| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was no exterior light at the basement entrance/exit to the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The provider acknowledges that, at the time of inspection, there was no exterior lighting at the basement entrance/exit of the home, which does not comply with 55 PA Code Chapter 6400.66, requiring that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes be adequately lighted to ensure safety and prevent accidents.
Immediate corrective action was taken. An exterior light was installed at the rear basement door to ensure adequate illumination of the entrance/exit area. This correction ensures safe visibility for individuals and staff during entry and exit of the basement area, particularly during low-light or nighttime conditions.
A walkthrough of the exterior of the home was completed to ensure that all other required areas are adequately illuminated. No additional lighting deficiencies were identified.
All maintenance and supervisory staff were informed of the correction and the requirement to immediately report any lighting deficiencies to ensure timely repair or replacement. |
05/04/2026
| Implemented |
| 6400.71 | Emergency telephone numbers were not posted on or near the telephone located in the basement office. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The provider acknowledges that, at the time of inspection, emergency telephone numbers were not posted on or near the telephone located in the basement office, which is not in compliance with 55 PA Code Chapter 6400.71.
Immediate corrective action was taken. A label containing all required emergency contact numbers---including the nearest hospital, police department, fire department, ambulance service, and poison control center---was placed directly on the telephone located in the basement office. This ensures that emergency information is immediately accessible to staff and individuals in the event of an emergency.
A review of all telephones within the home was completed to ensure that emergency contact information is posted on or near each telephone with an outside line. No additional deficiencies were identified.
All staff were informed of the correction and reminded of the requirement to ensure emergency contact information remains visible, current, and accessible at all times. |
05/04/2026
| Implemented |
| 6400.110(e) | The home has three levels and the smoke detectors in the home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The provider acknowledges that, at the time of inspection, the smoke detectors in the home were not interconnected across all three levels, which is not in compliance with 55 PA Code Chapter 6400.110(e).
Immediate corrective action was taken. A system of wireless interconnected smoke alarms was installed throughout the home to ensure that when one alarm is activated, all alarms sound simultaneously and are audible on each level of the home, including the basement and upper floors. This corrective action ensures compliance with fire safety requirements and enhances the safety of all individuals residing in the home.
A full inspection of the smoke detection system was completed following installation to verify proper functionality and interconnection of all devices. No additional deficiencies were identified.
All staff were informed of the correction and instructed on the importance of maintaining functional, interconnected smoke detection systems at all times. |
05/04/2026
| Implemented |
| 6400.141(c)(6) | Individual #1 did not have tuberculin with negative results or, if positive, a chest x-ray showing no active disease at the time of admission. Individual #1 was admitted on 1/13/2025 and had a physical examination completed on 5/06/2024, prior to admission to the home. That physical examination did not include tuberculin testing. The individual has since had a subsequent physical examination on 5/14/2025 which did include tuberculin testing which was five months after admission to the home. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The TB screening for Individual #1 was completed on 1/15/2025 and read on 1/17/2025.
Documentation of the completed tuberculin skin test was obtained from the physician's office.
The TB screening results have now been placed in the individual's record, ensuring compliance with documentation requirements.
The individual also received a subsequent physical examination on 5/14/2025, which included tuberculin testing, further confirming compliance with health monitoring requirements. |
05/05/2026
| Implemented |
| 6400.181(e)(2) | The annual assessment completed on 4/01/2025 for Individual #1 did not contain or document the individual's dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The annual assessment for Individual #1 has been reviewed and updated to include the individual's dislikes, in addition to previously documented likes and interests.
The updated information was obtained through direct communication with the individual and, as applicable, input from staff familiar with the individual's preferences.
The revised assessment now clearly reflects likes, dislikes, and interests in both the section heading and content, in full compliance with regulatory requirements.
The corrected assessment has been placed in the individual's record. |
05/05/2026
| Implemented |
| 6400.165(g) | If medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every three months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 is currently prescribed the medication Temazepam 30 mg. caps to be administered by mouth once per day at 8:00 PM for sleep/anxiety, and Quetiapine 25 mg. tabs, to be administered 1 tab by mouth at 8:00 PM and ½ tab by mouth at 8:00 AM for insomnia/anxiety, and there have not been medication reviews conducted at least every three months. | 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. | The individual was receiving psychotropic medications prescribed and monitored through the Primary Care Physician. During review of the medications, the PCP determined that a psychiatric specialist would more appropriately manage ongoing psychiatric medication management. A referral to psychiatry has been initiated, and the individual is currently awaiting an appointment for psychiatric evaluation and ongoing medication reviews. The PCP has reviewed the current medications, and continuation orders remain in place pending psychiatric follow-up. |
05/05/2026
| Implemented |