| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no self-assessment form completed for the home. | 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.
| During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC experienced operational staffing changes which included the resignation of one Assistant Director, the termination of one Behavioral Specialist, the termination of 3 site managers, & the resignation of a Program Specialist; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Policies & Procedures related to 6400.15(a) will be re-evaluated to include auditing requirements and accountability disclosure statements
regarding the assigned home. |
11/18/2025
| Implemented |
| 6400.21(a) | Staff Person #2 who was hired 7/7/2025 and the background check was completed 7/26/2025.
The criminal history background check for Staff Person #4 was not completed timely. Staff was hired on 2/19/2025 and the check was completed on 4/2/2025. | 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.
| To ensure compliance with new hire background checks, 6400.21(a), Human Resources will develop an
internal auditing tracking system to sustain ongoing adherence to 6400,21(a). A monthly compliance report,
submitted by Human Resources, will be reviewed by Complete Comforts' Quality Improvement Committee. |
11/18/2025
| Implemented |
| 6400.65 | In the bathroom adjacent to the bedroom designated as an office area, the exhaust fan was not working. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Facilities will adjust the exhaust as needed to ensure there ae no pre-existing blockages, dust mites present/build up to present such blockages or occurrences in the office area location by 11/24/25. A LETTER of the fans function will be sent to the Lead Inspector via email for the plan of correction supporting documentation. |
11/24/2025
| Implemented |
| 6400.71 | There were no emergency numbers posted on or near the phone in the dining area. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency numbers have been posted near the phone in the dining area on 10/15/25 before 8pm. Photos of Postings and actual postings have been sent to lead inspector. Provider will resend for transparency. |
10/15/2025
| Implemented |
| 6400.76(a) | The toilet paper holder in Individual #1's bathroom was broken and not able to hold the toilet paper on the roll. The several slats were broken from the blinds in the kitchen. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Facilities will repair the toilet paper holder and the kitchen blinds by 11/24/25. |
11/24/2025
| Implemented |
| 6400.81(k)(6) | There was no mirror in individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Complete Comfort iD Residential has replaced the mirror in individual #1's bedroom by 10/15/2025 before 8pm. A picture has been sent to lead inspector on 10/15/25. This photo will be resent for transparency to the Lead Inspector via email for the plan of correction supporting documentation. |
10/15/2025
| Implemented |
| 6400.82(f) | In the bathroom adjacent to Individual #1's bedroom there was no paper towels or hand towel available and no hand soap. In the bathroom adjacent to the bedroom designated as an office area, there was no non-slip mat in the tub. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Paper towels, safe/non-poisonous hand soap has been placed in the bathroom adjacent from
Individual#1's bedroom. A non-slip mat has been placed in the tub in the adjacent bathroom
designated as the office area. |
11/03/2025
| Implemented |
| 6400.104 | No notification to the fire department on file for Individuals #1 and #2. | 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.
| Notifications to the Fire Department were sent on 10/01/2025 for Individual #1 and Individual #2.
