| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | A Walmart receipt dated 12/24/25 with a total spent of $193.17 was recorded on the provider financial log as $199.53. There was no accounting for the additional amount recorded on the financial log. | Individual funds and property shall be used for the individual's benefit. | The $6.36 was replaced to the individuals account on 1/14/26 |
01/14/2026
| Implemented |
| 6400.83(b) | Individual #1 was noted to need a "Mother or Maroon Spoon" as documented in her Individual Support Plan (ISP) to assist in eating at the table. At the time of inspection, the recommended spoons were not in the home. Spoons stated to be "baby spoons" by staff were in a kitchen drawer and offered as the ones used daily by Individual #1. | Special provisions shall be made and adaptive equipment shall be provided, when necessary, to assist individuals in eating at the table. | The correct spoon, a Mother Spoon, was provided to the home for the individual to be used on 1/14/26. |
01/14/2026
| Implemented |
| 6400.141(c)(7) | A letter from the physician dated 10/1/15 was located in the file for Individual #1. The letter stated that due to "inability to cooperate for past gynecological examinations, it has been deemed unnecessary for [them] to return." There was no record of GYN exams being completed. The documentation presented for not attending GYN exams does not meet the minimum requirements as outlined in the Regulatory Compliance Guide (RCG) as gynecological examinations and mammograms are required unless:
1. There is documentation from a licensed physician that the examinations are not required based on the individual's physical condition or based on standards of care; exempting a person from preventative screening based solely on the person's intellectual disability or autism is not permitted." | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Arc of NEPA is scheduling with her gynecologist on 1/14/26, to complete the exam and discuss future options for future exams. |
01/14/2026
| Implemented |
| 6400.141(c)(8) | There was no documentation that mammograms have been completed nor documentation as to why provided for Individual #1. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The Arc of NEPA is scheduling with her PCP on 1/14/26, to complete the exam and discuss future options for future exams. |
01/14/2026
| Implemented |
| 6400.141(c)(14) | The physical, provider dated as 8/25/25, and physician dated as 8/27/25 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The section assigned for the information was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The provider followed up with the PCP on 1/14/26 regarding the missing information. Missing information will be attached to the 2025 physical. |
01/14/2026
| Implemented |
| 6400.142(d) | Documentation indicates that Individual #1 was seen by a dentist for exams only on 3/19/24, 3/11/25 and 4/9/25. There was no evidence to indicate that cleaning was completed on an annual basis as required. | The dental examination shall include teeth cleaning or checking gums and dentures. | The provider has been in contact with a new dental clinic to assist with ensuring that appointments can be scheduled and maintained properly |
01/14/2026
| Implemented |
| 6400.142(e) | On 11/3/22 Individual #1 was seen by a dentist and received orders to "Patient needs sedation. Wait list for OR to be seen at TBD-scheduled at OR." There was no documentation that the work was completed or that attempts had been made to schedule the OR services required until a 3/19/24 visit that indicated "On wait list at Geisinger Danville" On 3/11/25 a referral was received for Geisinger from Special Care Smiles. Documentation indicated that an exam only was completed at Geisinger on 4/19/25. Provider notes indicate that an appointment was scheduled for Geisinger on 10/31/25. There was no documentation that the appointment had been completed as scheduled. Additional documentation was requested and a note from Geisinger dated 12/30/25 provided which stated "[Individual #1] was scheduled for an appointment on 10/31/25 but was cancelled due to the patient being seen sooner." An appointment is now scheduled for 1/8/26. It is not clear that the appointment was for OR services that were recommended to be completed on 11/3/22. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Provider reached out to Geisinger Danville on 1/7/26 to confirm that this was for the OR, Geisinger Danville noted that they needed to reach out again to schedule. The appointment on the 8th of January was cancelled as it was not for the OR. Documentation from Geisinger was received. Provider is also exploring alternative practices. |
01/07/2026
| Implemented |
| 6400.143(a) | Individual #1 is documented to refuse GYN and Mammograms. There was no documentation to illustrate that the refusals and continued attempts to train the individual about the need for health care was completed as required. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The Arc of NEPA is scheduling with her gynecologist on 1/14/26, to complete the exam and discuss future options for future exams. |
01/14/2026
| Implemented |
| 6400.144 | The physical, provider dated 8/25/25, and physician dated 8/27/25, indicated that Individual #1 should be on a pureed diet of 1,600 calories and thin liquids. The swallow study completed on 10/1/24 noted that Individual #1 should "consume a pureed diet with thin liquids via a cup." During inspection of the home staff reported that Individual #1 was on a pureed diet with honey consistency liquids. No additional dietary instructions were noted to indicate that staff had knowledge of, or were assisting Individual #1, to limit calories to 1600 as prescribed. Consistency of liquids stated by staff also differed from the prescribed diet.
