| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. Individual #1 has a closet in their bedroom that the individual blocks access with their bed. The individual told the licensing inspector that they like to keep their cereal in there because they "don't like people getting into their things." The individual showed the licensing representative a partially obstructed view into the closet. No cereal boxes were observed; only partial bottles of hot sauce were seen on the closet shelf. But it appeared that the floor of the closet was covered with empty soda and drink bottles and other food packaging that could attract insects and other pests. | Clean and sanitary conditions shall be maintained in the home. | Individual #1 is on probation from his recent incarceration. As a result, he is very protective over his things and will not often allow LHSS staff to assist him with maintaining sanitary conditions. Individual #1 recently began receiving behavior support and this issue will be addressed as part of his Functional Behavioral Analysis and Behavior Support Plan. |
04/03/2026
| Implemented |
| 6400.72(b) | Screens, windows and doors shall be in good repair. The latching mechanism on the bedroom door/door lock on Individual #1's bedroom door was not in good repair and the door would not stay closed. | Screens, windows and doors shall be in good repair. | LHSS operations manager replaced the door lock on 04/02/26. |
04/02/2026
| Implemented |
| 6400.141(c)(6) | Individual #1 was admitted on 12/01/2025 and did not have tuberculin skin testing with negative results or, if positive, a chest x-ray with results noted, within twelve months prior to admission. | 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. | Individual #1 is scheduled to have tuberculin skin testing by Mantoux method performed on 04/27/26 with results to be read on 04/29/26. |
05/01/2026
| Implemented |
| 6400.144 | Health services that are planned or prescribed shall be provided. Individual #1 was prescribed Albuterol Nebulizer 0.083%, 3 mil/2.5 mg. to be administered via a nebulizer, every six hours as needed for wheezing. The medication was dispensed on 3/12/2026 but could not be administered because the home had not obtained a nebulizer to deliver the medication. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual #1's pharmacy does not stock nebulizers. LHSS program manager contacted Individual #1's PCP on 04/10 to have a script sent to another pharmacy. Program manager followed-up on 04/23/26 and was informed that the script was expected to be sent to the other pharmacy later that day. Program manager will continue to follow-up to resolve this issue.
((nebulizer received -CH 6/12/2026)) |
04/22/2026
| Implemented |
| 6400.163(h) | Prescription medications that are discontinued or expired shall be disposed of in a safe manner. Earwax removal drops, dispensed on 3/12/2026, were to be used for a five-day course of treatment which would have concluded on or about 3/17/2025. At the time of inspection on 4/01/2026, the medication was still stored with Individual #1's current medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This medication was removed from the home and destroyed in a safe manner on 04/02/26 by LHSS program manager. |
04/22/2026
| Implemented |
| 6400.165(f) | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs (SEEN plan) of the individual related to the symptoms of the psychiatric illness, Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and there was not a SEEN plan in the individual's record. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Individual #1 has begun receiving behavior supports, so an FBA-BSP is in-process.
Additionally, LHSS has hired a new program specialist who will be starting on 04/27/26. They will ensure that any individuals served by LHSS who take psychotropic medications but do not have a BSP have a written protocol to address their social, emotional, and environmental needs. |
04/27/2026
| Implemented |
| Article X.1007 | Lehigh Human Support Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15).¿ A FBI background check was not completed for Staff #1, a direct support staff (DSP) hired on 9/23/2025, who stated on their employment application that they were not a resident of Pennsylvania for two years prior to hire. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Staff #1 has lived in Pennsylvania since at least 2020, so an FBI background check is not required. On the employment application used by Staff #1, the question related to Pennsylvania residency was improperly worded (contradictory language) resulting in Staff #1's response being unclear. |
01/01/2026
| Implemented |