Supporting documentation was provided during licensing inspection date 10/15/25 by 8pm. Documentation will be resent via email by 11/24/25. |
10/01/2025
| Implemented |
| 6400.112(a) | No fire drills were provided or conducted per Staff during the review period. | An unannounced fire drill shall be held at least once a month. | House Managers & Program Specialists for their assigned homes and caseloads will be responsible for
ensuring compliance with monthly fire drills. |
11/17/2025
| Implemented |
| 6400.113(a) | Fire safety training was not given and fire drills were not conducted upon admission for Individual #1 or 2. | 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. | During the months of late July 2025 through early September 2025, Complete Comfort ID Residential, LLC
experienced operational staffing changes which included the resignation of one Assistant Director, the
termination of one Behavioral Specialist, the resignation of 1 Program Specialist, the
termination of 2 house manager's, & the resignation of 1 house manager ; totaling six key staffing operational roles. To date, 11/18/25, house managers are being re-trained , roles are being re-organized; including hiring structures. Complete Comfort will ensure that fire safety training is provided to Individual #1 and Individual #2 by 11/26/25 through a certified trainer. |
11/17/2025
| Implemented |
| 6400.151(a) | Staff Person #2 Physical completed on 8/29/2025, and Staff hired 7/7/2025. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff Person #2 will have a physical completed by 11/30/25. Human Resources will be required to develop
an auditing tool regarding all regulatory hiring requirements relating to staff physicals, training, &
background checks. |
11/17/2025
| Implemented |
| 6400.151(c)(2) | There are no results of Tuberculin Testing on file for Staff Person #3 on file from letter dated 10/10/2023 referencing physical dated 12/14/2022. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff Person #3 will have a physical completed by 11/30/25 which includes Tuberculin Testing with
the documented results. |
11/17/2025
| Implemented |
| 6400.151(c)(3) | There is a letter on file date 10/10/2023 stating a physical was performed on 12/14/2022 for Staff Person #3 and it does not include a signed statement staff is free from communicable disease. The subsequent physical completed on 10/4/2024 does not a signed statement staff is free from communicable disease | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff Person #3 will have a physical completed by 11/30/25 which includes Tuberculin Testing with
the documented results. |
11/17/2025
| Implemented |
| 6400.171 | There was a 20-pack of hash browns in the refrigerator that was opened, with several removed, and not covered, leaving the hash browns exposed and not protected. In individual Derek Self's bedroom there was a semi-finished jar of nacho cheese on the bedstand that had been unrefrigerated for an unknown length of time. | Food shall be protected from contamination while being stored, prepared, transported and served.
| All non protected food has been removed from the Individual's refrigerator & bedroom. |
11/17/2025
| Implemented |
| 6400.46(a) | Staff Person #2 Fire Safety training was completed on 8/28/2025, hire date of 7/7/2025. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking
system to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will
be reviewed by Complete Comforts' Quality Improvement Committee. |
11/03/2025
| Implemented |
| 6400.51(b)(1) | Training required as orientation not completed within 30 days past hire for Staff Person #2 who was hired 7/7/2025.
- Person Centered Practice completed 8/28/2025
- Community Participation Support completed 8/28/2025 | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking
system to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will
be reviewed by Complete Comforts' Quality Improvement Committee. |
11/03/2025
| Implemented |
| 6400.51(b)(2) | Training required as orientation not completed within 30 days past hire for Staff Person #2 who was hired 7/7/2025.
- Abuse completed 8/28/2025 (51b 2) | 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. | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking
system to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will
be reviewed by Complete Comforts' Quality Improvement Committee. |
11/03/2025
| Implemented |
| 6400.51(b)(3) | Training required as orientation not completed within 30 days past hire for Staff Person #2 who was hired 7/7/2025.
- Individual Rights completed 8/27/2025. | The orientation must encompass the following areas: Individual rights. | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking system
to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will be reviewed by Complete Comforts' Quality Improvement Committee. |
11/03/2025
| Implemented |
| 6400.51(b)(4) | Training required as orientation not completed within 30 days past hire for Staff Person #2 who was hired 7/7/2025.
- Recognizing and Reporting Incidents completed 10/14/2025. | The orientation must encompass the following areas: recognizing and reporting incidents. | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking system
to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will be
reviewed by Complete Comforts' Quality Improvement Committee. |
11/03/2025
| Implemented |
| 6400.51(b)(5) | Training required as orientation not completed within 30 days past hire for Staff Person #2 who was hired 7/7/2025.
- Incident Management completed 8/28/2025.
- Foundations of ISP completed 9/18/2025. | The orientation must encompass the following areas: Job-related knowledge and skills. | To ensure compliance with staff trainings, Human Resources will develop an internal auditing tracking
system to sustain ongoing adherence. A monthly compliance report, submitted by Human Resources, will
be reviewed by Complete Comforts' Quality Improvement Committee. |
11/03/2025
| Implemented |
| 6400.43(c)(1) | Staff Person #1, designated as CEO, does not meet qualifications, as Staff does not have a bachelor's or master's degree. | (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. | On 10/15/25, Complete Comfort designated a staff person with the required CEO education requirements;
bachelor's or master's degree. On October 23, 2025, this designation was submitted through email to our
Lead Inspector. All trainings will be fully completed by 11/24/25. These completed trainings will be
submitted via email to the Lead Inspector as supporting plan of correction documentation. |
10/15/2025
| Implemented |