| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home between 3/17/25 to 3/19/25, did not provide a written summary of corrections for the following regulation items identified as violations: .141c6 and .181e10. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| A written summary of corrections to the violations identified in the agency¿s self-assessment has been provided to the POCs. |
08/28/2025
| Implemented |
| 6400.113(a) | Individual #1 completed fire safety training on 7/26/24, and then again on 7/11/25. However, both of these trainings did not address 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. [Repeated Violation-7/30/24 et al.] | 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. | The individual completed an updated fire safety training that includes content related to their place of residence: 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 procedures if the individuals smoke at home.
The updated fire training safety training signed by the Individual to be sent as part of the POC. |
09/01/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's current physical examination, completed on 3/19/25, did not include their need for bloodwork at recommended intervals, as the "Routine Bloodwork Required" field was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | - Individual¿s physician was contacted and an assessment of the individual's health
maintenance needs, medication regimen and the need for blood work at recommended
intervals.
- Documentation of the review was obtained and added to the individual¿s record. |
09/05/2025
| Implemented |
| 6400.151(a) | Direct Service Provider/ Team Lead #1 had physical examinations completed on 5/1/23, and then again on 6/1/25. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The HR Recruiter will review the Employee Tracking sheet each month. The HR Recruiter will check all physical exams and TB tests that are about to expire within the month and notify employees accordingly. The HR Recruiter will also update the employee tracking sheet once the exams are completed and new expiration dates are recorded. |
09/05/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's current assessment, completed on 7/26/24, did not include an applicable psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | In the future, the Program Specialist will submit an assessment cover page to the individual¿s Support Coordinator and treatment team, which includes the following:
o Lifetime Medical History
o Yearly Doctor Appointments
o Psychological Evaluation
o Current List of Medications
A copy of the Assessment Cover Page Checklist will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.32(r)(1) | At 2:36 PM on 7/23/25, the privacy door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not provide Individual #1 with a unique mechanism or entry device to lock and unlock their bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | A new locking system that enables individuals to lock and unlock the door. |
09/15/2025
| Implemented |
| 6400.32(r)(4) | At 2:36 PM on 7/23/25, the privacy door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff in the event of an emergency.
A picture of the new system will be sent to the Department. |
09/12/2025
| Implemented |
| 6400.46(b) | Direct Service Provider/ Team Lead #1 completed fire safety training on 6/1/24, and then again on 7/18/25. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff immediately identified and assigned the fire safety module. HR Recruiter was retrained on August 27, 2025, on the annual training module to ensure records are kept up to date in the appropriate training year. |
09/05/2025
| Implemented |
| 6400.46(d) | Direct Service Provider/ Team Lead #1's date-of-hire is 5/31/23. Direct Service Provider/ Team Lead #1 last completed training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 7/21/24. However, their content of records did not include a previous such training. Therefore, compliance could not be measured. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The HR Recruiter will review the Employee Tracking sheet each month. They will check all CPR training set to expire within the month and notify employees accordingly. CPR training will be scheduled to ensure compliance. The HR Recruiter will also update the employee tracking sheet after CPR training is completed, and the new expiration date has been recorded. |
09/05/2025
| Implemented |
| 6400.52(c)(2) | Direct Service Provider/ Team Lead #1's record for the annual training year from February 1, 2024, to February 1, 2025, did not include training in the application of person-centered practices and community integration. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | HR Recruiter retrained on August 27, 2025, using the annual training module to ensure all required annual training are assigned and maintain compliance. |
09/05/2025
| Implemented |
| 6400.195(a) | Individual #1's Service Plan, last updated 7/11/25, states the following in regard to sharps: "[Individual #1] is not permitted access to knives due to threatening [their] uncle in the past. There are no documented or reported issues with operated utensils, but the team will be discussing possible alterations around [Individual #1's] accessibility to sharps, as [Individual #1] has used them in a threatening manner." At 2:40 PM on 7/23/25, knives, scissors, and other sharp objects were locked in a cabinet located in the staff office. However, Individual #1 does not currently have a restrictive procedure plan approved by the human rights team, limiting access to these sharp objects. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | All sharps, scissors, and knives were unlocked and made accessible to the individual. The individual has not had an aggressive behavior this past year. There is no concern to request an HRT meeting due to no data or incidents have occurred. |
09/01/2025
| Implemented |