| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's assessment, completed 5/2/2026, stated they required verbal prompting to complete the following tasks related to financial management: produce exact change, select affordable items, and accept the importance of saving money. The assessment also stated "[Individual #1] has a rep-payee that manages [their] finances. [Individual #1] can identify coins, recognize different dollar bill denominations, and independently purchase items. However, [Individual #1] does not independently use other monetary skills, such as those used to conduct bank transactions. Staff continue to educate [Individual #1] on budgeting, monitoring [their] finances, and building financial responsibility." Individual #1's support plan, last updated 6/1/2026 stated "[Individual #1] needs assistance when it comes to managing [their] money. [Individual #1] can spend [their] money within a week and gets upset when [they do] not have any money until [they] get paid again. [Individual #1]'s staff will assist [them] in learning how to budget [their] money and pay [their] bills. The home does not have an up-to-date financial record that includes funds received by or deposited with the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A financial ledger has been developed to track the individual receipts and disbursements from his Truelink account. The financial ledger includes a starting balance, deposits, withdrawals, expected ending balance, actual ending balance, variance, and explanation, if any. The Team Lead will complete the ledger, and the Team Lead Supervisor will approve it monthly. |
08/21/2026
| Implemented |
| 6400.22(d)(2) | Individual #1's assessment, completed 5/2/2026, stated they required verbal prompting to complete the following tasks related to financial management: produce exact change, select affordable items, and accept the importance of saving money. The assessment also stated "[Individual #1] has a rep-payee that manages [their] finances. [Individual #1] can identify coins, recognize different dollar bill denominations, and independently purchase items. However, [Individual #1] does not independently use other monetary skills, such as those used to conduct bank transactions. Staff continue to educate [Individual #1] on budgeting, monitoring [their] finances, and building financial responsibility." Individual #1's support plan, last updated 6/1/2026 stated "[Individual #1] needs assistance when it comes to managing [their] money. [Individual #1] can spend [their] money within a week and gets upset when [they do] not have any money until [they] get paid again. [Individual #1]'s staff will assist [them] in learning how to budget [their] money and pay [their] bills. The home does not have an up-to-date financial record that includes disbursements made to or for the individual. | (2) Disbursements made to or for the individual.
| A financial ledger has been developed to track the individual receipts and disbursements from his Truelink account. The financial ledger includes a starting balance, deposits, withdrawals, expected ending balance, actual ending balance, variance, and explanation, if any. The Team Lead will complete the ledger, and the Team Lead Supervisor will approve it monthly. |
08/21/2026
| Implemented |
| 6400.62(a) | Individual #1's assessment, completed 5/2/2026, stated "As a safety precaution, all poisonous household cleaners are securely stored." At 10:40am on 7/31/2026, the following poisonous substances, with instructions to contact Poison Control or a physician if ingested, were observed unlocked and accessible under the bathroom sink: a 20-ounce can of Scrubbing Bubbles Bathroom Grime Fighter Bathroom Disinfectant, a 24-fluid ounce spray bottle of Comet Classic All Purpose Cleaner with Bleach, a 32-fluid ounce spray bottle of Great Value All Purpose Cleaner with Bleach, a 19-ounce spray can of Clorox Disinfecting Spray, a 15-ounce spray can or Hot Shot Flying Insect Killer, a 24-fluid ounce bottle of Clorox Clinging Bleach Gel toilet bowl cleaner, and a 32-fluid ounce spray bottle of Great Value Bathroom Cleaner with Bleach. At 10:47am on 7/31/2026, the following poisonous substances, with instructions to contact Poison Control or a physician if ingested, were observed unlocked and accessible in the cold cellar in the basement: nine 1-gallon cans of paint and three 5-gallon buckets of paint. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials were placed in locked containers. |
08/21/2026
| Implemented |
| 6400.66 | At 10:47AM on 7/31/2026, there was no light source in the cold cellar in the basement. There was a light fixture hanging from the ceiling; however, this light fixture did not have a light bulb. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A light bulb was added to the light fixture hanging from the ceiling of the cold cellar in the basement. |
08/21/2026
| Implemented |
| 6400.68(b) | At 10:41AM on 7/31/2026, the hot water temperature measured 131.5°F at the bathtub in the bathroom on the second-floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water tank was properly adjusted to correct the hot water temperature. |
08/21/2026
| Implemented |
| 6400.76(c) | At 11:03AM on 7/31/2026, there was a white plastic folding Lifetime table and chair in the dining room in lieu of home-like dining room table and chairs. The agency's self-assessment, completed from 4/15/2026 through 7/28/2026 indicated that Individual #1 had broken the previous dining room table and chairs and a new set was on order; however, the purchase order was not provided for review. | Furniture shall be comfortable and home-like. | A home-like dining room table and chairs were ordered. The replacement was delayed while selecting a durable, home-like option after repeated property damage. |
