| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | Individual #3's bedroom did not contain a mirror at the time of inspection. | In bedrooms, each individual shall have the following: A mirror. | At the time of inspection, a mirror was not visible in Individual #3's bedroom. Prior to the exit interview, the mirror was located within the individual's room. The individual had removed the mirror from the wall and placed it behind clothing in the bedroom. Staff ensured the mirror was returned and appropriately accessible within the room to maintain compliance with 55 Pa. Code §6400.81(k)(6). |
05/08/2026
| Implemented |
| 6400.101 | At the time of inspection, the foot of the stairway leading from the basement to the ground level outdoors was blocked by a box of assorted items, an empty TV box, a TV, and boots, impeding safe egress from the basement in case of fire or other emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| At the time of inspection, items located at the foot of the basement stairway impeded safe egress from the area. The items were immediately removed during the inspection to restore a clear and safe exit pathway in compliance with 55 Pa. Code §6400.101. |
05/05/2026
| Implemented |
| 6400.141(a) | Per the Individual Record, Individual #2's two most recent physical examinations took place on 01/10/2025 and 03/02/2026---more than one year apart. This individual did not receive a physical examination annually as required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 transitioned into the agency's program on 10/06/2025. The individual's annual physical examination appointment was rescheduled due to weather-related circumstances, resulting in the examination occurring on 03/02/2026. The agency will continue to monitor annual medical appointments and reschedule missed appointments as promptly as possible to ensure compliance with 55 Pa. Code §6400.141(a). Please see attachment 20 |
05/08/2026
| Implemented |
| 6400.141(c)(6) | Individual #2 was admitted to the provider's program effective 10/06/2025. There was a pre-admission physical examination present for the individual, which was dated 01/10/2025. This pre-admission physical examination noted that tuberculin testing was last completed for this individual on 01/09/2023 and that the result was negative. There are two areas of non-compliance: 1) the results of this tuberculin testing were issued more than 12 calendar months prior to this individual's admission to the provider's program and 2) the actual results of the tuberculin testing were unavailable for review. The individual received Quantiferon Plus tuberculin testing on 03/01/2026 that returned a negative result; however, this result was not available prior to the date of 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. | At the time of admission, Individual #2's most recent physical examination and tuberculin testing were within the limits permitted by the individual's insurance coverage, which would not authorize repeat annual physical examinations or TB testing prior to the one-year timeframe. A follow-up appointment for updated testing was scheduled; however, the appointment required rescheduling due to weather-related circumstances. The individual subsequently received Quantiferon Plus tuberculin testing on 03/01/2026 with negative results. Additionally, placement within the agency's program was a condition established by the court, and delaying admission until updated testing could be completed may have placed the individual at risk of incarceration. The agency will continue efforts to obtain and maintain all required medical documentation as timely as possible while coordinating with medical providers, insurance limitations, and court-related placement requirements. |
05/08/2026
| Implemented |
| 6400.141(c)(10) | Individual #2's physical examination, dated 03/02/2026, contains a line item asking if the individual is free from communicable disease. The medical professional completing the physical form checked "No," indicating that the individual was not free from communicable disease---based on the content of the physical, it could not be determined whether this was in error. The physical did not include any specific precautions that must be taken if the individual has a communicable disease, to prevent 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. | The physical examination dated 03/02/2026 was completed; however, it appears the medical provider misread or incorrectly marked the communicable disease section of the form. Based on the remaining content of the physical examination and subsequent negative Quantiferon testing, the agency believes the selection was made in error. The agency has contacted the medical provider and requested that the necessary corrections be made to the original physical examination form. The agency is currently awaiting the provider's response and updated documentation. |
05/08/2026
| Implemented |
| 6400.144 | On a dental appointment form dated 05/07/2025, Individual #2's dentist noted that, "PT needs crown [ILLEGIBLE WORD(S)] Front teeth." There was no record that the individual had a follow-up appointment so that a crown could be installed as recommended by the dentist. | 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.
| The dental appointment attended on 05/07/2025 occurred while Individual #2 was receiving services through a previous provider. Individual #2 transitioned into the agency's program on 10/06/2025. Following admission, the agency experienced difficulty scheduling follow-up dental care due to the individual's prior noncompliance with dental services and subsequent insurance-related issues impacting scheduling and authorization. A follow-up dental appointment has since occurred on May 11, 2026. The agency will continue efforts to coordinate and arrange recommended dental follow-up services to ensure ongoing compliance with 55 Pa. Code §6400.144. |
05/11/2026
| Implemented |
| 6400.213(1)(i) | Individual #2's Individual Record did not contain the following required information: the presence or absence of identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | The record for Individual #2 has been updated to include the presences or absences of identity marks as required. Please see the attached updated face sheet. Please see attachment 21 |
06/01/2026
| Implemented |
| 6400.213(1)(i) | Individual #2's Individual Record did not contain the following required information: The language spoken or understood by the individual. | Each individual's record must include the following information: Personal information, including: (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. | The record for Individual #2 has been updated to include the The language spoken or understood by the individual. |
06/01/2026
| Implemented |