| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The agency did not provide written notification to the local fire department 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 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.
| 6400.104 -- Notification to the Fire Department
Immediately following the licensing inspection, Armstrong Care, Inc. provided written notification to the local fire department that included:
· The address of the licensed home.
· A diagram identifying the layout of the home.
· The exact location of bedrooms occupied by individuals requiring assistance with evacuation.
· The location of smoke detectors and fire extinguishers.
· The designated outdoor meeting location.
· General information regarding evacuation assistance needs.
This notification has been placed into the home's permanent records and will be updated whenever there is a change affecting evacuation assistance or the home's layout.
|
07/22/2026
| Implemented |
| 6400.113(a) | Individual #1 was trained in fire safety on 6/25/2026. The training certificate states that the training only included, "fire extinguisher operation class, utilizing a live fire conducted by JAWCO Fire, INC of Punxsutawney, PA." This training did not include site specific evacuation procedures, responsibilities during dire drills and the designated meeting place. | 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. | 6400.113(a) -- Fire Safety Training for Individuals
Following the licensing inspection, Armstrong Care, Inc. reviewed the fire safety training provided to individuals. Although fire extinguisher instruction had been completed, the documentation did not verify that all components required by 55 Pa. Code §6400.113(a) had been included.
The agency developed a revised fire safety training program that includes all required topics:
· General fire safety
· House-specific evacuation procedures
· Individual responsibilities during fire drills
· The designated meeting location for that residence
· Smoking safety procedures, when applicable
Each residential home will receive fire safety instruction specific to that home's layout and evacuation procedures. The training will be conducted in the individual's primary language or mode of communication, and written documentation will include the content presented and the individuals who attended.
|
07/22/2026
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment, completed 11/12/2025, did not include an assessment of Individual #1's ability to self-administer medications. This section was left blank. | The assessment must include the following information: The individual's ability to self-administer medications. | The Individual Assessment was revised to include a mandatory section evaluating the individual's ability to self-administer medications. The revised section documents the individual's level of independence, need for prompting or assistance, any changes since the previous assessment, and a narrative describing the individual's medication management abilities and required staff supports. Individual #1's assessment has been updated to include this information. Program Specialists were instructed that this section may not be left blank. |
07/22/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #1 was trained in fire safety on 5/6/2026. The training certificate states that the training only included a, "fire extinguisher operation class, utilizing a live fire conducted by JAWCO Fire, INC of Punxsutawney, PA." This training did not include site specific evacuation procedures, responsibilities during dire drills and the designated meeting place. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Plan of Correction -- 6400.46(b)
Armstrong Care, Inc. acknowledges that although annual fire safety training was completed by JAWCO Fire, Inc., the training did not include all of the required components outlined in 55 Pa. Code §6400.46, specifically site-specific evacuation procedures, staff responsibilities during fire drills, and the designated meeting place for each home.
To correct this deficiency, Armstrong Care, Inc. will ensure that all Program Specialists and Direct Support Professionals receive annual fire safety training conducted by a qualified fire safety expert that includes all required elements of the regulation. The training will include, at a minimum:
· Site-specific evacuation procedures for each assigned home.
· Staff responsibilities during fire drills and actual fire emergencies.
· The designated meeting place for each home.
· General fire safety procedures and the proper use of fire extinguishers.
|
07/22/2026
| Implemented |
| 6400.165(g) | Individual #1 had a psychiatric medication review on 7/2/25 and then again on 12/22/25. | 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. | Following the licensing inspection, Armstrong Care, Inc. reviewed the individual's medical records and confirmed that the required psychiatric medication review was not completed within the required 90-day timeframe. The delay was the result of a breakdown in the appointment scheduling and tracking process.
To correct this deficiency, Armstrong Care, Inc. has implemented the following corrective actions:
· House Supervisors will schedule the next psychiatric medication review before leaving the provider's office whenever possible. If an appointment cannot be scheduled at that time, the psychiatrist's office will be contacted within five (5) business days to secure the appointment.
· The agency's weekly Program Specialist Report has been revised to include all upcoming compliance-related appointments, including psychiatric medication reviews, allowing Program Specialists to verify that required appointments have been scheduled.
· When a psychiatric medication review cannot be completed within the required 90-day timeframe due to circumstances outside the agency's control (such as provider availability, weather, hospitalization, or office rescheduling), documentation from the prescribing provider will be obtained and maintained in the individual's medical record.
· House Supervisors and Program Specialists have been re-educated regarding the requirements of 55 Pa. Code §6400.165(g) and their respective responsibilities for scheduling, tracking, and documenting psychiatric medication reviews. |
07/22/2026
| Implemented |