| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | At 12:12PM on 7/22/2026, there was a slide locking mechanism on the inside of the door leading to the exit in the basement of the home posing an obstructed egress. At 12:13PM, there was a slide locking mechanism on the outside of the door leading to a storage room in the basement of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Regulation: 55 Pa. Code §6400.101
Immediately following the licensing inspection, the slide locking mechanisms identified on basement exit doors and storage room doors were removed from the cited homes and replaced with magnetic catch latches that do not obstruct egress and are compliant with the requirements of 55 Pa. Code §6400.101.
To ensure the deficiency was not present elsewhere within the agency, the Maintenance Department conducted an agency-wide review of all licensed residential homes. Any remaining slide locking mechanisms identified on interior doors were removed and replaced with compliant magnetic catch latches.
Maintenance staff were re-educated regarding the requirements of 55 Pa. Code §6400.101, emphasizing that locking devices may not obstruct stairways, halls, doorways, passageways, or exits from rooms or the building.
In addition, Armstrong Care, Inc. has revised its maintenance standards to require that all future residential homes utilize only approved door hardware that complies with egress requirements
|
07/22/2026
| Implemented |
| 6400.104 | The agency did not provide written notification to the local fire department of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| 6400.104 -- Notification to the Fire Department
Immediately following the licensing inspection, Armstrong Care, Inc. provided written notification to the local fire department that included:
· The address of the licensed home.
· A diagram identifying the layout of the home.
· The exact location of bedrooms occupied by individuals requiring assistance with evacuation.
· The location of smoke detectors and fire extinguishers.
· The designated outdoor meeting location.
· General information regarding evacuation assistance needs.
This notification has been placed into the home's permanent records and will be updated whenever there is a change affecting evacuation assistance or the home's layout.
|
07/22/2026
| Implemented |
| 6400.107 | At 12:24PM on 7/22/2026, a portable space heater was on the floor of the closet of Individual #2's bedroom on the second floor of the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| Immediately upon discovery, the portable space heater was removed from the individual's bedroom.
The individual was educated regarding the safety hazards associated with portable space heaters and the regulatory prohibition against their use within licensed residential homes. The individual agreed to remove the heater.
All residential homes were inspected by supervisors with the individuals residing in the homes to ensure no portable space heaters were present. No additional prohibited heaters were identified.
All staff received re-education regarding 55 Pa. Code §6400.107, emphasizing that portable space heaters are prohibited in all areas of the home, including staff offices, bedrooms, and other living spaces. |
07/22/2026
| Implemented |
| 6400.113(a) | Individual #1 was trained in fire safety on 6/26/2025 and 6/26/2026. The training certificate states that the training only included a, "fire extinguisher operation class, utilizing a live fire conducted by JAWCO Fire, INC of Punxsutawney, PA." This training did not include site specific evacuation procedures, responsibilities during dire drills and the designated meeting place. | 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. | 6400.113(a) -- Fire Safety Training for Individuals
Following the licensing inspection, Armstrong Care, Inc. reviewed the fire safety training provided to individuals. Although fire extinguisher instruction had been completed, the documentation did not verify that all components required by 55 Pa. Code §6400.113(a) had been included.
The agency developed a revised fire safety training program that includes all required topics:
· General fire safety
· House-specific evacuation procedures
· Individual responsibilities during fire drills
· The designated meeting location for that residence
· Smoking safety procedures, when applicable
Each residential home will receive fire safety instruction specific to that home's layout and evacuation procedures. The training will be conducted in the individual's primary language or mode of communication, and written documentation will include the content presented and the individuals who attended. |
07/22/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 11/10/2025, does not include a lifetime medical history. This section reads, "Lifetime Medical History is filed in residential book." | The assessment must include the following information: A lifetime medical history. | Armstrong Care, Inc. developed and implemented a comprehensive Lifetime Medical section that is incorporated directly into the Individual Assessment. The Lifetime Medical History now documents historical and current medical information including diagnoses, physician information, developmental history, past medical history, body systems review, immunizations, medications, current diagnoses, and ongoing medical updates. Individual #1's assessment has been updated to include the required lifetime medical history rather than referencing information maintained elsewhere. Program Specialists received training on completing this section in its entirety. |
07/23/2026
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment, completed 11/10/2025, did not include progress or current level in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Plan of Correction
The Individual Assessment was revised to include a dedicated section documenting the individual's progress over the previous 365 calendar days and current level of functioning in the area of Health. The assessment for Individual #1 has been corrected to include this required information. All Program Specialists were retrained on the revised assessment format and the requirements of 55 Pa. Code §6400.181(e) to ensure all required assessment components are completed prior to finalization. |
07/23/2026
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment, completed 11/10/2025, did not include progress or current level in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Plan of Correction
The Individual Assessment was revised to include both a comprehensive assessment of the individual's ability to manage personal property and a required narrative documenting the individual's progress over the previous 365 calendar days and current level of functioning in this area. Individual #1's assessment has been updated accordingly. Program Specialists received instruction on documenting both current abilities and measurable progress.
