Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00293497 Renewal 07/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Program Specialist #1, hired on 4/27/2026, did not have a criminal history check. [Repeat Violation, 7/23/2025]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. The provider acknowledges that Program Specialist #1 was hired into the Program Specialist position on 4/27/2026 and that a Pennsylvania criminal history record check was not completed within 5 working days of that hire date as required by 55 Pa. Code Chapter 6400.21(a). The Pennsylvania criminal history record check was completed on 8/13/2026, reviewed, and placed in the employee's personnel file. Although the employee had a prior background check completed at the time of the employee's original Team Lead hire on 4/4/2024 and remained on payroll while providing PRN services, the provider recognizes that the promotion/hire into the Program Specialist role required review and verification of background-check compliance based on the 4/27/2026 hire date. This correction has been completed, and the personnel file now contains the required Pennsylvania criminal history record check documentation. 08/13/2026 Implemented
6400.106There was a furnace inspection done on 7/7/2025, and then again on 7/28/2026.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The provider acknowledges that the furnace inspection completed on July 28, 2026, occurred more than 12 months after the previous inspection completed on July 7, 2025. A qualified contractor inspected and cleaned the furnace on July 28, 2026. The provider reviewed its annual preventive maintenance process and adjusted inspection scheduling procedures to ensure future annual inspections are completed prior to the anniversary due date. 08/31/2026 Implemented
6400.151(b)Program Specialist #1, hired on 4/27/2026, had a physical examination that was not signed or dated by the licensed physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. A physical examination for Program Specialist #1 was completed on August 24, 2026, by an approved medical professional and included the required signature and date. Human Resources reviewed the completed physical examination form to verify that it was signed and dated by a licensed physician, certified nurse practitioner, or licensed physician assistant. The completed and compliant physical examination was placed in the employee's personnel file. This correction has been completed. 08/24/2026 Implemented
6400.171At 10:07AM on 7/31/2026, there was a partially used, unsealed 12 ounce can of Minute Maid Fruit Punch in the refrigerator.Food shall be protected from contamination while being stored, prepared, transported and served. The unsealed 12-ounce can of Minute Maid Fruit Punch was immediately removed from the refrigerator on July 31, 2026. Staff was reminded that opened food and beverage containers must be protected from contamination by being sealed, covered, labeled, and properly stored before being returned to the refrigerator. 07/31/2026 Implemented
6400.181(a)Individual #1 had an assessment completed on 2/5/2025, and then again on 4/2/2026. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual #1's annual assessment was completed and finalized on April 2, 2026. The provider acknowledges that the annual assessment was not completed within 365 calendar days of the prior assessment dated February 5, 2025, as required by 55 Pa. Code Chapter 6400.181(a). The Compliance Director conducted an agency-wide audit of individual records across all residential homes to identify each individual's annual assessment due date and to verify whether any additional assessments were overdue. No other overdue annual assessments were identified through this review. The Program Specialist and designated administrative staff received targeted re-training on 55 Pa. Code Chapter 6400.181(a), with emphasis that annual assessments must be updated and finalized within 365 calendar days of the prior assessment date. This correction has been completed. 08/28/2026 Implemented
6400.43(c)(1)Chief Executive Officer #2 provided a transcript of a Master's Degree that did not show the name of the issuing institution. Verification of Chief Executive Officer #2 completing a bachelor's degree also was not provided. Therefore, compliance could not be measured.(c) A chief executive officer shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years work experience in administration or the human services field.he provider acknowledges that the documentation submitted for Chief Executive Officer #2 did not clearly verify the issuing institution for the master's degree transcript and did not include verification of a bachelor's degree, which prevented compliance with 55 Pa. Code Chapter 6400.43(c)(1) from being measured. Chief Executive Officer #2 completed an RN-to-MSN program through Western Governors University, and the provider has requested an official degree transcript and documentation from the accredited institution to verify the master's degree or above. Upon receipt, Human Resources will review the official documentation to confirm that it identifies the issuing institution, verifies the degree awarded, and supports the required educational qualification. The verified documentation will be placed in the CEO's personnel/credential file. This correction will be completed when the official documentation is received, reviewed, and filed. 08/24/2026 Implemented
