| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment of the home, completed by the agency on 4/30/2025, did not address regulations 6400.42-52c6 and 6400.151a-152c. This section was left blank. [Repeated violation: 9/25/2024 et al] | 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.
| LIIs will be completed by Program Specialists between 2/23/26 and 3/23/26. Director and QCC will review by 4/15/26 to ensure completion. Shared calendar invites have been created for both timeframes. |
10/13/2025
| Implemented |
| 6400.21(b) | Direct Service Worker #2, date of hire 7/11/2022, was a resident of the state of Ohio upon their hire at the agency. The agency did not complete an application for a Federal Bureau of Investigation criminal history record check in addition to the Pennsylvania criminal history record check within 5 working days after their date of hire. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Human Resources will complete a New Hire Checklist during onboarding which includes FBI Clearance, if applicable. |
10/13/2025
| Implemented |
| 6400.106 | The furnace in the home was cleaned and inspected by a professional furnace cleaning company on 4/17/2024 and then again on 5/8/2025. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace inspections will be scheduled by the Director of Facilities 10 months from the date of the previous inspection. A reminder has been added to shared calendars including the QCC, Director of Residential, Executive Director and CFO. |
10/13/2025
| Implemented |
| 6400.112(d) | The fire drill conducted on 9/26/2024 had a documented evacuation time of 3 minutes and 42 seconds. The fire drill conducted on 12/23/2024 had a documented evacuation time of 3 minutes and 15 seconds. The home does not have documentation of an extended evacuation time written by a fire safety expert within the last year. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A meeting with a local fire inspector was held on 9/29/25 to begin the process of inspections of all homes, with the first inspection being completed on the same date. Once all homes are completed, information and recommendations will be reviewed. |
09/29/2025
| Implemented |
| 6400.112(e) | For the fire drill records that were reviewed from 9/26/2024 to 8/15/2025, the only drill that was conducted during sleeping hours was held on 9/26/2024. [Repeated violation: 9/25/2024 et al] | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight fire drill was conducted on 10/13/25 at 1:30 am. |
10/13/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's most recent hearing screening was completed on 7/19/2024. Additionally, Individual #1 does not have a record of completing a vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 has a vision appointment scheduled for 10/22/25. |
10/13/2025
| Implemented |
| 6400.141(c)(6) | Individual #1's medical appointment summary from their 2/12/2025 physical examination indicates that a pulmonary TB screening was ordered; however, there is no documentation that the screening was completed. | 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 has a TB screening scheduled for 10/10/25. |
10/13/2025
| Implemented |
| 6400.141(c)(7) | Individual #1's most recent gynecological examination was completed on 6/1/2021. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 has a gynecological exam scheduled for 10/29/25. |
10/13/2025
| Implemented |
| 6400.141(c)(8) | Individual #1's most recent mammogram was completed on 3/19/2024. The agency provided documentation that appointments had been scheduled for 3/22/2025 and 8/29/2025; however, there was no documentation to verify that the appointments were either completed or refused. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual #1 has a mammogram scheduled for 11/4/25. |
10/13/2025
| Implemented |
| 6400.141(c)(10) | Individual #1's medical appointment summary from their 2/12/2025 physical examination did not address specific precautions that must be taken if the individual has a communicable disease, to prevent the spread of the disease to other individuals. | 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. | Physical forms, to include precautions that must be taken if the individual has a communicable disease, will be placed in an appointment form binder at all homes. |
10/13/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's medical appointment summary from their 2/12/2025 physical examination did not assess the individual's health maintenance needs, medication regiment and the need for blood work at recommended intervals. | 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. | Physical forms, to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals, will be placed in an appointment form binder at all homes |
10/13/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's medical appointment summary from their 2/12/2025 physical examination did not address the physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | Physical forms, to include physical limitations of the individual, will be placed in an appointment form binder at all homes. |
