| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.23(a) | Staff #2 who is a household member did not have a criminal history background check completed prior to Individual #1 residing in the home. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home. | On 9/15/2025, a criminal background check was completed for staff #2. |
09/15/2025
| Implemented |
| 6500.121(a) | Individual #1's did not have an annual physical examination. Individual #1 completed a physical examination on 5/22/24 and did not complete another until 7/22/25. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | Individual #1¿s physical examination was completed on 9/12/2025Individual #1¿s physical examination will be conducted prior or by 7/22/2026 to ensure compliance. |
08/27/2025
| Implemented |
| 6500.125(a) | Staff #2 who is a household member did not complete a physical within 12 months prior to Individual #1 moving into the home. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | On 9/18/2025, staff # 2¿s physical was completed. |
09/18/2025
| Implemented |
| 6500.32(r)(1) | Individual #1 does not have an appropriate locking mechanism on the individual's bedroom door. Individual #1 has a pinhole lock on the individual's bedroom door. | An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | As of 9/15/2025, the lock on individual #1¿s door was replaced with a standard turning knob mechanism on the interior, along with an exterior key lock. |
09/15/2025
| Implemented |
| 6500.151(a) | Individual #1 had an initial assessment completed on 5/8/25. The assessment does not fully assess Individual #1's skills and abilities. The assessment includes multiple areas that the skill level is marked as non-applicable or no opportunity for everyday tasks/opportunities that Individual #1 appears to have the functioning and skills to be assessed Individual #1 in these areas.
Individual #1 is not assessed properly in the following areas: the ability to self-medicate. Individual #1's assessment states that Individual #1 requires verbal prompts for self-medicating, the individual is independent in opening a medication container and storing the medication in a safe place, but further states that Staff #1 stores the medication in a secure place. Individual #1's assessment indicates that it is not applicable for Individual #1 to self-administer medication and Staff #1 places medication in a pill organizer and Individual #1 gets the medication from the pill organizer. Individual #1 requires verbal prompts to recognize and distinguish medications. Individual #1's Individual Service Plan indicated that Individual #1 is unable to self-administer medication. Staff #1 administers Individual #1's medication in the home. There is conflicting information in the assessment regarding Individual #1's ability to self-medicate. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home. | By 9/30/2025, individual #1 will be full assessed in the areas of skill and ability. |
09/30/2025
| Implemented |
| 6500.152(c) | Individual #1's Individual Service Plan does not contain revisions based on the most recent assessment. Individual #1 has an assessment completed on 5/8/25. The assessment identifies that Individual #1 has one hour of unsupervised time in the home. Individual #1's ISP indicates that the individual has 8 hours of unsupervised time in the home. The assessment indicates that Individual is able to self-medicate. The ISP states that Individual #1 is unable to self-administer medications. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | By 9/30/2025, individual #1 will be full assessed in the areas of skill and ability. Program Specialist will provide updated assessment to the support coordinator to update the ISP and provide update ISP to us. |
09/30/2025
| Implemented |