SIN-00249611 Renewal 07/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. On the self-assessment provided, with a completion date of "August 2024," the following regulations were left blank: 6400.183(c).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. To correct the violation, LRS will implement a physical site inspection checklist that the team leads for each location will complete monthly to maintain all sites in compliance. LRS will also begin the self-assessment on March 1st, six months before the certification of the compliance expiration date. The self-assessment must be completed in its entirety and forwarded to Mr. Andrew Wimbish, President, by May 31, 4 months before the certification of the compliance expiration date. The self-assessment will include the beginning and end dates on which the assessment was conducted. The completed self-assessments with supporting documentation will be maintained in the LRS shared drive. 09/13/2024 Implemented
6400.112(e)A fire drill was held between sleeping hours on 7/21/2023, and then again on 5/29/2024. This exceeds the every 6-months requirement. [Repeat violation 8/15/23, et. al.]A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill is to take place in July and in January of the same fiscal year not exceeding 6 months. An overnight drill will be held between the hours of 11pm - 7am. See QMP document, memo regarding drills and email to leads uploaded in shared drive. 09/04/2024 Implemented
SIN-00229440 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Documentation of the furnace being inspected and cleaned at least annually by a professional furnace cleaning company was not provided. Therefore, compliance could not be measured. [Repeat violation: 8/17/22 Et al.]Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. LRS has updated our annual service agreement with Armstrong Comfort Solutions & Matz Plumbing to provide furnace inspection services for our Waterfront, Beacon Hill, and Lawrenceville apartment locations. Prior inspections only included LRS's single-family location. Upon completion, a copy of the furnace inspection and cleaning will be submitted to the Department. 09/01/2023 Implemented
6400.142(a)Individual #1, date of birth 10/24/1996, had a dental examination 3/11/22 and then again 4/14/23.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The Nurse Coordinator will obtain written documentation confirming that the next appointment date will exceed the anniversary of the previous appointment to remedy this violation. 08/30/2023 Implemented
6400.142(g)Individual #1 had dental hygiene plans competed 3/11/22 and then again 4/14/23.A dental hygiene plan shall be rewritten at least annually. The dental hygiene plan will be updated by the Program Specialist every six months or more frequently than annually after dental appointments to reflect the current recommendations of the dental provider. 08/31/2023 Implemented
6400.18(g)Certified Investigation documentation regarding Incident #9251656, Individual to Individual psychological abuse on 7/22/23, involving Individual #1, was not provided. Therefore, compliance could not be measured.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.Incident #9251656 was discovered on July 22, 2023, at 12:00 AM, and the investigator was assigned on the same day at 05:30 PM. The investigation started on July 23, 2023, at 01:38 PM, within 24 hours of being discovered by a staff member Photos of the area where allegedly heavy trash bags were made to carry to the designated trash and recycling area will be sent to the Department. 07/23/2023 Implemented
6400.32(d)On 8/16/23, located on the wall, next to Individual #2's bedroom is a sign stating, "limit amount of toilet paper and paper towels given to [Individual #2]."An individual shall be treated with dignity and respect.The sign near Individual #2's bedroom that stated, "Limit the amount of toilet paper and paper towels given to Individual #2" has been removed by LRS. Pictures of both the sign and the wall where it was posted will be sent to the Department. 08/30/2023 Implemented
6400.32(h)On 8/16/23, the toilet seat, located in the bathroom in Individual #2's bedroom, has a sensor to alert staff when the toilet is used. Staff reported it was placed there to "keep [Individual #2] from playing in the toilet."An individual has the right to privacy of person and possessions.LRS removed the sensor from the toilet seat used to prevent clogging. Photos of the toilet without the sensor will be sent to the Department. 08/30/2023 Implemented
6400.32(n)On 8/16/23, located on the wall in the livingroom, behind the television and landline telephone is a sign stating, "No calls are to be made by consumers after 8 PM".An individual has the right to unrestricted and private access to telecommunications.LRS took down the sign stating, "No calls after 8 PM by consumers". The Department will receive photos of the wall and the sign. 08/30/2023 Implemented
6400.32(t)On 8/16/23, located on the wall in the dining area is a sign with specific mealtimes for breakfast, lunch and dinner.An individual has the right to access food at any time.LRS removed the sign with specific mealtimes for breakfast, lunch, and dinner. Photos of the wall and the sign will be sent to the Department. 08/30/2023 Implemented
SIN-00270855 Renewal 07/22/2025 Compliant - Finalized