| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 10:51AM on 5/28/2026, the hot water temperature at the bathroom sink measured 131.9°F. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Upon receipt of the deficiency notice, the Clinical Manager adjusted the hot water heater to reduce the water temperature within the home. On the following day, the Clinical Manager verified the corrective action by measuring the water temperature at the bathroom sink. The recorded temperature was 118.2°F, bringing the home into compliance with Regulation 6400.63(a). |
06/12/2026
| Implemented |
| 6400.68(b) | At 10:53 AM on 5/28/2026, the hot water temperature at the bathtub measured 134.2° F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Upon receipt of the deficiency notice, the Clinical Manager adjusted the hot water heater to reduce the water temperature within the home. On the following day, the Clinical Manager verified the corrective action by measuring the water temperature at the bathtub. The recorded temperature was 117.2°F, bringing the home into compliance with Regulation 6400.63(a)(b). |
06/12/2026
| Implemented |
| 6400.141(c)(3) | Individual #1, date of admission 11/24/2025, had physical examination completed on 10/21/2025 which indicated their most recent tetanus, diphtheria, and pertussis vaccination was "unknown." The agency could not provide any further documentation to demonstrate that Individual #1 had a current tetanus, diphtheria, and pertussis vaccination. 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 attempted to obtained Individual #1's historical DTaP immunization record from his legal guardian and SC. Unfortunately, individual #1's SC did not have a copy of Individual #1's immunization record and individual #1's legal guardian is not available at this time to provide this documentation. Individual #1 current is in Allegheny County Prison. Communication with the prison to facilitate individual #1 receiving the vaccination has occurred. We can not ensure that individual #1 received the vaccination as of 6/15/2026. |
06/15/2026
| Implemented |
| 6400.181(a) | Individual #1, date of admission 11/24/2025, had an initial assessment completed by Program Specialist #1; however, this assessment was not signed or dated. Therefore, compliance with the 60-day requirement could not be measured. | 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. | Upon notice of this deficiency, the program specialist, who was the original author of the assessment, dated the assessment for the day they sent the assessment to the Support Coordinator. This new assessment has been added to Individual #1's file on 6/11/2026. |
06/12/2026
| Implemented |
| 6400.181(d) | Individual #1, date of admission 11/24/2025, had an initial assessment completed; however, this assessment was not signed or dated by Program Specialist #1. | The program specialist shall sign and date the assessment. | Upon receipt of the deficiency notice, the Program Specialist, who was the original author of the annual assessment, signed and dated the document and ensured it was properly filed in Individual #1's record. This corrective action was completed on June 11, 2026, bringing the assessment into compliance with Regulation 6400.181(d). |
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 immediately attempted to obtain a copy of Individual #1's most recent psychological evaluation. The Clinical Manager contacted Individual #1's county representative; however, the county AE was unable to provide a copy of the evaluation. Efforts were also made to obtain the document from Individual #1's guardian. At the time of the request, the guardian was unavailable due to incarceration and was therefore unable to provide the requested documentation. However, on 6/11/2026, the SC of Individual #1 was able to send a psychological evaluation that was completed while Individual #1 was in high school. This psychological evaluation is not signed by the evaluator, but it does show measured psychological testing. |
06/12/2026
| Implemented |