| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water temperature was measured at 123.3° F in the bathroom tub/shower. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The apartment is a rental and LHSS is does not have appropriate access to adjust the water temperature. LHSS operations director alerted the property/landlord's maintenance department on 04/02/26 to request the water temperature be lowered and will follow-up as necessary to ensure this has been resolved. |
04/20/2026
| Implemented |
| 6400.46(b) | Staff #1, a direct support staff hired on 9/18/2023, did not complete training in fire safety during training year 1/01/2025 through 12/31/2025. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff #1 completed training in fire safety on 02/15/26. |
02/15/2026
| Implemented |
| 6400.52(a)(1) | Staff #1, a direct support staff hired on 9/18/2023, did not complete 24 hours of training during training year 1/01/2025 through 12/31/2025. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| Implemented |
| 6400.52(c)(1) | Staff #1, a direct support staff hired on 9/18/2023, did not complete the following annual trainings during training year 1/01/2025 through 12/31/2025: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| Implemented |
| 6400.52(c)(2) | Staff #1, a direct support staff hired on 9/18/2023, did not complete the following annual trainings during training year 1/01/2025 through 12/31/2025: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| Implemented |
| 6400.52(c)(3) | Staff #1, a direct support staff hired on 9/18/2023, did not complete the following annual trainings during training year 1/01/2025 through 12/31/2025: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| Implemented |
| 6400.52(c)(4) | Staff #1, a direct support staff hired on 9/18/2023, did not complete the following annual trainings during training year 1/01/2025 through 12/31/2025: Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| Implemented |
| 6400.52(c)(5) | Staff #1, a direct support staff hired on 9/18/2023, did not complete the following annual trainings during training year 1/01/2025 through 12/31/2025: The safe and appropriate use of behavior supports if the person works directly with an individual. | 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. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| Implemented |
| 6400.52(c)(6) | Staff #1, a direct support staff hired on 9/18/2023, did not complete the following annual trainings during training year 1/01/2025 through 12/31/2025: Implementation of the individual plan if the person works directly with an individual. | 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. | Staff #1 completed all training which had not been completed during the 2025 training year by 02/17/26. |
02/17/2026
| 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 |
| 6400.181(f) | Assessments must be sent to the supports coordinator and individual plan team members at least thirty days prior to the annual meeting. The annual meeting for Individual #1 was held on 11/03/2025 and the assessment was not sent until 3/25/2026. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | LHSS has hired a new program specialist who will be starting on 04/27/26. They will ensure that assessments for each individual are set to the individual plan team members at least 30 calendar days prior to an individual plan meeting. |
04/27/2026
| Implemented |