| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 10:23AM on 1/23/2025, the hot water temperature measured 140°F at the sink in ensuite bathroom in Individual #2's bedroom. At 10:32AM on 1/23/2025, the hot water temperature measured 139.1°F at the sink in the bathroom on the second floor of the home. | 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. | Our Maintenance person, sub-contractor, installed water heater regulators to all the sinks and shower areas that were in violation of exceeding 120 degrees Fahrenheit to heat temperatures between 108 to 115 degrees. A Paid Invoice with the completed installation of heat regulators to all the homes was issued on 21 February 2025. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to each home quarterly throughout the year to ensure that the water heat regulators are working properly with compliant code 6400.63(a). The training/consolation form was signed and dated by the contractor on 21 February 2025. In addition, the Site Operations Managers were given a training/counseling session by the CFO in the steps of overseeing their Direct Support Staff of daily checking the water temperatures. The counseling/training form was signed and dated 24 February 2025. The steps consist of DSS performing daily temperature checks throughout the house. If the water temperature is over 120 degrees, the staff are trained to check the water heater to see if it¿s on the lowest level, report it to their supervisor. Still not in compliance, the supervisor will contact the sub-contractor for assistance to ensure that we become compliant, immediately. |
02/21/2025
| Implemented |
| 6400.73(a) | At 10:11AM on 1/23/2025, there was no railing on the three stairs in the garage of the home leading to the kitchen. At 10:12AM on 1/23/2025, there was no railing on the first four interior stairs leading to the basement of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Maintenance Sub-Contractor installed extended railings on the first four interior stairs leading to the basement and the three steps leading in the garage (Please SEE Pictures) on 4 February 2025. A Paid Invoice with the completed installation of an extended railing was issued on 21 February 2025. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to each home quarterly throughout the year to ensure that the railings are secured properly with compliant code 6400.73(a). The training/consolation form was signed and dated by the contractor on 21 February 2025. |
02/21/2025
| Implemented |
| 6400.80(a) | At 10:06AM on 1/23/2025, the exterior stairs attached to the deck at the back exit of the home were covered in several inches of snow. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The walkway was cleared on 24 January 2025 by a Direct Support Staff. The Site Operation Managers were given a counseling session to make sure that the duties would be performed by the DSS to clear way the walkways. The signed agreement was signed on 24 February 2025 by all Site Operations Managers. For Major snowstorms over three inches, there was a counseling session given to our land-care sub-contractor. to clear the driveways for all of the Homes. The agreement was signed on 24 February 2025. |
02/24/2025
| Implemented |
| 6400.81(k)(2) | At 10:36AM on 1/23/2025, the right side of Individual #1's mattress is sunken downward. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | The Set was purchased on 24 January 2025 and was installed on 4 February. During the in between time, the mattress was turned around so that it would be leveled and sturdy enough for a solid foundation. (Please See Pictures). |
02/04/2025
| Implemented |
| 6400.106 | The furnace inspection, completed 9/12/2024, did not include a cleaning. | 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 CFO contacted the Heating & Air Conditioning Company to instruct them to correct the maintenance Invoices to say, "cleaning" on the documents. The annual Inspection from the heating company on 6 February 2025 documented the Maintenance Invoices to reflect, "cleaning" for all of the furnaces. (Please SEE Documents). |
02/06/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 7/31/2024, does not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 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. | Individual #1¿s physical examination completed on 7/31/2024 did not include medical health maintenance needs, medication regimen and needs for blood work at recommended interverals. These sections were left blank by the physician. Site Operations Manager has taken over the Physical dated 7/31/2024 to the PCP office and asked that it is completed by the PCP in its entirety on 2/1/2025 Per 55 Code Chapter 6400.141(c)(11). Site Operations Manager received back the Annual Physical completed 2/1/2025 before leaving the Physician¿s office. Site Operations Manager checked all other individual physical forms to ensure all areas of the annual physical were completed by the PCP and were in good standing. |
02/25/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 7/31/2024, does not address medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1¿s physical examination completed on 7/31/2024 did not include medical information pertinent to diagnosis and treatment in case of emergency These sections were left blank by the physician. Site Operations Manager has taken over the Physical dated 7/31/2024 to the PCP office and asked that it is completed by the PCP in its entirety on 2/1/2025 Per 55 Code Chapter 6400.141(c)(11). Site Operations Manager received back the Annual Physical completed 2/1/2025 before leaving the Physician¿s office. Site Operations Manager checked all other individual physical forms to ensure all areas of the annual physical were completed by the PCP and were in good standing. |
02/25/2025
| Implemented |
| 6400.181(d) | Individual #1's assessment, completed 1/27/2024, was not signed and dated by the program specialist. [Repeat Violation, 1/25/2024] | The program specialist shall sign and date the assessment. | Individual #1¿s current assessment, completed on 1/27/2024 was signed by the Program Specialist on 2/5/2025. Program Specialist has since reviewed all Skill Assessments and made sure all Program Specialist signatures were signed and dated for 2/5/2025, Per 55 PA Code Chapter 6400.181(d). |
02/25/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 1/27/2024, does not include the preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #1¿s current assessment, completed on 1/27/2024 did not include the preference of the Individual. Individual #1¿s current Skill Assessment was changed by the Program Specialist 1/27/2025 to reflect Individual #1¿s disability, including functional and non-medical limitations per 55 PA Code Chapter 6400.181(e)(1). |
02/25/2025
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment, completed 1/27/2024, does not include documentation of the individual's disability including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #1¿s current assessment, completed on 1/27/2024 did not include the Individuals disability, including functional and non-medical limitations. Individual #1¿s current Skill Assessment was changed by the Program Specialist 1/27/2025 to reflect Individual #1¿s disability, including functional and non-medical limitations per 55 PA Code Chapter 6400.181(e)(9). |
02/25/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 1/27/2024, does not include lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual #1¿s current assessment, completed on 1/27/2024 did not include Individual #1¿s Lifetime Medical History. Individual #1¿s current Skill Assessment was changed by the Program Specialist 1/27/2025 to reflect Individual #1¿s Lifetime Medica; History per 55 PA Code Chapter 6400.181(e)(10). |
02/25/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 1/27/2024, does not include recommendations for specific areas of training, programming and services. This section was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1¿s current assessment, completed on 1/27/2024 did not include Individual #1¿s recommendations for specific areas of training, programming and service. Individual #1¿s current Skill Assessment was changed by the Program Specialist 1/27/2025 to reflect Individual #1¿s recommendations for specific areas of training, programming and service per 55 PA Code Chapter 6400.181(e)(12). |
02/25/2025
| Implemented |