| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.83(a) | The emergency evacuation procedures dated April 2025 does not clearly define what the individuals' responsibilities are during an emergency evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the Emergency Evacuation Procedure policy following the licensing citation indicating that the existing policy did not clearly define the responsibilities of individuals during an emergency evacuation.
To correct this deficiency, the Emergency Evacuation Procedure (Policy DAY-03) was revised in March 2026 to include a clearly defined section outlining individual responsibilities during an emergency evacuation, including following staff direction, proceeding to designated exit routes, reporting to the assigned emergency assembly area, and remaining with staff until further instruction is provided. The revised policy also clarifies the chain of command for evacuation leadership, including the roles of the Program Specialist, Program Manager, Program Coordinator, and trained Direct Support Professionals when necessary.
The revised procedure now also clearly identifies designated on-site emergency assembly locations for each Adult Day Services location, including Somerset and Summerhill, and maintains documentation of evacuation routes and diagrams.
All Adult Day Services staff will be trained on the revised emergency evacuation procedure and their responsibilities during emergencies. Individuals receiving services will continue to participate in routine evacuation drills and receive instruction appropriate to their abilities regarding emergency evacuation procedures.
C-NTA will ensure ongoing compliance by reviewing emergency evacuation procedures annually and continuing to conduct monthly evacuation drills to reinforce procedures with staff and individuals.
Date of Correction: March 2026
Person Responsible for Correction: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.91(a) | Individual #1's date of admission was 8/15/25 and they did not have their fire safety training until 9/19/25. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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, and smoking safety procedures if individuals smoke at the facility. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.91(a), which identified that Individual #1, admitted on 8/15/2025, did not receive documented fire safety instruction until 9/19/2025. This occurred due to the absence of a clearly defined internal procedure ensuring that individual fire safety instruction was completed and documented on the individual's first day of attendance in the Adult Day Services Program.
To correct this deficiency, C-NTA developed and implemented a new policy titled DAY-12: Individual Fire Safety Instruction and Annual Reinstruction Procedure. This policy establishes that "initial admission" is defined as the individual's first day of billable services and requires that individuals be instructed at that time in general fire safety, evacuation procedures, and their responsibilities during an emergency in their primary language or preferred mode of communication. The policy also requires that individuals be reinstructed annually thereafter.
The policy identifies the Program Specialist as primarily responsible for ensuring fire safety instruction occurs and is documented on the individual's first day of billable services. In the absence of the Program Specialist, the Program Manager or Program Coordinator will ensure the training occurs. If leadership staff are not present, a trained Direct Support Professional (DSP) may provide the instruction to ensure compliance with the regulation.
Policy DAY-12 will be distributed and relaunched to all Adult Day Services staff to ensure staff understand the requirement and their responsibilities for providing and documenting individual fire safety instruction upon admission and annually thereafter.
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.111(c)(1) | Individual #1's 2/26/26 annual physical says that the medical history is attached, however this was not attached to the physical. | The physical examination shall include: A review of previous medical history. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.111(c)(1), which identified that Individual #1's annual physical examination dated 2/26/2026 indicated that a medical history was attached; however, the previous medical history was not included with the documentation in the individual's record. This occurred due to an oversight during the review process conducted by the Medical Specialist when verifying that all required components of the physical examination were received.
To correct this deficiency, C-NTA has implemented the following corrective actions:
· The Adult Day Services admission packet has been updated to clearly state that a complete lifetime medical history must accompany the physical examination completed by the individual's physician.
· The C-NTA physical examination form has been updated to include instructions for physicians completing the form indicating that a review of previous medical history must be documented or attached for the physical examination to be considered complete.
· The New Enrollment Checklist used by the Medical Specialist has been updated to include verification that documentation of a review of previous medical history is included with the physical examination prior to the document being filed in the individual's record.
· The Medical Specialist has been retrained on the regulatory requirement under PA Code 55 §2380.111(c)(1) to ensure that physical examinations include documentation of the review of previous medical history prior to acceptance into the individual's record.