Due to inconsistencies, it could not be verified that the prescribed dietary considerations were implemented.
Individual #1 received a referral for a colonoscopy on 2/25/25. As of 12/29/25 the colonoscopy had not been scheduled nor completed. An additional referral dated 12/30/25 was presented with a reason for referral as "PT is due for colonoscopy-original referral sent 2/25/25."
Health services prescribed shall be provided. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Staff have been retrained on dietary of individual. Staff contacted the PCP on 12/31/25 to schedule with a GI doctor. The PCP has yet to call back with a new date of the procedure. The staff are following up on 1/14/26. |
12/31/2025
| Implemented |
| 6400.216(a) | At time of inspection there were shelves in the basement extending to the ceiling. The top two shelves contained numerous binders labeled with Individuals names. The binders and information contained were not properly secured when not attended as required. | An individual's records shall be kept locked when unattended.
| Heavy duty storage bins will be purchases for all homes. Historical records will be kept for 7 years and then disposed of via shredding. |
01/16/2026
| Implemented |
| 6400.163(d) | A container of pharmacy labeled Balmex was found in the unlocked personal items closet of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Container of Balmex was secured on 12/30/25. |
12/30/2025
| Implemented |
| 6400.163(h) | At time of inspection a container of Balmex was in use for Individual #1 dated as filled on 10/3/24 with a pharmacy expiration date of 37/25.
A tube of Triamcinolone Cream in use for Individual #1 at the time of inspection was dated as filled on 2/6/25 with a pharmacy expiration date of 8/12/25. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired medication of Balmex was properly disposed of. |
12/30/2025
| Implemented |
| 6400.165(g) | The record presented for Individual #1 at time of inspection contained documentation of one medication review completed on 2/13/25. Additional reviews were requested. Provider submitted provider generated documentation on Medication Review Forms noting reviews on 5/8/25, 8/14/25 and 11/5/25. The reviews were not signed by a doctor. A release of information to the doctor's office completed on 12/20/25 was also submitted.
The documentation presented was not sufficient to illustrate that the appointments had occurred as required. | 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. | Documentation has been secured by the doctors office to note all appointments were maintained. |
01/05/2026
| Implemented |
| 6400.166(b) | At approximately 4pm on 12/29/25 staff members offered Individual #1 their 4pm medications consisting of Carbamazepine, Clonazepam and Oystershell Calcium. Individual #1 would not take the medications. Licensing Representative (LR) continued conducting the inspection of the home at this time. At approximately 4:15pm LR began reviewing the medications and medication administration records (MAR) for Individual #1. It was noted at that time that the staff initialed the Oystershell Calcium and Clonazepam as being administered when the pills remained in a container on the table at the time the MARs were reviewed. Medications are to be initialed after the medication has been administered, not prior. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Provider staff will complete a med admin refresher and on policies and procedures. Training will be completed by 1/16/25. |
01/16/2026
| Implemented |
| 6400.186 | The Individual Support Plan (ISP) last updated on 9/30/25 for Individual #1 indicated that Individual #1 was to use a "Mother Spoon" also known as a "Maroon" spoon. | The home shall implement the individual plan, including revisions. | The correct spoon, a Mother Spoon, was provided to the home for the individual to be used on 1/14/26. |
01/14/2026
| Implemented |