10/13/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's medical appointment summary from their 2/12/2025 physical examination did not address medical information pertinent to diagnosis and treatment in case of an emergency. [Repeated violation: 9/25/2024 et al] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical forms, to include medical information pertinent to diagnosis and treatment, will be placed in an appointment form binder at all homes. |
10/13/2025
| Implemented |
| 6400.142(a) | Individual #1 does not have a record of completing a dental examination. [Repeated violation: 9/25/2024 et al] | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 has a dental appointment scheduled for 10/27/25. |
10/13/2025
| Implemented |
| 6400.144 | Individual #1's physical examination, completed on 2/12/2025, indicated that the following lab work was ordered: basic metabolic panel, hemoglobin a1c, microalbumin/creatine with ratio urine, QuantiFERON TB Gold plus, and thyroid-stimulating hormone. The physician noted that these labs were due to be completed by March 2025. The agency did not complete the ordered blood work until 6/11/2025. | 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 has bloodwork scheduled for 10/10/25. |
10/13/2025
| Implemented |
| 6400.171 | On 9/25/2025 at 11:22am, there was a shaker bottle of parmesan cheese, with instructions to refrigerate after opening, sitting open on a shelf in the kitchen. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Parmesan cheese was disposed of on 9/24/25. |
10/13/2025
| Implemented |
| 6400.181(a) | Individual #1's annual assessments were completed on 8/7/2024 and then again on 8/25/2025. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. | A calendar reminder will be placed in the site's calendar one year from the current assessment date and ongoing annually alerting site management that the annual assessment is due. |
10/13/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's annual assessment, completed 8/25/2025 did not address the strengths, needs, and preferences of the individual. [Repeated violation: 9/25/2024 et al] | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #1's assessment has been updated to include functional strengths, needs and preferences of the individual. The updated assessment was sent to members of the team on 10/13/25. |
10/13/2025
| Implemented |
| 6400.181(e)(5) | Individual #1's annual assessment, completed 8/25/2025 did not address the individual's ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Individual #1's assessment has been updated to include the individual's ability to self-administer medication. The updated assessment was sent to members of the team on 10/13/25. |
10/13/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment, completed 8/25/2025 did not address recommendations for specific areas of training, programming, and services. Program Specialist #1 only indicated that Individual #1 does not attend any day services or training and that Individual #1 receives residential habilitation through CHC. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1's assessment has been updated to include recommendations for specific areas of training, programming and services. The updated assessment was sent to members of the team on 10/13/25. |
10/13/2025
| Implemented |
| 6400.214(b) | On 9/25/2025 at 11:16am, the most current copy of Individual #1's support plan that was available on-site in the residential home was last updated 10/8/2024 and covered the 7/1/2024-6/30/2025 plan year. The most current plan available in the Home and Community Services Information System was last updated 4/2/2025 and covered the 7/1/2025-6/30/2026 plan year. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Individual #1's ISP was requested via email from the supports coordinator on 9/23/25. Additionally, access to view Individual #1's plan was requested in the same email. |
10/13/2025
| Implemented |
| 6400.18(i) | Enterprise Incident Management incident #9667213 had a due date of 8/29/2025 for the Incident Final Section. The Incident Final Section was submitted by the agency on 9/4/2025 at 3:40pm. No extensions were filed by the agency.
Enterprise Incident Management incident #9671228 had a due date of 9/4/2025 for the Incident Final Section. The Incident Final Section was submitted by the agency on 9/5/2025 at 5:01pm. No extensions were filed by the agency. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Point person(s) will notify the QCC of incidents upon submission of the initial section. QCC will schedule an administrative review for 10 business days from the date of discovery. QCC will create a calendar invite including point person, Director and Executive Director for 21 days from date of discovery as a reminder that an incident is coming due to close. |
10/13/2025
| Implemented |
| 6400.24 | Enterprise Incident Management incident #9663172, classified as Serious Illness, had a due date for the Incident First Section of 7/24/2025 at 2:44pm. The Incident First Section was submitted by the agency on 7/25/2025 at 11:58am.
