| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #1 has a reported hire date of 5/5/25 and a first day with individuals date of 5/14/25. The Pennsylvania criminal history report submitted was dated as completed on 5/14/25. Pennsylvania criminal history checks must be completed within five working days after the person's hire date. | 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.
| Human resources will submit request for criminal history report prior to the first day of working with the individual. The House manager will not schedule the staff to work and until report is returned. |
10/28/2025
| Implemented |
| 6400.141(a) | Individual #1 was admitted into the program on 4/28/25. Physicals were completed on 1/29/24 and 7/3/25 both outside of the regulatory time frame for admission physicals to be completed. Additionally, all sections must be completed on the physical form. Sections such as vision and hearing shall be completed and not marked as "not done." Tuberculin skin testing must also be completed prior to admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Director of Health Services will review all medical records of potential individuals. Director of Heath Services will inform Program Specialist of all non compliant matters as it relates to the annual physical. The Program Specialist will inform the Supports Coordinator of what needs to be address prior to transitioning and move in date being confirmed. When completing physicals House Manager will confirm all sections of physical form was completed
((appointment for physical exam and TB testing scheduled for 1/2/26 -CH 11/25/25)) |
10/28/2025
| Implemented |
| 6400.181(e)(3)(iii) | The assessment dated 6/28/25 for Individual #1 included a section to address the area of personal adjustment but there was no information to address the needs of the Individual in the designated section. | The individual's current level of performance and progress in the following areas: Personal adjustment. | Program Specialist will complete personal adjustment section of the assessment in its entirety and in a timely manner. Upon completion, will forward for review to the Coordinator of Compliance for review. |
11/10/2025
| Implemented |
| 6400.181(e)(3)(iv) | The assessment dated 6/28/25 for Individual #1 included a section to address the area of personal needs with or without assistance from others but there was no information to address the needs of the Individual in the designated section. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Program Specialist will complete personal needs section of the assessment in its entirety and in a timely manner; assuring it includes current level of performance and progress in identified areas. Upon completion, will forward for review to the Coordinator of Compliance for review. |
11/10/2025
| Implemented |
| 6400.34(a) | Individual #1 was admitted into the program on 4/28/25. There was no documentation to support that a review of their rights had been completed at time of admission. A Civil Rights document was signed and dated as reviewed on 4/28/25 but there was no documentation to support that Individual Rights as outlined in 32(a)-32(v) were reviewed as required. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Program Specialist will ensure that individual rights are included in the intake packet and thoroughly explained to the individual upon admission and annually. A signed copy of the intake documents will be provided to the individual and filed in their record. |
11/01/2025
| Implemented |
| 6400.166(a)(11) | The October 2025 Medication Administration Record (MAR)for Individual #1 did not include the diagnosis or purpose for the medication for the prescribed Propranolol or Citalopram as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Director of Health Services will amend the Medication Administration Record (MAR) to include the prescribed medications Propranolol and Citalopram, corresponding diagnosis/ purpose. |
11/01/2025
| Implemented |
| 6400.181(f) | The Individual Support Plan annual meeting was held on 8/5/25. The Assessment for Individual #1 was completed on 6/28/25 but not sent to the plan team members until 8/5/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist will provide assessment to all team members at least 30 days prior to annual ISP Meeting. Upon completion of assessment, Program Specialist will send an email to the team and maintain documentation. |
10/28/2025
| Implemented |