The Individual Assessment was revised to include a dedicated section documenting the individual's progress over the previous 365 calendar days and current level of functioning in the area of Health. The assessment for Individual #1 has been corrected to include this required information. All Program Specialists were retrained on the revised assessment format and the requirements of 55 Pa. Code §6400.181(e) to ensure all required assessment components are completed prior to finalization.
The Individual Assessment was revised to include a mandatory section evaluating the individual's ability to self-administer medications. The revised section documents the individual's level of independence, need for prompting or assistance, any changes since the previous assessment, and a narrative describing the individual's medication management abilities and required staff supports. Individual #1's assessment has been updated to include this information. Program Specialists were instructed that this section may not be left blank.
Armstrong Care, Inc. developed and implemented a comprehensive Lifetime Medical section that is incorporated directly into the Individual Assessment. The Lifetime Medical History now documents historical and current medical information including diagnoses, physician information, developmental history, past medical history, body systems review, immunizations, medications, current diagnoses, and ongoing medical updates. Individual #1's assessment has been updated to include the required lifetime medical history rather than referencing information maintained elsewhere. Program Specialists received training on completing this section in its entirety |
07/24/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #1, date of hire 7/25/2022, was trained in fire safety on 6/26/2025 and 6/26/2026. The training certificate states that the training only included a, "fire extinguisher operation class, utilizing a live fire conducted by JAWCO Fire, INC of Punxsutawney, PA." This training did not include site specific evacuation procedures, responsibilities during dire drills and the designated meeting place. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Plan of Correction -- 6400.46(b)
Armstrong Care, Inc. acknowledges that although annual fire safety training was completed by JAWCO Fire, Inc., the training did not include all of the required components outlined in 55 Pa. Code §6400.46, specifically site-specific evacuation procedures, staff responsibilities during fire drills, and the designated meeting place for each home.
To correct this deficiency, Armstrong Care, Inc. will ensure that all Program Specialists and Direct Support Professionals receive annual fire safety training conducted by a qualified fire safety expert that includes all required elements of the regulation. The training will include, at a minimum:
· Site-specific evacuation procedures for each assigned home.
· Staff responsibilities during fire drills and actual fire emergencies.
· The designated meeting place for each home.
· General fire safety procedures and the proper use of fire extinguishers. |
07/22/2026
| Implemented |
| 6400.163(a) | Individual #1 is prescribed Carbamazepine 200 MG with instructions to, "Take 2 and 1/2 tablets (500MG) by mouth twice daily for mood." At 12:38PM on 7/22/2026, a half tablet of Carbamazepine was on the bottom of the medicine drawer in the staff office on the first floor of the home. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Immediate Corrective Action
Immediately upon discovery, the half tablet of Carbamazepine found in the medication drawer was removed from the drawer, identified, and disposed of in accordance with Armstrong Care's medication disposal procedures. The medication storage area was thoroughly inspected to ensure no additional loose or improperly stored medications were present.
The Medication Administration Records (MARs), medication cards, and medication storage containers were reviewed to verify that all medications remaining in the medication room were maintained in their original pharmacy-labeled containers.
Systemic Corrective Action
All Direct Support Professionals, Residential Supervisors, and medication-certified staff will receive retraining on proper medication storage requirements, including:
· Maintaining all prescription medications in their original pharmacy-labeled containers.
· Inspecting medication cards and drawers for loose or damaged medication during each medication pass.
· Proper procedures for handling broken, dropped, or loose medication.
· Immediate notification of the Residential Supervisor if a loose medication is discovered and documentation of appropriate follow-up.
· Requirements of 55 Pa. Code §6400.163(a).
The Medication Trainer will reinforce these procedures during medication competency reviews and medication refresher trainings. |
07/23/2026
| Implemented |