| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Individual #1's financial ledger includes a purchase of $100 at Kennywood on 6/16/2025. No receipt was provided to verify this purchase. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Create receipt tracking protocol and purchase receipt folders. |
09/17/2025
| Implemented |
| 6400.72(c) | On 9/4/2025 at 11:28AM, there was no locking mechanism on the exit door on the left side of the living room on the first floor of the home. | Outside doors shall have operable locks. | The Maintenance Director put a lock on the outside door. |
09/08/2025
| Implemented |
| 6400.73(a) | On 9/4/2025 at 11:25AM, there was no handrail on the three, exterior, concrete steps leading to the side entrance of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Maintenance Director added a handrail to the stairs. |
09/15/2025
| Implemented |
| 6400.80(b) | On 9/4/2025 at 11:26AM, there was used foil, plastic bags, a plastic bottle and other debris in the window well outside the basement window, next to the entrance door on the side of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The trash was cleaned up. |
09/18/2025
| Implemented |
| 6400.101 | On 9/4/2025 at 11:33AM, there was a deadbolt lock with a keyed mechanism on each side requiring a key to unlock the door from the inside when the deadbolt lock is engaged. Individual #1 has not been provided with a key to lock and unlock the door independently. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Maintenance Director removed the deadbolt lock. |
09/04/2025
| Implemented |
| 6400.112(e) | A fire drill was conducted during sleeping hours on 1/6/2025 and then again on 8/7/2025. This exceeds the every 6-month requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | The sleep fire drill was completed in August. |
09/11/2025
| Implemented |
| 6400.141(c)(7) | Individual #1 had a gynecological examination completed on 1/29/2024 and then again on 2/25/2025. This exceeds the annual requirement. [Repeat violation 9/17/24, et. al.] | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The individual received her gynecological exam. The Program Specialist will be retrained on the regulations. |
10/06/2025
| Implemented |
| 6400.214(b) | On 9/4/2025 at 11:40AM, Individual #1's psychiatric evaluation and Social, Emotional, Environmental Plan was not present in the home and staff interviews revealed that they are not regularly stored at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The required plans were filed in the program book at the residential home. |
09/10/2025
| Implemented |
| 6400.32(d) | On 9/4/2025 at 11:20AM, there was writing on a whiteboard on the wall in the dining room of the home that included the following personal statements about Individual #1, "Check [Individual #1's] bed to see if [they] had an accident/incontinence (if [they] did immediately wash everything! Please prompt [Individual #1] to wash [their] hands/wipe after using the restroom. Prompt [Individual #1] to follow [their] Skype schedule hanging above and redirect [them] not to call mom at unscheduled times. [Individual #1] needs verbal prompting to wash [themself] properly in the shower and may ask for assistance with turning the shower on and washing [their] hair. Remind [Individual #1] to brush [their] teeth, brush [their] hair, and to put on deodorant. [Individual #1] wears pull-ups at night (prompt [them] to throw it away in the morning. Please prompt [Individual #1] to stop drinking after 8PM meds and remind [them] to use the restroom before going to sleep. Monitor [Individual #1] in the kitchen and while [they] eat to avoid overeating and choking. Prompt [Individual #1] to exercise daily and to follow [their] snack times." | An individual shall be treated with dignity and respect. | An incident was filed on 9.4.2025. The white board was moved into the closet on 9.4.2025. |
09/04/2025
| Implemented |
| 6400.32(r)(1) | On 9/4/2025 at 11:33AM, there was a deadbolt lock with a keyed mechanism on each side and a doorknob with a turn locking mechanism on the inside and a keyed mechanism on the outside. Individual #1 has not been provided with a key to lock and unlock the door independently. | 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. | The deadbolt was removed |
09/04/2025
| Implemented |
| 6400.166(a)(13) | Direct Service Worker #1 administered medications to Individual #1 at 8AM on 9/2/2025 and did not sign Individual #1's September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The DSP was written up for failure to sign the MAR. |
09/16/2025
| Implemented |