These updates ensure that all future physical examinations received include the required documentation of medical history in accordance with regulatory requirements.
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.111(c)(7) | Individual #2's initial physical dated 10/1/25 does not address health maintenance needs. This section of the physical is blank. | 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. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.111(c)(2), which requires that a physical examination include an assessment of the individual's health maintenance needs, medication regimen, and recommendations for bloodwork when applicable. During review of the individual's physical examination documentation, this section of the form was not fully completed by the physician's office, and the area on the physical examination form was left blank.
To correct this deficiency, C-NTA has implemented the following corrective actions:
· The Adult Day Services Physical Examination Form has been updated to include clearer instructions to physicians indicating that the section addressing health maintenance needs, medication regimen, and recommended bloodwork must contain a written description or the word "None" if no needs or recommendations exist, and may not be left blank or marked "N/A."
· The Adult Day Services admission packet provided to individuals and guardians has been updated to include guidance explaining that the physician must complete all sections of the physical examination form in order for the document to be accepted.
· A completed sample physical examination form has been developed and will be provided to individuals and their physician's office to serve as a reference for how the form must be completed.
· The Medical Specialist has been retrained on reviewing clinical documentation to ensure that required sections of the physical examination are fully completed before the document is accepted into the individual's record.
· If required information is missing, the physician's office will be contacted and asked to correct the physical examination documentation prior to the individual beginning services.
These actions ensure that physical examinations maintained in individual records include all required elements in accordance with PA Code 55 §2380.111(c)(2).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.115(1) | Individual #1's Emergency Medical Plan does not identify the hospital or source of health care that will be used in an emergency. | The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.115(1), which identified that Individual #1's Emergency Medical Plan did not specify the hospital or source of health care that would be used in the event of an emergency, nor did it identify transportation other than 911 that may be used if emergency services are not required.
To correct this deficiency, C-NTA has implemented the following corrective actions:
· The Emergency Medical Plan and Consent forms included in the Adult Day Services admission packet have been updated to include designated fields identifying the individual's preferred hospital or source of health care and transportation options other than 911 that may be used in an emergency.
· The Individual Emergency Information Sheet maintained within each individual's program record has been updated to include fields documenting the hospital or source of health care and transportation method other than 911.
· The Emergency Medical Plan for Individual #1 has been reviewed and updated to include the required hospital and transportation information.
· The Program Specialist and Medical Specialist have been retrained on reviewing emergency medical documentation to ensure that required information is completed prior to filing the document in the individual's record.
These updates ensure that each individual's Emergency Medical Plan clearly identifies the required emergency medical resources and transportation options in accordance with PA Code 55 §2380.115(1).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.115(2) | Individual #1's Emergency Medical Plan does not identify the method of transportation to be used. | The facility shall have a written emergency medical plan listing the following: The method of transportation to be used. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.115(2), which identified that Individual #1's Emergency Medical Plan did not identify transportation other than 911 that may be used in the event of an emergency.
To correct this deficiency, C-NTA has implemented the following corrective actions:
· The Emergency Medical Plan and Consent forms included in the Adult Day Services admission packet have been updated to include designated fields identifying transportation options other than 911 that may be used in the event of a medical emergency.
· The Individual Emergency Information Sheet maintained within each individual's program record has been updated to include documentation of the transportation method other than 911 that may be used in an emergency.
· The Emergency Medical Plan for Individual #1 has been reviewed and updated to include transportation options other than 911.
· The Program Specialist and Medical Specialist have been retrained on reviewing emergency medical documentation to ensure that required information is completed prior to filing the document in the individual's record.
These updates ensure that Emergency Medical Plans maintained for individuals receiving services identify transportation options other than 911 in accordance with PA Code 55 §2380.115(2).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.173(1)(iv) | Individual #2's emergency information sheet does not identify a religion. This was left blank. | Each individual's record must include the following information: Personal information including Religious affiliation. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation indicating that Individual #2's Emergency Information Sheet contained a blank field for religion. The Emergency Information Sheet is required to contain complete information for each field, and entries may not be left blank.
