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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 9/10/2025 at 10:32AM, the hot water temperature measured 122.3°F at the sink in the full bathroom the first floor of the home. Furthermore, noted in Individual #1's Service Plan, last updated 8/27/2025, is that extreme hot and cold temperatures could trigger a seizure, as Individual #1 is diagnosed with seizure disorder. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | A Request for Maintenance form was made on 9/10/2025 to check water temperatures and adjust hot water tank. On 9/11/25 water temperatures were tested and the hot water tank was turned down with a plan to recheck temperatures. On 9/17/25 the water temperatures were rechecked and found to be too low so the hot water tank was adjusted again. When rechecked again, the water temperatures were found to be acceptable. |
09/17/2025
| Implemented |
| 6400.181(e)(10) | Individual # 1's current assessment, completed 3/16/2025, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | On 9/16/25 KVOU Program Specialist reread, and signed off acknowledging she read, DHS ODP RCG 55 PA Code Chapter 6400 3/15/23 edition pages 1-18, 37-52, 107-128.
On 9/23/2025 KVOU Program Specialist emailed this person's Support Coordinator his current 2025 Lifetime Medical History as well as his 2024 LMH. |
09/23/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 8/27/2025, reads, "[Individual #1] is supervised around heat sources," and added that extreme hot and cold temperatures could trigger a seizure, as Individual #1 is diagnosed with seizure disorder. In contrast, Individual #1's assessment, completed on 3/16/2025, indicated that "Individual #1 understands the dangers of hot surfaces···and will avoid [them]." Individual #1's Service Plan, last updated 8/27/2025, explained that Individual #1 requires 24/ 7 supervision with a 1:1 staffing ratio and that staff are always within earshot. In addition, Individual #1's Service Plan reads, "when [Individual #1] is in [their] bedroom after showering, staff are to remain at close proximity outside the door. Staff should stand in front of [Individual #1] when [they are] going down the stairs and walk behind [Individual #1] when [they are] going up the stairs," and that "when [Individual #1] is in [their] reclining chair, staff must check on [them] every 15 minutes to ensure [Individual #1] is not having a seizure." However, Individual #1's assessment, completed on 3/16/2025, indicated vaguely that staff assist Individual #1 throughout the day within the home and that Individual #1 has a sleep staff, defining sleeping hours from 11:00PM to 7:00AM. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 9/16/25 KVOU Program Specialist reread, and signed off acknowledging this, DHS ODP RCG 55 PA Code Chapter 6400 3/15/23 edition pages 1-18, 37-52, 107-128.
On 9/25/25 KVOU Program Specialist updated his assessment information, typed out the changes needed in his ISP and emailed the changes and clarification to this person's Support Coordinator. |
09/25/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment did not include a completion date; therefore, compliance was unable to be measured. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A procedure will be written that the Executive Director will disburse the current Licensing Inspection Instrument Scoresheet Facility Chapter 6400 Community Homes annually on or before January 19th which is 6 months prior to the expiration date of the Certificate of Compliance. The inspection instruments will be due from the following positions on or before March 31st: Residential Program Supervisor and Program Specialist. The inspection instrument will be due from the Administrative Officer who completes the Staffing section including the training requirements in Regulation 46 and Staff Health including physicals on or before April 15th which is approximately 3 months prior to the expiration of the Certificate of Compliance. The Executive Director will ensure the deadlines are met and then compile the data into one scoresheet for each residential home on or before April 18th which is 3 months prior to the expiration date. |
10/04/2015
| Implemented |
| 6400.141(c)(15) | Physical examination, dated 7/7/2015, for Individual #1 did not include special instructions for diet. | The physical examination shall include:Special instructions for the individual's diet. | The Annual Physical Exam form will be revised to include a separate line item for special diet instructions and a procedure will be written to include that all sections are to be completed or responded to by the physician prior to leaving the medical provider's office. The Residential Program Supervisor responsible for the Individual Health section of the regulations will ensure each section is completed or responded to by the physician before processing including filing and submission to appropriate team members.[Residential Program Superviors will immediately review all current physicals for all individuals to ensure completion for all required information and will address as needed. (AS 10/7/15)] |
10/04/2015
| Implemented |
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