| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Poisons were found not stored in their original container. A Softsoap brand antibacterial soap dispenser labeled "White Tea and Berry" formula was found in the hall bathroom filled with a different liquid soap. Softsoap white tea and berry soap is a clear, slightly purple-colored liquid, and the liquid in the dispenser was an opaque white color resembling the contents of a large refill bottle of Member's Mark brand hand soap found in a kitchen cabinet at the time of the inspection. | Poisonous materials shall be stored in their original, labeled containers. | The dispenser was removed from the home and replaced with soap in its original container. The house supervisor was addressed/educated on chapter 6400.62(c). During the 6/12/2026 staff meeting, this violation was reviewed with the team and chapter 6400.62(c) reviewed. |
06/11/2026
| Implemented |
| 6400.68(b) | The hot water temperature was measured at 125.1° F in the hall bathroom tub/shower. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Maintenance team were informed of the violation and they addressed it on 5/12/2026. |
05/12/2026
| Implemented |
| 6400.104 | The notification letter to the fire department was dated 6/03/2025 and did not reflect the addition of Individual #1 who moved into the home on 11/12/2025. | 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.
| An updated notification was sent to the fire department and a copy filed in the fire drill binder. |
05/15/2026
| Accepted |
| 6400.112(c) | The fire drill record for the drill conducted on April 22, 2026 did not document the time of day that the drill occurred or if all individuals reached the meeting place. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The house leadership and the staff conducting fire drills were reeducated on proper documentation of fire drills. |
05/13/2026
| Implemented |
| 6400.112(e) | Fire drills must be held at least every six months during sleeping hours. During the eight-month period from June 2025 through January 2026, no fire drills were held during sleeping hours. A fire drill was held during sleeping hours on February 8, 2026 at 3:00 AM. | A fire drill shall be held during sleeping hours at least every 6 months. | Leadership reviewed chapter 6400.112 with the staff and house supervisor to ensure that the team understand the regulations and also the importance of compliance. |
05/15/2026
| Accepted |
| 6400.181(a) | Individuals must have an initial assessment completed up to one year prior to admission or within 60 calendar days after admission. Individual #1 was admitted on November 12, 2025 and there was no record that an initial assessment has been completed. | 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 initial assessment was completed on 12/30/2026. The Provider failed to make the document available during inspection. A copy of the document was placed in the books and a copy filed. |
05/15/2026
| Accepted |
| 6400.51(b)(2) | Staff #1 was hired as a direct support professional (DSP) on 12/02/2025; their first day was 12/09/2025, and they did not complete orientation training in the Prevention, Detection and Reporting of Abuse, Suspected Abuse and Alleged Abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act and applicable protective services regulations prior to working alone with individuals, and within thirty days of hire. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Staff #1 has completed all the mandatory orientation trainings including Prevention, detection, and reporting of Abuse, suspected abuse, and alleged abuse. |
05/15/2026
| Accepted |
| 6400.51(b)(3) | Staff #1 was hired as a direct support professional (DSP) on 12/02/2025; their first day was 12/09/2025, and they did not complete orientation training in Individual Rights prior to working alone with individuals, and within thirty days of hire. | The orientation must encompass the following areas: Individual rights. | Staff #1 has currently completed all the required orientation trainings including individual rights training. |
05/15/2026
| Accepted |
| 6400.51(b)(4) | Staff #1 was hired as a direct support professional (DSP) on 12/02/2025; their first day was 12/09/2025, and they did not complete orientation training in Recognizing and Reporting Incidents prior to working alone with individuals, and within thirty days of hire. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff #1 has currently completed all the required orientation trainings including recognizing and reporting incidents. |
05/15/2026
| Accepted |
| 6400.165(a) | A prescription medication, including over-the-counter (OTC) medications, shall be prescribed in writing by an authorized provider. At the time of the inspection there was a box of Day Quil VapoCool cold and flu medication with Individual #1's current medications. This medication was not listed on the current medication administration record (MAR), nor was there a written standing order for the medication with the medication record. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Provider contacted the PCP and requested for a new script for the said medication to be sent to the pharmacy in order to maintain compliance. |
05/13/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and has not had reviews by a licensed physician at least every three months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 had a medication review on 12/19/2025 and there was no documentation that another medication review has occurred since that date. | 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. | Individual #! has been seen virtually by her psychiatrist. House Supervisor would normally submit the medication review document to the doctor's office prior to the appointment. There has been a few times when the doctor has not signed the document in a timely manner. Individual #1 is currently up to date with her reviews and documentations have been promptly filed in her medical book and ready for review. |
06/10/2026
| Accepted |
| 6400.169(a) | Staff #1 was hired on 12/02/2025 and began working with individuals on 12/09/2025. The staff did not complete medication administration training until 3/27/2026 but has been administering medication since January 2026 as evidenced by documentation on the Medication Administration Records from January 2026, February 2026 and March 2026. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Upon hire, staff #1 produced incomplete documents indicating previous training and compliance in administering medication. Provider requested staff to not administer medication but failed to make adequate follow up before staff #1 was found to be administering medications. Staff #1 was retrained on 3/27/2026. |
05/29/2026
| Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed two medications to be administered on a pro re nata (PRN) or as needed basis to control acute or episodic behavior related to diagnosed psychiatric illness or disorder. The medication Risperidone, 1 mg. tablet, take ½ tablet twice daily as needed for mental/mood disorder; and Hydroxyzine Hcl 50 mg. tablet, take I tablet by mouth three times per day as needed for anxiety. The prescribing instructions on the medication record did not include symptoms the individual would need to be exhibiting to require the administration of these medications. Additionally, the home did not have a written protocol for when to administer the medication, including documentation from a physician with a clear description of the explicit symptoms of the psychiatric diagnosis, and the procedure for staff to follow to obtain authorization from the agency CEO or a designee to administer the medication. Without a protocol in place that meets the guidelines described in the Chapter 6400 Regulatory Compliance Guide for the pro re nata (PRN) administration of medications to treat the symptoms of an underlying psychiatric disorder, the administration of these medications is considered a chemical restraint which is prohibited. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | An in person appointment was made for individual #1 with her psychiatrist. Protocols were created and reviewed with the doctors. The instructions were sent to the pharmacy and instructions on the label are now clear as to when the PRNs should be ministered and for what symptoms. The protocols were reviewed with staff on 6/11/2026. |
06/11/2026
| Submitted |