08/21/2026
| Implemented |
| 6400.80(a) | At 9:58AM on 7/31/2026, a self-locking gate latch was on the interior side of the gate on the front porch, at the top of the steps that lead down to the walkway at the right side of the home. When engaged, the latch obstructs the walkway and creates a potential hazard in the event of an emergency evacuation. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | A request was submitted to the property owner to remove the self-locking gate latch from the front porch. |
08/21/2026
| Implemented |
| 6400.81(k)(6) | At 10:45AM on 7/31/2026, Individual #1's bedroom did not contain a mirror. | In bedrooms, each individual shall have the following: A mirror. | A bedroom mirror was ordered and will be installed in Individual #1's bedroom. Due to the individual's known propensity for self-injurious behavior, including breaking glass over his head and putting his fist through glass objects, the provider ordered a non-glass, shatter-resistant mirror to meet the regulatory requirement while reducing the risk of injury. The mirror will be securely installed in the bedroom upon receipt and checked to confirm that it is safe, functional, and available for the individual's use. |
08/21/2026
| Implemented |
| 6400.106 | The home's furnace was inspected and cleaned on 7/28/2026. There was no documentation of the furnace previously being inspected and cleaned so compliance could not be measured. | 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 it failed to provide documentation supporting the inspection performed in July 2025, the month in which inspections occur at all LRS sites. A qualified contractor inspected and cleaned the furnace on July 28, 2026. |
08/31/2026
| Implemented |
| 6400.112(h) | The record for the fire drill conducted on 12/24/2025 indicated that Individual #1 did not meet at the designated meeting place outside of the home as the individual refused to go outside during the fire drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The provider reviewed the 12/24/2025 fire drill record and identified that Individual #1 did not evacuate to the designated meeting place outside of the building due to refusal. Staff will provide Individual #1 with fire safety retraining, including the expectation to evacuate to the designated meeting place or fire-safe area during each fire drill and in the event of an emergency. The Program Specialist or designee will review the refusal with the individual's support team to determine whether additional supports, prompts, desensitization strategies, or updates to the ISP/fire safety plan are needed to increase successful evacuation participation. Staff will document the retraining, support-team review, and any follow-up actions taken. |
08/21/2026
| Implemented |
| 6400.141(a) | Individual #1's annual physical examinations were completed on 7/3/2025 and again on 7/27/2026. [Repeat Violation, 7/23/2025] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The provider reviewed Individual #1's annual physical examination dates and confirmed that the annual physical was not completed within the required 12-month timeframe. The individual's annual physical examination was completed on 7/27/2026. The Medical Compliance Coordinator or designee will update the individual's health tracking record to reflect the completed examination date, obtain and retain documentation of the completed physical examination in the individual's record, and notify the Program Specialist and Team Lead Supervisor of the next annual physical due date. Because this is a repeat violation, the Compliance Director or designee will review the health tracking process to determine why the prior due date was missing and will document the corrective follow-up taken to prevent recurrence. |
08/19/2026
| Implemented |
| 6400.181(c) | Individual #1's assessment, completed 5/2/2026, indicated under the Home Supervision Section "The ISP explicitly notes that outgoing staff must remain on duty until designated emergency staff arrive to ensure that [Individual #1]'s required staffing ratio is maintained at all times" and under the Community Supervision Section "[Their] ISP Explicitly sets [their] community supervision requirement at 24-hours." Individual #1's assessment was based on the Individual Support Plan rather than assessment instruments, interviews, progress notes, and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The Program Specialist will reissue Individual #1's assessment using validated assessment tools, staff and individual interviews, direct observations, and recent progress notes. |
09/15/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. Individual #1's psychiatric medication review, completed 12/23/2025, did not include a list of Individual #1's prescribed psychiatric medications, the reason for prescribing the medications, or the necessary dosages. [Repeat Violation, 7/23/2025] | 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. | The provider acknowledges that Individual #1's psychiatric medication reviews were not completed within the required 3-month timeframe. The provider contacted the prescribing physician and obtained updated psychiatric medication review documentation. The provider reviewed the documentation and placed it in the individual's record. The provider verified that the psychiatric medication review documentation includes the reason for prescribing the medication, the need to continue the medication, and the necessary dosage, as required by 55 PA Code Chapter 6400.165(g). Team Leads were retrained on psychiatric medication, review documentation requirements, and the importance of timely follow-up for individuals prescribed medications to treat symptoms of a psychiatric illness. |