Enterprise Incident Management incident #9667213, classified as Serious Illness, had a due date for the Incident First Section of 7/31/2025 at 11:10pm. The Incident First Section was submitted by the agency on 8/1/2025 at 1:41am.
Enterprise Incident Management incident #9671228, classified as Serious Illness, had a due date for the Incident First Section of 8/6/2025 at 5:30pm. The Incident First Section was submitted by the agency on 8/7/2025 at 1:03pm.
According to pages 16 through 25 of the Department's Office of Developmental Program's Incident Management Bulletin Number 00-21-02, all incidents classified as Serious Illness must be reported through the Department's information management system within 24 hours. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | All residential employees will be retrained on the agency Incident Management Policy, including recognition of reportable incidents, definition of time of discovery and timeframes for reporting. |
10/31/2025
| Implemented |
| 6400.46(a) | Program Specialist #1, date of 2/12/2025, did not participate in training to include general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms and notification of the local fire department as soon as possible after a fire is discovered prior to working with individuals. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Program Specialist #1 completed Fire Safety training on 10/1/25. |
10/01/2025
| Implemented |
| 6400.52(c)(5) | Direct Service Worker #2 did not participate in training to include the safe and appropriate use of behavior supports during the 7/1/2024 through 6/30/2025 training year. [Repeated violation: 9/25/2024 et al] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Direct Service Worker #2 will be trained on the safe and appropriate use of behavior supports. |
10/31/2025
| Implemented |
| 6400.52(c)(6) | Direct Service Worker #2 did not participate in training to include the implementation of the individual plan for the individuals they work directly with during the 7/1/2024 through 6/30/2025 training year. [Repeated violation: 9/25/2024 et al] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Direct Service Worker #2 will be trained on implementation of the individual plan for all individuals residing in the home. |
10/31/2025
| Implemented |
| 6400.163(a) | On 9/25/2025 at 10:46am, Individual #1's prescribed Albuterol Sulfate inhalation aerosol was not being stored in the original box with the pharmacy issued medication label. [Repeated violation: 9/25/2024 et al] | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Albuterol Sulfate inhalation aerosol for Individual #1 was reordered from the pharmacy on 9/24/25 to ensure medication is stored in the proper packaging with related label. |
10/13/2025
| Implemented |
| 6400.163(h) | Individual #1 is prescribed Metroprol Suc Tab 200mg ER with instructions to take 1 tablet by mouth daily. On 9/26/2025 at approximately 10:30am, there was another blister pack of Metoprol Tar Tab with a strength of 100mg located in Individual #1's medication lock box. Staff interviews revealed that this medication was increased from 100mg to 200mg and the 100mg was to be discontinued on 7/24/25. The blister pack containing the 100mg dose of Metroprol Tar was not destroyed when the medication was discontinued by the prescriber. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Individual #1's discontinued Metroprol was disposed of by Program Specialist and RHM on 10/2/25. |
10/13/2025
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the name of the medication. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the strength of the medication. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the dosage form of the medication. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the dose of the medication. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the route of administration. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the frequency of administration. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the administration times. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Senna-time tab 8.6mg with instructions to take 2 tablets (17.2mg) by mouth every night at bedtime as needed for constipation. The blister pack for this medication was initialed that the medication was administered on 9/22/2025; however, the September 2025 medication administration record did not include the diagnosis or purpose for the medication. [Repeated violation: 9/25/2024 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Individual #1's Senna-time Tab 8.6 mg was added to the MAR on 9/24/25. |
