| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | On 6/4/2026, the "individual records" section, regulations 6400.211a through and including 6400.217, of the self-assessment, dated 2/6/2026, was not completed. This section of the self-assessment form was blank. [Repeat violation 6/10/25 et. al.] | 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.
| 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 the agency's certificate of compliance, to measure and record compliance with this chapter. The CEO has retrained the Residential coordinator, Program Specialist and Site managers on the importance of completing the self-assessments in its entirety |
07/21/2026
| Implemented |
| 6400.72(b) | On 6/5/2026, the screen on the sliding door leading to the back patio area was torn. The tear was approximately 8 inches wide by 4-5 inches in height. [Repeat violation 6/10/25, et. al.] | Screens, windows and doors shall be in good repair. | Materials were purchased from Salix hardware store to repair the screen. The screen was replaced on 7/22/2026. |
07/22/2026
| Implemented |
| 6400.111(f) | On 6/5/2026, the fire extinguishers were last inspected and approved by a fire safety expert in May of 2025. This exceeds the annual requirement. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The Fire extinguisher was taken to ABC Fire Extinguisher Inc at 4641 Peoples Road Pgh Pa 15237 to be serviced on 6/9/2026 |
06/09/2026
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination completed 6/26/2025 did not include immunization history. [Repeat violation 6/10/25 et. al.] | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The individual's exam completed 6/26/25 has been updated and immunization history has been attached to the individuals 2025 physical. |
06/17/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 6/26/2025 did not include a list of current medications. | 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. | The list of medications was attached to the physical dated 6/26/2025. |
06/08/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 6/26/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The medical information pertinent to diagnosis and treatment in case of an emergency were added to the physical dated 6/26/2025. |
06/08/2026
| Implemented |
| 6400.165(g) | Individual #1 had a medication review completed on 12/3/2025 and then again on 4/29/2026. This exceeds the at least every 3-month requirement. The medication review dated 4/29/2026 did not include a list of the medications. [Repeat violation 6/10/25 et. al.] | 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 Residential Coordinator will create a Medication List that includes the following: the individual's name, a list of medications, the dosage, the route, time the medication is to be given, and the reason these medications are to be given. This form will be attached to all psych review forms, in which the individuals will have at least every 3 months. This will be reviewed by the Program Specialist to ensure accuracy for all medication lists and the Program Specialist will review all Psych review forms to ensure the form is fully completed and accurate. |
07/23/2026
| Implemented |