To correct this deficiency, C-NTA has implemented the following corrective actions:
· The Emergency Information Sheet for Individual #2 has been reviewed and updated to include the individual's religion, or the word "None" if the individual does not identify a religious preference.
· The Emergency Information Sheet used for all individuals has been updated to include instructions indicating that all fields must contain a response and may not be left blank or marked "N/A." If the information does not apply, staff must enter "None."
· The Program Specialist and Medical Specialist have been retrained on reviewing Emergency Information Sheets to ensure all required fields are completed prior to filing the document in the individual's record.
These actions ensure that Emergency Information Sheets maintained in individual records contain complete information as required.
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.181(a) | -Individual #1's initial assessment on 9/17/25 did not identify 181e10 (Lifetime medical history), 181e11 (Phycological), 181e13i (current level of health), 181e13iv (current level of socialization), 181e13v (current level of recreation), and 181e13vi (community-integration).
- Individual #2's assessment dated 11/21/25 does not address all required areas outlined in the regulations specifically sections 181e10 (lifetime medical history), 181e11 (psychological), 181e13i (health), 181e13iv (socialization), 181e13v (recreation), and 181e13vi (community-integration). | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.181(a), which identified that the initial assessments for Individual #1 dated 9/17/2025 and Individual #2 dated 11/21/2025 did not address all required regulatory areas. Specifically, the assessments did not include documentation related to lifetime medical history (§2380.181(e)(10)), psychological information (§2380.181(e)(11)), and required areas describing the individual's current level of functioning including health, socialization, recreation, and community integration (§2380.181(e)(13)).
Although the assessments were completed within the required timeframe, the missing regulatory components resulted in the assessments being considered incomplete.
To correct this deficiency, C-NTA implemented the following corrective actions:
· The assessments for Individual #1 and Individual #2 were reviewed and updated to include all required regulatory components including lifetime medical history, psychological information, and documentation describing the individual's current level of health, socialization, recreation, and community integration.
· The Adult Day Services assessment template has been updated to include clearly labeled sections corresponding to the regulatory requirements outlined in PA Code 55 §2380.181(e) to ensure all required areas are addressed during completion of the assessment.
· The Program Specialist and Program Manager have been retrained on the regulatory requirements for completing initial and annual assessments to ensure all required components are addressed.
· A secondary review process has been implemented requiring the Program Manager to review all completed assessments prior to finalization to ensure regulatory compliance.
These corrective actions ensure that assessments completed for individuals receiving services include all required regulatory elements in accordance with PA Code 55 §2380.181(a).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Service |
03/17/2026
| Implemented |
| 2380.21(u) | -Individual #1 was not informed of rights 21r, 21s, and 21t on their 8/14/25 Individual Rights form.
- Individual #2 was only informed of rights 21(o), 21(p), and 21q prior to admission on 9/12/25. | The facility 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 facility and annually thereafter. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.21(u), which identified that Individual #1 was not informed of rights 21(r), 21(s), and 21(t) on the Individual Rights form dated 8/14/2025 and that Individual #2 was only informed of rights 21(o), 21(p), and 21(q) prior to admission on 9/12/2025. The citation occurred because the Individual Rights documentation previously used by the organization was developed for residential services under PA Code 6400 and did not include the complete set of rights applicable to Adult Day Services under PA Code 55 Chapter 2380.
To correct this deficiency, C-NTA implemented the following corrective actions:
· An Adult Day Services Individual Rights Addendum has been developed to accompany the existing Individual Rights policy to ensure that all individual rights outlined under PA Code 55 Chapter 2380 are included and explained to individuals receiving services in the Adult Day Program.
