| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | There was no record that Individual #1 received a hearing examination found within the Individual Record.
Vision examinations did not occur annually as required. Individual #1's two most recent vision examinations occurred on 04/03/2023 and 03/24/2026. There was documentation showing that Individual #1 refused vision examination attempts on 07/10/2025, 07/17/2025, and 12/08/2025; however, there were no records showing that appointments were attempted between 04/03/2023 and 07/10/2025. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | On the individual's current physical examination, hearing and vision were addressed through designated check boxes on the form. However, due to the quality and condition of the physical examination document returned electronically to the agency, the information was difficult to clearly interpret during review. The agency has requested the original physical examination form from the individual's Primary Care Physician to obtain clearer documentation and ensure the hearing examination information is accurately reflected within the Individual Record in compliance with 55 Pa. Code §6400.141(c)(4). Please see attachment 12 |
04/30/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's Physical Examination, dated 02/25/2026, was missing the following required information: Medical information pertinent to diagnosis and treatment in case of an emergency. The area of the form designated for this information was left blank by the medical provider. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency has requested that the individual's Primary Care Physician update the original physical examination form to include the required medical information pertinent to diagnosis and treatment in the event of an emergency. In the interim, the agency has consulted with a licensed medical professional within the organization to provide guidance regarding the missing information and ensure appropriate emergency medical information is available within the individual's record. Additionally, training was conducted for all pertinent staff regarding annual appointments and the proper completion and review of required medical forms and documentation to ensure ongoing compliance. |
04/30/2026
| Implemented |
| 6400.142(c) | The written record of Individual #1's 03/06/2026 Dental Examination did not include the procedures completed during the appointment. A line on the form labeled "Reason for Appointment" read "Annual." "Annual" does not convey the nature of any specific procedures that might have been performed during the appointment. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | A follow-up dental appointment for Individual #1 has been scheduled for September 8, 2026. The agency will ensure future dental documentation includes specific procedures completed during appointments in accordance with 55 Pa. Code §6400.142(c). |
05/08/2026
| Implemented |
| 6400.142(e) | A dental appointment form for Individual #1's 03/31/2025 dental examination noted that the individual was recommended to have "#8 + 9" (teeth) extracted and referred Individual #1 to an oral surgeon. A 03/06/2026 dental appointment form noted, "PT was referred to the oral surgeon in the past for extraction of #8 + 9," showing that this dental work was not completed as recommended after the previous appointment. The provider did not assist the individual in following up with an oral surgeon per the dentist's referral after the 03/31/2025 appointment. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Individual #1 refused multiple dental and oral surgery appointments following the referral for extraction of teeth #8 and #9. The individual's dental desensitization plan was reviewed to ensure it remained accurate and reflective of the individual's refusals and support needs related to dental services. The agency will continue to encourage participation in recommended dental follow-up care and document all appointment attempts, refusals, and interventions in accordance with regulatory requirements. |
05/08/2026
| Implemented |
| 6400.144 | Individual #1's 02/25/2025 Annual Physical Examination recommended that the individual see a dentist every 6 months for dental examinations. Per the Individual Record, this individual had dental examinations on 03/31/2025 and 03/06/2026---there were no records of additional dental examinations in the Individual Record. The provider did not arrange for dental services as instructed by the individual's Primary Care Physician (PCP). | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual #1 was not scheduled for the recommended six-month dental follow-up appointment between annual dental examinations as recommended by the individual's Primary Care Physician. The individual is currently scheduled for multiple follow-up dental appointments to address ongoing dental care needs. The agency will review medical recommendations more closely to ensure all follow-up appointments are scheduled and completed in accordance with provider recommendations and regulatory requirements. |
05/08/2026
| Implemented |
| 6400.151(a) | Per Staff #1's Staff Record, this staff's most recent physical examination occurred on 03/23/2026. As a previous physical examination could not be located for review, it could not be confirmed that this staff received a physical examination at least once every two years as required. | 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. | Per review of Staff #1's personnel record, a previous physical examination could not be located to verify compliance with the requirement for physical examinations at least every two years. Staff #1 completed a current physical examination on 03/23/2026. The agency will review personnel files to ensure required medical documentation is maintained and readily available for review in compliance with 55 Pa. Code §6400.151(a). |
04/30/2026
| Implemented |
| 6400.151(c)(3) | Staff #1's most recent staff physical examination, dated 03/23/2026, did not note whether this staff was free from communicable diseases. The area of the form designated for this information was left blank by the medical professional completing the form.
