized. The 8pm dosage was initialed as given on the 20th but remained in the blister pack. The individual takes medication for constipation, but the agency does not maintain any stool logs to confirm the success of the administered medication
. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| In accordance with 55 PA Code Chapter 6400.144, the executive director ensured that the pharmacy removed the discontinued Polyeth Glyc Powder from the MAR, requested a second Albuterol HFA Aer because the individual takes it to day program with them and was at day program during inspection, requested more of the PRN Acetaminophen 325MG Tab and Minerin Cream. The executive director will work in conjunction with the agency nurse to create and implement a stool log to track constipation, and conduct a refresher training for all medication administration trained staff by 2/28/26. |
02/28/2026
| Implemented |
| 6400.32(h) | There were cameras in the common spaces of the home and no signed agreements by the Individuals granting permission for their existence. | An individual has the right to privacy of person and possessions. | In accordance with 55 PA Code Chapter 6400.32(h), the program specialist will ensure that individuals in the program will have the reason for cameras in common areas and have individuals sign statements of permission if they choose. |
02/28/2026
| Implemented |
| 6400.166(a)(1) | During the medication review, Diltiazem ER 180MG was present in the home but not listed on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | In accordance with 55 PA Code Chapter 6400.166(a)(1), the Diltiazem ER 180MG was added to the MAR. The executive director will work in conjunction with the agency nurse to conduct a refresher training for all medication administration trained staff by 2/28/26. |
02/28/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's program book did not contain a face sheet, documentation of identifying marks, religion, primary language, physical description, and a current dated photo. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | In accordance with 55 PA Code Chapter 6400.213(1)(i), the executive director will ensure that program specialist is retrained on this section of the regulation and the agency's individual file checklist . The program specialist will ensure that individual #1's file is updated to include the facesheet to include a current photo, language, identifying marks, weight. |
02/28/2026
| Implemented |