| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency conducted a self-assessment for this home between 6/9/25 to 7/4/25 but left the following 6400 regulation items incomplete and unaddressed: .162a -.167a3;.167a5 -.169d;.182b-.209; and .191-.210b3. | 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.
| Immediate Action: The Agency will re-conduct an LIS immediately, ensuring all sections are completed in order to align with 6400.15a |
08/24/2025
| Implemented |
| 6400.21(a) | Direct Service Provider #1's date-of-hire is 9/24/24. The agency completed a Pennsylvania criminal history check to the State Police on 8/15/24, revealing a final report of criminal history involvement. However, the agency did not provide documentation of a criminal record review outlining their consideration for hiring Direct Service Provider #1 based on the following factors: the nature of the crime; the facts surrounding the conviction; the time elapsed since the conviction; the evidence of Direct Service Provider #1's rehabilitation; and the nature and requirements of the job. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Actions to be taken immediately: What should we do right now?
1) The provider is currently rerunning all of the Criminal Background records of staff who have a prohibitive offense, including Direct Support Provider #1, on or before 8/15/2025, according to 6400.21(a).
2) Once the staff with prohibitive staff are identified, the HR Specialist will perform a risk analysis by having the providers perform the criminal conviction case process through the providers' attorney. The legal team will determine whether the staff need to be placed on a provisional basis.
3) The provider has updated its Background Checks Policy, revised the Criminal Conviction Case form, and created an action plan since 6/10/2025. (see enclosed)
4) Not Forgotten also updated the Residential Record Management Process on 7/21/2025, emphasizing the importance of maintaining accurate Criminal History records and reducing staff access to these records (risk assessments) to mitigate the risk of lost or missing documentation. (see enclosed)
5) NFHCS no longer employs the former HR Manager, who was responsible for following the Criminal Background Prohibitive Process. A new HR Specialist was hired on June 30, 2025, and received training on the updated policies, forms, and action plan.
1) The LIS section of 6400.21(a) of staff records will be performed quarterly by the HR Specialist and submitted to the Director of Compliance for final review. |
08/15/2025
| Implemented |
| 6400.65 | At 10:27 AM on 7/9/25, the half-bathroom located in the home's game room did not have an operable window or a mechanical exhaust fan for ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Immediate Action: Operations Director met with a contractor on 7.18.25. to initiate work order. Work to install fans/vents will begin the weekend of 7.18.-7.20.25 |
08/15/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's current physical examination, completed on 2/11/25, did not address the individual's physical limitations, as the corresponding field was left blank. | The physical examination shall include: Physical limitations of the individual. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Physical examinations were completed in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ On July 17th 2025. Individual #1 was taken to the doctor on July 17th 2025 and a new physical examination paperwork was provided to the healthcare provider with specific instructions to complete all required sections including physical limitations information. * Please see attached the completed physical examination.
¿ The Nurse Specialist is in the process of reviewing all individuals' physical examination records. These reviews will be completed on or before August 1st 2025. To identify any similar documentation gaps.
¿ The team leaders will schedule identified follow-up appointments by Aug 5th for any individuals requiring updated or complete physical examinations. New physicals will be scheduled immediately for any individual with incomplete paperwork.
¿ Documentation of reviews will be listed on the LIS for all physical examinations. |
08/15/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's current physical examination, completed on 2/11/25, did not address medical information pertinent to diagnosis and treatment in case of an emergency, as the corresponding field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Physical examinations were completed in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ On July 17th 2025. Individual #1 was taken to the doctor and new physical examination paperwork was provided to the healthcare provider. with specific instructions to complete all required sections including the medication pertinent to diagnosis section. * Please see attached the completed physical examination.
¿ The Nurse Specialist is in the process of reviewing all individuals' physical examination records. These reviews will be completed on or before August 1st 2025. To identify any similar documentation gaps.
¿ The team leaders will schedule identified follow-up appointments by Aug 5th for any individuals requiring updated or complete physical examinations. New physicals will be scheduled immediately for any individual with incomplete paperwork.