Staff #2's initial staff physical examination, dated 01/07/2026, did not note whether this staff was free from communicable diseases. The area of the form designated for this information was left blank by the medical professional completing the form. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The medical providers who completed the physical examinations for Staff #1 and Staff #2 were not available to make the necessary corrections to the forms regarding communicable disease status. Additionally, other medical providers were reluctant to make changes or amendments to forms they did not originally complete. The agency has reviewed its procedures for receiving and reviewing completed physical examinations to ensure all required sections are completed prior to acceptance into the personnel record and to ensure compliance with 55 Pa. Code §6100.151(c)(3). |
04/30/2026
| Implemented |
| 6400.165(g) | Individual #1 takes medications to treat a diagnosed psychiatric illness and has these medications reviewed by a psychiatrist. Per the Individual Record, this individual had psychotropic medication reviews completed on 10/01/2025, 10/29/2025, 12/17/2025, and 02/27/2026. There were no psychotropic medication reviews in the individual's record prior to 10/1/2025. Psychotropic medication reviews did not occur at least every 3 months. | 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 agency is fortunate to have an in-house psychiatric team that meets regularly with individuals receiving services. Review of the record indicated that psychotropic medication review documentation was not consistently maintained within the individual record prior to 10/01/2025, and reviews were not documented at least every three months as required. It appears that during clinical sessions, documentation expectations were not consistently communicated or verified by attending staff. During the weekly clinical rounds meeting held on 05/08/2026, expectations regarding psychotropic medication review frequency, documentation requirements, and follow-up responsibilities were reviewed with psychiatric and clinical staff to ensure compliance with 55 Pa. Code §6400.165(g). |
05/08/2026
| Implemented |
| 6400.181(f) | Per Individual #1's Individual Record, this individual's most recent Individual Plan Meeting occurred on 08/27/2025. There was no record that Individual #1's most recent Individual Assessment, dated 07/28/2025, was sent to the members of the Individual Plan team by the program specialist at least 30 calendar days prior to the Individual Plan meeting as required. | 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 agency is unable to provide documentation demonstrating that the Individual Assessment dated 07/28/2025 was distributed to the Individual Plan team at least 30 calendar days prior to the Individual Plan meeting held on 08/27/2025. As the information is now outdated, the agency cannot retroactively complete this requirement. Moving forward, the agency will ensure assessments are distributed within the required regulatory timeframe and documentation of distribution is maintained within the individual record to ensure compliance with 55 Pa. Code §6400.181(f). |
06/01/2026
| Implemented |
| 6400.183(c) | Individual #1's most recent Individual Plan meeting occurred on 08/27/2025. The provider did not maintain a record of the participants in this meeting as required. | The list of persons who participated in the individual plan meeting shall be kept. | Historically, the agency has relied on the Supports Coordination Organization (SCO) to provide copies of ISP meeting sign-in sheets and participant documentation following Individual Plan meetings. Due to staffing and procedural changes within the SCO, the agency was unable to obtain or reproduce the sign-in sheet for the meeting held in August 2025. Moving forward, the agency will maintain its own participant attendance documentation for all Individual Plan meetings to ensure compliance with 55 Pa. Code §6400.183(c). |
06/01/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's Individual Record did not contain the following required information: the presence or absence of identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | The record for Individual #1 has been updated to include the presences or absences of identity marks as required. Please see the attached updated face sheet. Please see attachment 8 |
06/01/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's Individual Record did not contain the following required information: The language spoken or understood by the individual. | Each individual's record must include the following information: Personal information, including: (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. | The record for Individual #1 has been updated to include the language spoken or understood by the individual as required. Please see the attached updated face sheet. Please see attachment 8 |
06/01/2026
| Implemented |
| Article X.1007 | The Provider is required to maintain criminal history checks and hiring policies for the hiring, retention, and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). A Federal Bureau of Investigation (FBI) background check was not completed for Staff #2, and there was no indication that this staff was a resident of Pennsylvania for two years prior to hire. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Corrections were made to the agency's provisional hiring form to ensure proper verification of Pennsylvania residency requirements and the need for FBI background checks in accordance with OAPSA regulations. Additionally, training was conducted for all personnel responsible for completing and reviewing background checks to ensure hiring documentation is completed accurately and in compliance with applicable regulations. |
05/08/2026
| Implemented |