| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Poisonous materials shall be stored in their original labeled containers. A light purple-colored liquid hand soap was found in an Equate brand hand soap bottle that was labeled "clear hand soap, comparable to Softsoap Aquarium series" on the bathroom sink vanity. In a cabinet under the bathroom sink was a large refill-size bottle of Softsoap brand antibacterial hand soap in white tea and berry scent. The color, consistency and scent of the product in both bottles was the same. The Softsoap brand product was being used to refill the Equate brand hand soap bottle. | Poisonous materials shall be stored in their original, labeled containers. | LHSS operations director removed Equate brand from the home on 04/03/26. |
04/17/2026
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. Individual #1's bedroom had a foul odor and a fish tank was observed on individual's dresser. The tank contained a couple of inches of cloudy water with at least two dead fish in a state of advanced decomposition laying on the bottom left corner of the tank. Additionally, there were three additional fish in individual containers to the left of the tank; those fish were still alive but were cloudy, dirty water. | Clean and sanitary conditions shall be maintained in the home. | This has been an ongoing issue for Individual #1 for several years. Various (unsuccessful) supports and services having been attempted and/or offered; however, individual #1 has directly stated that he is in uninterested in maintaining sanitary conditions in his room and will frequently not allow LHSS staff to clean his room with or without his assistance. A team meeting (LHSS, SCO, Behavior Supports, CPS provider) was held on 04/09/26 to discuss additional approaches to ensure sanitary conditions in Individual #1's room without violating his rights.
((Fish tank was removed -CH 6/12/26)) |
04/09/2026
| Implemented |
| 6400.67(a) | Floors, walls and other surfaces shall be in good repair. The folding closet doors on the closet to the right of the front doors had been pulled off of the tracks and were leaning against the closet. The folding doors on the hall closet were slightly off the track and difficult to open as the movement of the doors was impeded by a large tear in the carpet on the left front of the closet. The folding doors on the individual's bedroom closet were partially off the track; and were unable to be closed because they were very dented from being kicked or punched. | Floors, walls, ceilings and other surfaces shall be in good repair. | The apartment is a rental. LHSS operations director alerted the property/landlord's maintenance department on 04/17/26 to request the tear in the carpet and the closet doors be repaired as soon as possible. |
04/17/2026
| Implemented |
| 6400.112(c) | A written fire drill record shall be kept with documentation including the exit route used. The fire drill record for the drill conducted on 9/26/2025 did not document the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drills and related documentation are the responsibility of LHSS program managers. Program managers were retrained on PA Chapters 6100 and 6400 on 04/22/26 to ensure ongoing compliance. |
05/01/2026
| Implemented |
| 6400.112(h) | The fire drill records for all drills conducted during the review period, April 2025 through March 2026, did not document whether all individuals evacuated to the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Fire drills and related documentation are the responsibility of LHSS program managers. Program managers were retrained on PA Chapters 6100 and 6400 on 04/22/26 to ensure ongoing compliance. |
05/01/2026
| Implemented |