09/15/2026
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the name of this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | he provider corrected Individual #1's medication administration record to include the name of the prescribed medication, Albuterol AER HFA inhaler, with the physician's order instructions. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication name was accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the strength of this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. Individual #1 is prescribed Amlodipine 5mg tab with instructions to "take 1 tablet by mouth daily for hypertension." The pharmacy issued medication label confirmed that the prescribed dosage of this medication was 5mg; however, Individual #1's July 2026 medication administration record indicated that the prescribed strength of this medication was 10mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The provider corrected Individual #1's medication administration record to include the strength of the prescribed Albuterol AER HFA inhaler and corrected the strength of Amlodipine to accurately reflect the pharmacy label and physician's order of 5mg. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's orders, pharmacy labels, and medication administration record to verify that all medication strengths were entered accurately and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the dosage form of this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The provider corrected Individual #1's medication administration record to include the prescribed Albuterol AER HFA inhaler and its dosage form. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication and dosage form were accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the dose of this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The provider corrected Individual #1's medication administration record to include the prescribed Albuterol AER HFA inhaler and the ordered dose of "2 puffs" in accordance with the physician's order and pharmacy label. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication and dose were accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the route of administration for this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. Individual #1 is prescribed Fluticasone HFA AER 220mcg spray with instructions to "inhale and swallow 2 puffs by mouth twice a day for eosinophilic esophagitis *do not eat 30 mins after*." Individual #1's July 2026 medication administration record indicated that the administration instructions were to "swallow 2 puffs by mouth twice a day for eosinophilic esophagitis *do not eat 30 mins after*." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The provider corrected Individual #1's medication administration record to include the prescribed Albuterol AER HFA inhaler and the ordered route of administration, "by mouth/inhalation," in accordance with the physician's order and pharmacy label. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication and route of administration were accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the frequency of administration for this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The provider corrected Individual #1's medication administration record to include the prescribed Albuterol AER HFA inhaler and the ordered frequency of administration, "every four hours as needed for wheezing/shortness of breath," in accordance with the physician's order and pharmacy label. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication and frequency of administration were accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the administration times for this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The provider corrected Individual #1's medication administration record to include the prescribed Albuterol AER HFA inhaler and the administration time instructions, "every four hours as needed for wheezing/shortness of breath," in accordance with the physician's order and pharmacy label. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication and administration time instructions were accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Albuterol AER HFA inhaler with instructions to "inhale 2 puffs by mouth every four hours as needed for wheezing/shortness of breath." Individual #1's July 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. This medication was omitted entirely from Individual #1's July 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The provider corrected Individual #1's medication administration record to include the prescribed Albuterol AER HFA inhaler and the diagnosis or purpose for the medication, "as needed for wheezing/shortness of breath," in accordance with the physician's order and pharmacy label. The Medical Compliance Coordinator and Team Lead Supervisor reviewed the physician's order, pharmacy label, and medication administration record to verify that the medication and PRN purpose were accurately entered and that the MAR reflects all currently prescribed medications. Staff responsible for medication administration were notified to ensure the corrected MAR is used going forward. |
08/21/2026
| Implemented |