| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Temporary Direct Service Provider #2's date-of-hire is 4/7/25. The agency provided a completed Pennsylvania criminal history check that submitted to the State Police on 8/13/24, 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 Temporary Direct Service Provider #2. | 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.
| A Criminal History Submission Log was created to record Staff name, Date of hire, Date of submission, Submission method, and Confirmation number to ensure compliance with submitting criminal history check to state police within 5 days of person's date of hire. |
09/05/2025
| Implemented |
| 6400.101 | On 7/23/25 at 1:41 PM, in the basement, the door leading to the storage room/cold cellar had a hook-and-eye lock, which can cause an entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Legacy Residential Services had the hook-an-eye lock removed from the basement door.
A picture of the door was taken and will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.113(a) | Individual #1's fire safety training, completed on 12/26/24, did not include instruction on site-specific 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. | 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. | The individual completed an updated fire safety training that includes content related to their place of residence: 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 procedures if the individuals smoke at home. |
09/01/2025
| Implemented |
| 6400.141(c)(6) | Individual #1's date-of-admission is 12/26/24. Individual #1 had a tuberculin skin testing by Mantoux method with negative results on 6/16/25. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | House Manager has been trained on 6400.141(c)(6) requirements. |
09/05/2025
| Implemented |
| 6400.151(a) | Direct Service Provider #1, with a date-of-hire on 5/7/25, did not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The HR Recruiter will review the Employee Tracking sheet each month. The HR Recruiter will check all physical exams and TB tests that are about to expire within the month and notify employees accordingly. The HR Recruiter will also update the employee tracking sheet once the exams are completed and new expiration dates are recorded. |
09/05/2025
| Implemented |
| 6400.151(c)(2) | Direct Service Provider #1, with a date-of-hire on 5/7/25, did not have a tuberculin skin testing. | 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. | The HR Recruiter will review the Employee Tracking sheet each month. The HR Recruiter will check all physical exams and TB tests that are about to expire within the month and notify employees accordingly. The HR Recruiter will also update the employee tracking sheet once the exams are completed and new expiration dates are recorded. |
09/05/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, dated 2/24/25, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | A lifetime medical history was developed for the individual.
Individual #1's developed lifetime medical history will be sent to the Department. |
09/08/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, dated 2/24/25, did not include an applicable psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | In the future, the Program Specialist will submit an assessment cover page to the individual¿s Support Coordinator and treatment team, which includes the following:
o Lifetime Medical History
o Yearly Doctor Appointments
o Psychological Evaluation
o Current List of Medications
A copy of the Assessment Cover Page Checklist will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.62(b) | On 7/23/25 at 1:39 PM, a 48-fluid ounce (1.416L) bottle of Briggs & Stratton Premium 4 -cycle Small Engine Oil was on a shelf in the unlocked storage room/cold cellar of the basement. According to individual #1's Restrictive Procedure Plan, dated 1/16/25, all poisons must always be locked. | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment. | The bottle of Briggs & Stratton Premium 4-cycle Small Engine Oil was removed from the cold cellar in the basement.
A picture of the area where the oil was removed will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.51(b)(5) | Temporary Direct Service Provider #2's date-of-hire is 4/7/25. Their orientation training did not include course completion of job-related knowledge and skills, regarding individual-specific reviews of behavior support plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | All temporary staff used within the past 12 months were audited for orientation compliance. Staff missing orientation in job-related knowledge and skills, regarding individual-specific reviews of behavior support plans were retrained on using a revised curriculum tailored to their specific roles. |
09/05/2025
| Implemented |
| 6400.167(a)(4) | On 7/23/25, the following medications for individual #1 had a prescribed administration time of 12:00 PM but were given more than one hour after this administration time: Insulin Aspart Flexpen 100 Unit/mL Pen was administered at 1:10 PM; Dicyclomine 10mg capsule was administered at 1:09 PM; and Diazepam 10mg tablet was administered at 1:09 PM. | 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. | All staff retrained on medication administration and error prevention. |
09/05/2025
| Implemented |