| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment form that was completed did not include a date of completion and multiple items on the form were left blank on the form and not indicated that they were reviewed by the agency. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring
structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/03/2025
| Implemented |
| 6400.18(b) | Incidents 9610529 and 9628792 for Individual #3 were submitted more than 24 hours after their discovery date. | Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home.
| Incidents for 9610203, 9610529, and 9628792 for Individual #3 will be finalized within 5 days of 11/21/25. As
a result of Complete Comfort's operational hiring internal plan of correction, we will require 1 identified staff
person to become a certified investigator through ODP's cohort training. Additionally, we are in the process of re-evaluating our incident management policy & procedure relating to prevention, reporting, investigation & management of adverse or significant incidents. |
11/21/2025
| Implemented |
| 6400.21(a) | Criminal background check for Staff Person #5 completed 4/2/2025 despite hire date of 2/25/2025.
Criminal background check for Staff Person #6 completed 4/8/2025 despite hire date of 2/4/2025. | 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.
| To ensure compliance with new hire background check compliance , 6400.21(a), Human Resources will
develop an internal auditing tracking system to sustain ongoing adherence to 6400,21(a). |
11/17/2025
| Implemented |
| 6400.62(a) | Half empty, open bottle of lighter fluid for charcoal sitting in planter on terrace. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials have been removed (e.g. the bottle of lighter fluid sitting in the planter on the
terrace). |
11/03/2025
| Implemented |
| 6400.76(a) | Closet door near apartment entry damaged and could not be opened. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Towers Facilities repaired the closet door on 11/3/25. |
11/03/2025
| Implemented |
| 6400.104 | No notification to the fire department on file for Individual #3 who moved into the home in January of 2025. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Notifications to the Fire Department were sent by 10/01/25 for Individual #3. Supporting documentation will
be sent via email by 11/24/25. |
11/17/2025
| Implemented |
| 6400.112(a) | No fire drill was conducted in January or February of 2025. Individual #3 moved into the home on 1/31/2025 | An unannounced fire drill shall be held at least once a month. | House Managers & Program Specialists for their assigned homes and caseloads will be responsible for
ensuring compliance with monthly fire drills. |
11/17/2025
| Implemented |
| 6400.112(c) | The fire drill conducted on 4/15/2025 lists the drill was completed at 3:30 and does indicate if 3:30am or 3:30pm.
The drill conducted on 5/16/2025 does not indicate how long the fire drill lasted.
The fire drill conducted on 6/11/2025 lists the drill was conducted at 4:41 and does not indicate if it occurred at 4:41 am or 4:41 pm. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(c). |
11/17/2025
| Implemented |
| 6400.112(d) | The fire log from a drill conducted on 7/7/2025 states it lasted 30 mins. No additional drills attempted in July of 2025. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(d). |
11/17/2025
| Implemented |
| 6400.112(e) | No overnight fire drills have been conducted at least once every six months during the past year. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Specialists will be required to develop an auditing mechanism in collaboration with Complete
Comfort's Quality Improvement Committee and provide a report with the inclusion of any warranted
internal plans of correction on a monthly basis relating to 6400.112(e). |
11/17/2025
| Implemented |
| 6400.113(a) | Individual #3 was admitted on 1/31/25. Fire safety training was completed on 10/13/25 and was not completed upon the individual's admission to the home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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 home. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced
operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral
Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.141(a) | Individual #3 was admitted on 1/31/25 and did not have a physical nor TB test completed within 12 months prior to admission. There is no physical exam in the record as of the date of the inspection. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #3 will have a full physical exam by 01/01/2026. Physician appointments are unavailable any sooner as Ccid has sourced network covered provider's and the availability is as mentioned. |
11/17/2025
| Implemented |
| 6400.142(f) | Individual #3 does not have a written plan for dental hygiene in the record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A dental Hygiene plan will be completed by 12/01/25 for Individual #3. |
11/17/2025
| Implemented |
| 6400.18(i) | Incidents 9610203, 9610529, 9610360, and 9628792 for Individual #3 have not been finalized in EIM by the provided extension dates (09/17/2025, 09/20/2025, 09/20/2025, and 09/24/2025, respectively. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Incidents for 9610203, 9610529, 9610360, and 9628792 for Individual #3 will be finalized within 5 days of 11/19/25. As a result of Complete Comfort's operational hiring internal plan of correction, we will require 1 identified staff person to become a certified investigator through ODP's cohort training. Additionally, we are in the process of re-evaluating our incident management policy & procedure relating to prevention, reporting, investigation & management of adverse or significant incidents. |
11/17/2025
| Implemented |
| 6400.165(f) | Individual #3 is prescribed psychotropic medications and there is no individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness (SEEP) in the record. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Complete Comfort has identified individual #3's psychiatrist and will collaborate a plan with the physician to assist with SEEP evaluations. Individual #3 will have a SEEP completed by 01/02/2026. |
11/17/2025
| Implemented |
| 6400.165(g) | Individual #3 is prescribed psychotropic medications and there is no documentation that there has been a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 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. | Complete Comfort has identified individual #3's psychiatrist and will collaborate a plan with the physician to assist with Psychotropic Med Reviews. Individual #3 will have a SEEP completed by 01/02/2026. |
11/17/2025
| Implemented |
| 6400.181(f) | There is no documentation that the program specialist provided an individual assessment for individual #3 to the ISP team at least 30 days prior to the 9/15/25 ISP meeting | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.183(c) | There is no sign-in sheet/list of persons who attended the 9/15/25 ISP meeting for Individual #3 in the record. | The list of persons who participated in the individual plan meeting shall be kept. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |
| 6400.213(1)(i) | The record for Individual #3 is missing information regarding eye color, religion, height, weight and identifying marks. The areas designated for this information were all left blank on the agency forms per 213(1)(ii) | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced
operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the resignation of a house manager and the termination of 2 house managers; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements regarding the assigned home. |
11/17/2025
| Implemented |