| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #1, date of hire 9/15/2025, had a Pennsylvania criminal history record check submitted to the State Police on 9/15/2025. The criminal history record check indicated that Direct Service Worker #1 had a criminal record. The agency did not document the review of Direct Service Worker #1's criminal history check and the agency's decision-making process for hiring. | 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.
| HR has been retrained on the regulation. Provider will use the Department approved form on agency letterhead. |
12/12/2025
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication reviews completed on 8/14/2025 and 9/19/2025 did not specify the need to continue the prescribed medications. | 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 Program Director, Program Specialists, Quality Assurance Associate, and Program Managers have been retrained in the regulation. In addition to the Therap consultation form, which does not meet the regulation, personnel will also reinstitute the ABDD psychiatric form and ensure the prescribing doctor completes it in it's entirety. |
12/12/2025
| Implemented |
| 6400.169(d) | Program Manager #2 completed an observation of medication administration for Direct Service Worker #3 on 8/22/2025. The agency could not provide documentation to demonstrate that Program Manager #2 had successfully completed the Practicum Observer Course and was certified to complete the annual recertification activities when monitored by a certified trainer. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | HR has been retrained on the regulation. The provider will retrain all Practicum observers. The training will take place on December 29-30, 2025. |
12/11/2025
| Implemented |