| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.91(a) | Individual #1 was trained in fire safety on 07/28/25, not upon initial admission of 07/21/25 into the program. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | WHO: EXECUTIVE DIRECTOR SOP updated to specify fire safety training for clients to occur prior to or on first day of program entry. |
05/01/2026
| Implemented |
| 2380.111(a) | Individual #1's 06/12/25 does not contain all of the required components; specifically, the information stated in 2380.111c1, 2380.111c7, 2380.111c8, and 2380.111c9; these sections of the Physical Form were populated with "N/A". | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | WHO: PROGRAM SPECIALIST Individual #1's physical secured with proper documentation.
WHO: EXECUTIVE DIRECTOR SOP updated to prohibit blank fields and the use of "N/A." |
05/31/2026
| Implemented |
| 2380.111(c)(6) | Individual #4's 11/26/25 annual physical did not identify if the individual is free from communicable disease. The question is on the physical, but it is blank. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | WHO: PROGRAM SPECIALIST Individual #4's physical secured with documentation of communicable diseases.
WHO:EXECUTIVE DIRECTOR SOP updated to prohibit blank fields and the use of "N/A." Program Specialist required to review all physical and return for corrections if not complete. |
05/31/2026
| Implemented |
| 2380.111(c)(9) | Individual #3's 08/04/25 Physical Examination does not indicate if Individual #3 has any allergies or contraindicated medications; this section of the form is blank. | The physical examination shall include: Allergies or contraindicated medication. | WHO: PROGRAM SPECIALIST Individual #3's physical secured with proper documentation of allergies.
WHO: EXECUTIVE DIRECTOR SOP updated to prohibit blank fields and the use of "N/A." |
05/31/2026
| Implemented |
| 2380.173(1)(iv) | Individual #3's "Face Sheet" in the record states that Individual #1's "religion" is "N/A". | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | WHO: PROGRAM SPECIALIST Individual #3's face sheet updated with his religious affiliation.
WHO: EXECUTIVE DIRECTOR SOP updated to require all fields to be completed with none left blank or noted as "N/A." |
05/31/2026
| Implemented |
| 2380.173(1)(v) | -Individual #2 does not have a current and updated photograph in their record, as the most recent picture was uploaded on 6/26/24.
-Individual #3 does not have a current and updated photograph in their record, as the most recent picture was uploaded on 05/01/24.
-Individual #4 does not have a current and updated photograph in their record, as the most recent picture was uploaded on 6/19/24. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | WHO: PROGRAM SPECIALIST Individual's #2, #3, and #4's photos taken and stored in the electronic health record with date.
WHO: EXECUTIVE DIRECTOR SOP updated to required updated photos annually or upon any significant change of appearance. |
05/31/2026
| Implemented |
| 2380.181(a) | Individual #1's Initial Assessment does not contain a complete date, it states "9/2025", so it is unclear whether it was completed within the 60-day timeframe required. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | WHO: PROGRAM MANAGER Individual #1's initial assessment date to be identified and documented. All assessments to include full dates in the format MM/DD/YYYY. |
05/31/2026
| Implemented |
| 2380.181(c) | -Individual #1's 04/02/26 annual assessment does not state if the assessment was created based on assessment instruments, interviews, progress notes and observations.
-Individual #2's 3/27/26 annual assessment does not state if the assessment was created based on assessment instruments, interviews, notes, and observations.
-Individual #4's 2/18/26 annual assessment did not identify if the assessment was created based on assessment instruments, interviews, notes, and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | WHO: EXECUTIVE DIRECTOR Individuals #1, #2, and #4 will have the statement "Assessment was created based on assessment instruments, interviews, notes, and observations" included verifying the practice used when development the document. The assessment template will be updated to include the statement. |
05/31/2026
| Implemented |
| 2380.181(e)(9) | -Individual #1's 04/02/26 annual assessment does not include a review of the Individual Disability, including Functional and Medical limitations.
-Individual #2's 3/27/26 annual assessment does not include a review of the individual's disability, including functional and medical limitations.
-Individual #4's 2/18/26 annual assessment does not include a review 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. | WHO: PROGRAM SPECIALIST Individuals #1, #2, and #4 will have physical disability, and functional or medical limitations included in their assessments.
WHO: PROGRAM SPECIALIST The assessment template will be updated to include a section for this documentation. |
05/31/2026
| Implemented |
| 2380.21(u) | - Individual #1's 02/17/26 "Universal Individual Rights" Form does not include a review of all of the rights as required by regulation; specifically, the rights of Individuals under 2380.21h to not be discriminated against due to "religious affiliation, gender identity, and sexual orientation"; and the rights listed at 2380.21a through 2380.21i.
- Individual #2 was not informed of rights 21a-21i on their 2/19/26 Individual Rights form.
- Individual #3's 02/17/26 "Universal Individual Rights" Form does not include a review of all of the rights as required by regulation; specifically, the rights of Individuals to not be discriminated against due to "religious affiliation, gender identity, and sexual orientation"; and the rights listed at 2380.21a through 2380.21i.
-Individual #4 was not informed of rights 21a-21i on their 2/13/26 Individual Rights form. | The facility 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 facility and annually thereafter. | WHO: PROGRAM SPECIALIST Individuals #2, #3, and #4 will be issued updated Universal Individual Right's forms.
WHO: DIRECTOR OF QUALITY & COMPLIANCE The Universal Individual Right's document will be updated to include all required ODP language. |
05/31/2026
| Implemented |
| 2380.126(a)(2) | Individual #5's Medication Administration Record (MAR) does not include the name of the prescriber. This section is blank. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | WHO: PROGRAM SPECIALIST Individual #5's eMAR updated to include the prescriber's name. |
05/01/2026
| Implemented |
| 2380.126(a)(3) | Individual #5's Medication Administration Record (MAR) does not include Individual #5's Allergies. This section is blank. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | WHO: PROGRAM SPECIALIST Individual #5's eMAR updated to include allergies. |
05/01/2026
| Implemented |