| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service worker #1 had a criminal record history completed on 2/7/25, prior to her hire date of 4/6/25. The direct staff worker's background check identified a criminal record. However, no documentation was provided on the decision to hire. | 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.
| In accordance with 55 PA Code 6400 .21 (a) If a criminal history clearance and/or the criminal history record check identifies a criminal record, providers must make a case-by-case decision about whether to hire the person that includes consideration of the following factors:
· The nature of the crime,
· Facts surrounding the conviction,
· Time elapsed since the conviction,
· The evidence of the individual's rehabilitation; and
· The nature and requirements of the job.
Documentation of the review must be maintained for any staff that were hired whose criminal history clearance results or criminal history check identified a criminal record. |
12/29/2025
| Implemented |
| 6400.72(a) | On 11/5/25 at 10:36 am the bathroom window located on the second floor of the home was missing a well-secured screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | In accordance with 55 PA 6400.72 (a) windows, including windows in doors, shall be securely screened when windows or doors are open. |
12/19/2025
| Implemented |
| 6400.104 | A fire department notification was sent on 9/1/25. Individual #1 requires assistance to evacuate the home. The letter indicated there was a diagram of the home attached; however, no diagram was attached to the notification. | 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.
| In accordance 55 PA Cose 6400.104 the provider shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of the individuals who need assistance evacuating in the event of an actual fire. The notice shall be kept current. |
12/19/2025
| Implemented |
| 6400.181(e)(4) | Individual # 1's assessment, dated 4/14/25 did not address the individual's supervision needs in the home or in the community. | The assessment must include the following information: The individual's need for supervision.
| In accordance with 55 PA Code 6400.181 (e)(4) the assessment must include the individual's need for supervision. |
12/29/2025
| Implemented |
| 6400.181(e)(9) | Individual # 1's assessment, dated 4/14/25, had no documentation of the individual's disability. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | In accordance with 55 PA Code 6400.181(e)(9) the assessment must include documentation of the individual's disability, including functional and medical limitations. |
12/29/2025
| Implemented |
| 6400.181(e)(10) | Individual # 1's assessment, dated 4/14/25 did not contain the individual's lifetime medical history. | The assessment must include the following information: A lifetime medical history. | In accordance with 55 PA Code 6400.181(e)(10) the assessment must contain a lifetime medical history. |
12/29/2025
| Implemented |
| 6400.181(e)(12) | Individual # 1's assessment, dated 4/14/25, had no recommendation for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | In accordance with 55 PA Code 6400.181(e) (12) the assessment must include recommendations for specific areas of training. programming and services. |
12/29/2025
| Implemented |
| 6400.163(a) | Individual #1 is prescribed Incassia, 0.35 MG tablets to be taken at the same time everyday. The medication was discovered in a plastic bag, not in the original container, nor labeled by a label issued by a pharmacy. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | In accordance with 55 PA Code 6400.163(a) prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. |
12/29/2025
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Hydroxbyz pam cap 25 mg. Take 1 capsule by mouth daily, (between 10:30-11:00am) for anxiety, as indicated on the Medication Administration Record, (MAR). However, the individual was administered the medication on 11/1/25, 11/2/25, 11/3/25, 11/4/25 and 11/5/25 at 8am. | A prescription medication shall be administered as prescribed. | In accordance with 55 PA Code 6400.165(c) a prescription medication shall be administered as prescribed. |
12/29/2025
| Implemented |
| 6400.166(a)(13) | Direct Service Worker #1 initialed the Medication Administration Record, (MAR). on 11/1/25, 11/3/25, and 11/4/25 as administering medication; however, Direct Service Worker #1 did not sign and initial the Master Legend of staff administering medication on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | In accordance with 55 PA Code 6400.166 (a)(13) a medication record shall be kept for each individual for whom a prescription medication is administered which includes the name and initials of the person administering the medication. |
12/29/2025
| Implemented |
| 6400.167(a)(4) | Individual #1 is prescribed Hydroxbyz pam cap 25 mg. Take 1 capsule by mouth daily, (between 10:30-11:00am) for anxiety, as indicated on the Medication Administration Record, (MAR). However, the individual was administered the medication on 11/1/25, 11/2/25, 11/3/25, 11/4/25 and 11/5/25 at 8am. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | In accordance with 55 PA Code 6400.167 (a) (4) medication errors include failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. |
12/29/2025
| Implemented |