| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The notification letter to the local fire department dated 12/2/25 does not include all of the required information. Two individuals reside in the home. Individual #8 is documented to require "verbal cues" as they have "Slept through overnight fire drills." The notification letter does not include 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.
| The agency's understanding of the notification requirements to the local fire department differed from the clarification provided during the annual inspection and exit interview. Upon clarification, an updated notification letter reflecting the current individuals residing in the home was submitted to the local fire department to ensure compliance with 55 Pa. Code §6400.104 on 05/08/2026. Please see attachment #1. |
05/08/2026
| Implemented |
| 6400.141(c)(4) | Individual #7 had an annual vision exam on 2/17/25 with a notation of the next scheduled appointment to occur in 2/2026. There was no documentation to illustrate that the appointment had been completed as required. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | At the time of the inspection we were unable to retrieve the necessary documentation to support attendance at this appointment. An appointment was scheduled and attended on 2/18/2026 |
02/18/2026
| Implemented |
| 6400.141(c)(10) | The physical dated 2/5/26 for Individual #7 did not include information to determine if specific precautions must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The statement that Individual #7 was free from communicable diseases was blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | We have requested from Individual #7 Medical Provider an update on our physical form. That provider is unavailable and the current providers at the practice are not wiling to make changes. |
04/30/2026
| Implemented |
| 6400.141(c)(11) | The physical for Individual #7 dated 2/5/26 did not include a review of their medication regimen. The section assigned for the information noted that documentation was attached. There was no attachment. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | We have requested from Individual #7's Medical Provider an update on our physical form. That provider is unavailable and the current providers at the practice are not wiling to make changes. |
04/30/2026
| Implemented |
| 6400.151(c)(2) | The physical dated 12/16/25 for Staff #6 did not include documentation that the Tuberculin skin testing by Mantoux that was given on 12/16/25 was read. The date read and reaction section on the physical was blank with no indication if the test was read as positive or negative. | 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. | Staff #6 did have his Mantoux read. Please see attachment 18. |
04/30/2026
| Implemented |
| 6400.151(c)(3) | The physical dated 12/16/25 for Staff #6, the Quality Management Director who completes duties of a Program Specialist, did not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The section for the information was blank and not checked. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | We have requested that the provider that completed the initial physical make the necessary updates to the form. At this time they have declined and informed us via nursing staff that a new appointment will need to be made and a new physical completed. It scheduled for May 19, 2026 |
05/19/2026
| Implemented |
| 6400.165(c) | Individual #7 is prescribed Metamucil to be administered "Mix 2 teaspoons 8 ounces of water and take by mouth daily." The bottle in use at the time of inspection was filled on 2/20/26 and contained 72 teaspoons for a 36 day supply. The bottle in use was nearly full. Subtracting out refusals the bottle should have been about a ¼ full at the time of inspection. The medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | A staff meeting was held on April 27, 2026, to review staff expectations regarding medication administration practices, medication compliance, documentation accuracy, and follow-up responsibilities to ensure medications are administered as prescribed in accordance with 55 Pa. Code §6400.165(c). |
05/18/2026
| Implemented |
| 6400.169(a) | Documentation that Staff #7 completed their annual medication renewal requirements for the 7/24 to 7/25 training year was submitted. As of 4/7/26 there was no documentation that the six-month medication administration record review or observation of a medication pass were completed to ensure compliance with the annual course renewal requirements for the 7/25 to 7/26 training year. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Documentation verifying that Staff #7 completed the required medication practicum on 01/15/2026 is available; however, the documentation was not readily available for review at the time of the annual inspection. The agency has since reviewed its record organization procedures to ensure required medication administration renewal documentation, including medication pass observations and medication administration record reviews, are maintained and readily accessible for inspection to ensure compliance with 55 Pa. Code §6400.169(a). |
06/01/2026
| Implemented |
| 6400.181(f) | There was no documentation to support that the assessments for Individual #7 dated 7/10/25 or 3/17/26 were provided to the individual plan team members at least 30 calendar days prior to the individual plan meetings. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The agency is unable to provide documentation demonstrating that the Individual Assessment dated 07/10/2026 or 03/17/2026 was distributed to the Individual Plan team at least 30 calendar days prior to the Individual Plan meeting. As the information is now outdated, the agency cannot retroactively complete this requirement. Moving forward, the agency will ensure assessments are distributed within the required regulatory timeframe and documentation of distribution is maintained within the individual record to ensure compliance with 55 Pa. Code §6400.181(f). |
06/01/2026
| Implemented |
| 6400.183(c) | A signature sheet or list of persons who participated in the Individual plan meeting was requested and not produced. The list of persons who participated in the individual plan meeting shall be kept as required. | The list of persons who participated in the individual plan meeting shall be kept. | Historically, the agency has relied on the Supports Coordination Organization (SCO) to provide copies of ISP meeting sign-in sheets and participant documentation following Individual Plan meetings. Due to staffing and procedural changes within the SCO, the agency was unable to obtain or reproduce the sign-in sheet. Moving forward, the agency will maintain its own participant attendance documentation for all Individual Plan meetings to ensure compliance with 55 Pa. Code §6400.183(c). |
04/30/2026
| Implemented |
| 6400.213(1)(i) | The record for Individual #7 did not include the Individual's religious affiliations. | Each individual's record must include the following information: Personal information, including: (iv) The religious affiliation. | The record for Individual #7 has been updated to include religious affiliations. |
05/08/2026
| Implemented |