10/13/2025
| Implemented |
| 6400.166(b) | On 9/25/2025 at 10:27am, it was observed that the staff did not initial Individual #1's September 2025 Medication Administration Record at the time that the following medications were administered: Triad wound dress paste on 9/1/2025 at 8:00AM; Amlodipine Tab 5mg, Aspirin low tab 81mg, Baclofen Tab 10mg, Fiber lax tab 625mg, Furosemide tab 320mg, Lactulose Sol 10gm/15ml, Loratadine 10mg tabs, Mag oxide tab 400mg, Metformin tab 850mg, Metoprol Suc Tab 200mg ER, Multivitamin tab, Omeprazole cap 10mg, Oxybutynin tab 10mg ER, Spironolact tab 25mg, Brimondine Sol 0.2%, Timolol MAL SOL 0.5% OP, and Triad wound dress paste on 9/2/2025 at 8:00am; Amlodipine Tab 5mg, Asprin low tab 81mg, Baclofen Tab 10mg, Fiber lax tab 625mg, Furosemide tab 320mg, Lactulose Sol 10gm/15, Loratadine 10mg tabs, Mag oxide tab 400mg, Metformin tab 850mg, Metoprol Suc Tab 200mg ER, Multivitamin tab, Omeprazole cap 10mg, Oxybutynin tab 10mg ER, Spironolact tab 25mg, Brimondine Sol 0.2%, Timolol MAL SOL 0.5% OP, and Triad wound dress paste on 9/3/2025 at 8:00am; Amlodipine Tab 5mg, Asprin low tab 81mg, Baclofen Tab 10mg, Fiber lax tab 625mg, Furosemide tab 320mg, Lactulose Sol 10gm/15, Loratadine 10mg tabs, Mag oxide tab 400mg, Metformin tab 850mg, Metoprol Suc Tab 200mg ER, Multivitamin tab, Omeprazole cap 10mg, Oxybutynin tab 10mg ER, Spironolact tab 25mg, Brimondine Sol 0.2%, Timolol MAL SOL 0.5% OP, and Triad wound dress paste on 9/23/2025 at 8:00am; and Atorvastatin Tab 40mg, Baclofen Tab 10mg, Fiber lax tab 625mg, Furosemide tab 320mg, Lactulose Sol 10gm/15, Loratadine 10mg tabs, Brimondine Sol 0.2%, Timolol MAL SOL 0.5% OP on 9/24/2025 at 8:00pm. [Repeated violation: 9/25/2024 et al] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff working in the home will be retrained on the 15 Steps of Administration, which includes documentation. |
10/31/2025
| Implemented |
| 6400.167(a)(3) | Individual #1 is prescribed Metroprol Suc Tab 200mg ER with instructions to take 1 tablet by mouth daily. This medication is being administered daily as prescribed. In the individual's medication box, there was an additional blister pack of Metoprol Tar Tab with a strength of 100mg and instructions to take 1 tablet by mouth twice a day for hypertension. The blister pack for the 100mg medication was initialed as being administered by staff on 9/19/2025, 9/21/2025, and 9/25/2025. Staff interviews revealed that on 7/24/2025 this medication was increased from 100mg to 200mg and the 100mg was to be discontinued. Staff failed to administer Individual #1 the correct dose of medication. | Medication errors include the following: Administration of the wrong dose of medication. | Medication errors (wrong dose) was reported to service coordinator on 10/13/25. |
10/13/2025
| Implemented |
| 6400.207(5)(III) | On 9/25/2025 at 11:32am, Individual #1's bed contained full bilateral bed rails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bedrails on 10/3/2024. Although the bedrails are prescribed by the medical practitioner, the most current assessment dated 8/25/2025 does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's support plan, last updated 4/2/2025, does not include periodic relief of the device to allow freedom of movement. [Repeated violation: 9/25/2024 et al] | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | Individual #1's assessment has been updated to include bedrail usage. The updated assessment was sent to members of the team on 10/13/25. An email was sent to Individual #1's supports coordinator on 10/13/25 to request revisions to reflect the order and updated assessment. |
10/13/2025
| Implemented |