| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home between 6/9/25 to 7/4/25, did not provide a written summary of corrections made for any of the following 6400 regulation items identified as violations: .67b; .77b; .81k3; .112a; .112c; .143a; .63h; .65b; .181b; .181e1; .181e2; .181e3ii; .181e3iv; .181e4; .181e12; .18113ii; .181e13vii; .181e13viii; .181e13ix; .181e14; and .181f. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Immediate Action: The Agency will re-conduct an LIS immediately, ensuring all sections are completed and all that have been marked as (V) have an attached POC and completion date by 8.24.25. |
08/24/2025
| Implemented |
| 6400.21(a) | Direct Service Provider #1's date-of-hire is 10/21/24. The agency completed a Pennsylvania criminal history check to the State Police on 10/10/24, revealing a final report of criminal history involvement. However, the agency did not provide documentation of a criminal record review outlining their consideration for hiring Direct Service Provider #1 based on the following factors: the nature of the crime; the facts surrounding the conviction; the time elapsed since the conviction; the evidence of Direct Service Provider #1's rehabilitation; and the nature and requirements of the job. | 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.
| Actions to be taken immediately: What should we do right now?
1) The provider is currently rerunning all of the Criminal Background records of staff who have a prohibitive offense, including Direct Support Provider #1, on or before 8/15/2025, according to 6400.21(a).
2) Once the staff with prohibitive staff are identified, the HR Specialist will perform a risk analysis by having the providers perform the criminal conviction case process through the providers' attorney. The legal team will determine whether the staff need to be placed on a provisional basis.
3) The provider has updated its Background Checks Policy, revised the Criminal Conviction Case form, and created an action plan since 6/10/2025. (see enclosed)
4) Not Forgotten also updated the Residential Record Management Process on 7/21/2025, emphasizing the importance of maintaining accurate Criminal History records and reducing staff access to these records (risk assessments) to mitigate the risk of lost or missing documentation. (see enclosed)
5) NFHCS no longer employs the former HR Manager, who was responsible for following the Criminal Background Prohibitive Process. A new HR Specialist was hired on June 30, 2025, and received training on the updated policies, forms, and action plan.
6) The LIS section of 6400.21(a) of staff records will be performed quarterly by the HR Specialist and submitted to the Director of Compliance for final review. |
08/15/2025
| Implemented |
| 6400.65 | On 7/9/25, the full bathroom located in the home's basement did not have an operable window or a mechanical exhaust fan for ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Immediate Action: Operations Director met with a contractor on 7.18.25. to initiate work order. Work to install fans/vents will begin the weekend of 7.18.-7.20.25 |
08/15/2025
| Implemented |
| 6400.112(a) | According to the written fire drill record submitted from 7/20/24 to 6/22/25, a monthly drill was not conducted in April 2025. | An unannounced fire drill shall be held at least once a month. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Fire Drills were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ The Chief Executive Assistant is now responsible for reviewing and verifying all fire drills are completed monthly and in full compliance with Chapter 6400.
¿ The CEA has started this assignment. All the fire drills for each of our homes for June and July 2025 have been completed and compliant.
¿ A LIS have been completed for the Fire Drills. |
07/23/2025
| Implemented |
| 6400.151(c)(2) | Direct Service Provider #1's date-of-hire is 10/21/24. Their content of records included only a tuberculin skin test via Mantoux method that was read with negative results on 10/9/24. However, there was no signature of the medical professional who had interpreted the results, certifying this test. | 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. | Actions to be taken immediately: What should we do right now?
1) The organization has appointed a newly hired Human Resources Specialist, who will now assume complete oversight of the following, following 6400.151c(2) and all other individual records. Additionally, the Chief Operating Officer will provide secondary support to the HR Specialist, ensuring that the physical and TB processes are executed with the highest standards of accuracy and safety. This strategic change aims to streamline operations and improve the overall quality of care provided to residents.
2) Direct Support Provider #2. The nurse who read the TB is no longer employed at the facility where the TB was read. However, a letter is forthcoming from the place where she received the physical from the doctor, and where her TB test was performed. NFHCS also had the Direct Support Provider #2 conduct another TB, which is scheduled to be completed by July 28, 2025. That additional information will be forthcoming. In the meantime, Direct Support Provider #2 was informed that she is not to provide direct support until her TB is reread.
3) The provider is currently running an audit of all the staff TB/Physicals to ensure compliance with 6400.141c(2) on or before 8/15/2025. Staff identified will be removed from working at NFHCS until their TB test results are read correctly.
4) NFHCS updated a new Physical Form/TB form to ensure compliance, where the area is noted that the professional name, title, and signature are identified.
5) All staff TB tests will be conducted annually, based on the staff¿s hire date. |
08/15/2025
| Implemented |
| 6400.32(r)(1) | On 7/9/25, Individual #1's bedroom door was equipped with a privacy lock that had a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #1 with a unique mechanism in which to lock and unlock their bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Immediate Action: Operations Director met with a contractor on 7.21.25. to initiate work order for locking mechanisms that allow for more security and privacy and that better align with 6400.32r1. |
08/01/2025
| Implemented |
| 6400.46(d) | Direct Service Provider #2 completed two-year certification trainings through the American Red Cross in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 1/14/23, and then again on 2/21/25. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Actions to be taken immediately: What should we do right now?
1) The organization has appointed a newly hired Human Resources Specialist, who will now assume complete oversight of the following: 6400.46(d) and all other individual records. Additionally, the Chief Operating Officer will provide secondary support to the HR Specialist, ensuring that the CPR/First Aid training processes are executed with the highest standards of accuracy and safety. This strategic change aims to streamline operations and improve the overall quality of care provided to residents.
2) Although Direct Service Professional #2 CPR/First AID is current, A full CPR/First Aid audit is currently underway. The audit will be completed on or before August 20, 2025, to ensure that no other violations are found.
3) A Quarterly LIS will be completed, and those potential violations listed in the audit will be in the LIS. |
08/20/2025
| Implemented |
| 6400.169(a) | Direct Service Provider #2's date-of-hire is 3/6/19. On 7/8/25, the agency revealed that Direct Service Provider #2 administers medication. Direct Service Provider #2 successfully completed the Department-approved medication administration practicum on 11/5/24. However, their content of records did not include documentation of ever having completed the Department-approved medication administration practicum in 2023. Therefore, annual compliance could not be measured. | 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). | Actions to be taken immediately: What should we do right now?
1) Not Forgotten HCS has undertaken a significant restructuring of its Residential Management Team, leading to the removal of personnel previously tasked with overseeing the medication administration process. To enhance the effectiveness of the Medication Administration Program, the organization has appointed a newly hired Human Resources Specialist, who will now assume complete oversight of this critical function. Additionally, the Chief Operating Officer will provide secondary support to the HR Specialist, ensuring that the medication management process is carried out with the highest standards of accuracy and safety. This strategic change aims to streamline operations and improve the overall quality of care provided to individuals
2) After being notified by licensing, Direct Service Professional #2 was instructed not to administer medication. A backup staff member stepped in to administer the medication. On July 9, 2025, Direct Service Provider #2 underwent immediate retraining in medication administration. During this training, she also completed the required medication observations and a medication review. (See enclosed)
3) All staff will now receive two quarterly observations and medication reviews to maintain compliance with 6400.169(a).
4) A full Medication Training audit is currently underway. The audit will be completed on or before August 20, 2025, to ensure that there are no other violations. Staff identified as not having completed MAR reviews and observations will be immediately unable to administer medications until they are brought back into compliance.
5) A Quarterly LIS will be completed. |
08/20/2025
| Implemented |