¿ Documentation of reviews will be listed on the LIS for all physical examinations. |
08/15/2025
| Implemented |
| 6400.141(c)(15) | Individual #1's current physical examination, completed on 2/11/25, did not address special instructions for the individual's diet, as the corresponding field was left blank. | The physical examination shall include:Special instructions for the individual's diet. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Physical examinations were completed in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ On July 17th 2025. Individual #1 was taken to the doctor and new physical examination paperwork was provided to the healthcare provider. with specific instructions to complete all required sections including the Special instructions for Individual diet section. * Please see attached the completed physical examination.
¿ The Nurse Specialist is in the process of reviewing all individuals' physical examination records. These reviews will be completed on or before August 1st 2025. To identify any similar documentation gaps.
¿ The team leaders will schedule identified follow-up appointments by Aug 5th for any individuals requiring updated or complete physical examinations. New physicals will be scheduled immediately for any individual with incomplete paperwork.
¿ Documentation of reviews will be listed on the LIS for all physical examinations. |
08/15/2025
| Implemented |
| 6400.181(c) | Individual #1's current assessment, completed on 7/7/25, was not based on assessment instruments, interviews, progress notes, and observations, as the assessment was just copy and pasted from Individual #1's previous Service Plan, last updated 5/14/25. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Assessments were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ Individual # 1 was reassessed by the Program Specialist for the specific parameters on 07/22/2025 using a combination of:
¿ Updated progress notes from residential staff.
¿ Program Specialist met with Individual # 1 on 07/21/25. While attending another meeting.
¿ Input from residential staff, who work directly Individual # 1.
¿ The revised assessment reflects original narrative and individualized content drawn from valid, current data sources.
¿ All revisions will be uploaded to Monday.com and the finalized document will be sent to the Supports Coordinator on 07/25/2025. |
08/15/2025
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's current assessment, completed on 7/7/25, did not specifically address their current level of performance and progress in the acquisition of functional skills regarding Individual #1's ability to complete daily living skills, such as hygiene, grooming, toileting, folding clothes, completing laundry, telling time, written language skills, computation skills, problem solving skills, etc. The assessment's corresponding field read vaguely: "Individual #1 maintains an adequate level of functional skills." | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Assessments were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ An internal audit of all assessments was completed on 07/19/2025 by the Program Specialist to confirm compliance.
¿ A supplemental functional assessment scoring matrix (covering hygiene and water safety) was completed on 07/22/2025 and will be submitted to the SC on 07/25/2025.
¿ All relevant documentation has been uploaded to Monday.com and filed in Individual # 1 program binder. |
08/15/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained their rights as well as the process to report a rights violation on 6/22/23, and then again on 12/11/24. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Individuals rights were conducted in accordance with Chapter 6400.34 have been relieved of their duties permanently.
¿ The Chief Executive Assistant is now responsible for ensuring the Individuals rights are explained and the individual is informed.
¿ A review of all of the Individual¿s Rights Statements were conducted.
¿ To ensure all Individuals are informed of their rights. A re-training was conducted on July 21st 2025. * Please see enclosed the attachment for Individual #1. To ensure compliance all our Residential Individuals were informed. * One of our individuals is on vacation and another is currently hospitalized. When they return, they will be informed of their rights also. |
07/31/2025
| Implemented |
| 6400.181(f) | Individual #1's assessment, completed on 12/5/24, was sent to plan team members on 6/30/25 for an Individual Service Plan Annual Review Meeting that had been held on 1/7/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the SC Notification were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ The Chief Program Officer contacted individual SCs to confirm receipt and reflect the corrected assessment timeline and history. The staff didn¿t receive any follow-up information from the SC.
¿ The new Program Specialist will complete assessment review which will include retaining copies of notification submitted to the SC. This will be completed on or before July 31st 2025.
¿ A LIS will be composed to reflect compliance with the reviews. |
08/31/2025
| Implemented |