· The Individual Rights documentation for Individual #1 and Individual #2 was reviewed and updated, and the individuals were informed of all required rights under PA Code 55 Chapter 2380. Documentation of this review has been completed and maintained in their records.
· The Adult Day Services admission packet has been updated to include the revised Individual Rights documentation, the Adult Day Services Individual Rights Addendum, and updated consent forms acknowledging that individual rights have been reviewed and explained upon admission.
· The Program Specialist and Program Manager have been retrained on the regulatory requirements under PA Code 55 §2380.21 regarding informing individuals of their rights, explaining the process to report a rights violation, and ensuring documentation and consent forms are completed during admission.
These corrective actions ensure that individuals receiving services in the Adult Day Program are informed of all rights required under PA Code 55 Chapter 2380 upon admission and that documentation and consent acknowledging the review of rights is completed.
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.173(1)(i) | Individual #2's emergency information sheet did not identify the date of admission. This was left blank. | The name, sex, admission date, birthdate and Social Security number. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.173(1)(i), which identified that Individual #2's Emergency Information Sheet did not include the individual's date of admission and the field was left blank. The regulation requires that the Emergency Information Sheet include the individual's name, sex, admission date, birthdate, and Social Security number.
To correct this deficiency, C-NTA implemented the following corrective actions:
· The Emergency Information Sheet for Individual #2 has been reviewed and updated to include the individual's date of admission.
· The Emergency Information Sheet form has been updated to include instructions stating that all required fields must be completed and may not be left blank. If information is unavailable at the time of completion, the document will not be finalized until the required information is obtained.
· The Program Specialist and Program Manager have been retrained on reviewing Emergency Information Sheets to ensure all required fields, including admission date, are completed prior to filing the document in the individual's record.
· The Medical Specialist has been retrained on requirements for establishing clinical charts to ensure that all required demographic information is documented on the Emergency Information Sheet when the individual record is created.
· A secondary review process has been implemented, requiring the Program Manager to audit Emergency Information Sheets to ensure all required demographic information is completed and compliant with regulatory requirements.
These corrective actions ensure Emergency Information Sheets maintained in individual records contain all required information in accordance with PA Code 55 §2380.173(1)(i).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.181(f) | Individual #1's initial assessment on 9/17/25 did not identify that the assessment was provided to the individual plan team members. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.181(f), which identified that Individual #1's initial assessment dated 9/17/2025 did not include documentation verifying that the assessment was provided to members of the individual plan team at least 30 calendar days prior to the individual plan meeting.
At the time of review, the assessment cover sheet contained a signature from the individual's guardian acknowledging receipt of the assessment. However, the documentation maintained in the individual's record did not clearly demonstrate when the assessment had been provided to the individual plan team, as required by regulation. Because the timing of distribution was not documented, the assessment was determined to be out of compliance with the documentation requirement.
To correct this deficiency, C-NTA implemented the following corrective actions:
· An Assessment Distribution Attestation form has been developed to document that the Program Specialist has provided the assessment to members of the individual plan team at least 30 calendar days prior to the individual plan meeting.
· The Adult Day Services assessment process has been updated to require documentation verifying that assessments are distributed to individual plan team members within the required timeframe.
· Distribution of the assessment may now be documented through either a signed attestation form maintained in the individual's record or electronic verification such as email correspondence demonstrating that the assessment was provided to plan team members.
· The Program Specialist and Program Manager have been retrained on the regulatory requirements under PA Code 55 §2380.181(f) regarding the distribution of assessments to individual plan team members.
· A secondary review process has been implemented, requiring the Program Manager to verify that documentation confirming distribution of the assessment is present in the individual's record.
-Acknowledgement of receipt alone will no longer be used as verification of distribution timing.
These corrective actions ensure that documentation verifying the distribution of assessments to individual plan team members within the required timeframe is maintained in the individual's record in accordance with PA Code 55 §2380.181(f).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |
| 2380.183(a)(3) | There is no evidence that a direct support professional participated in the development of the ISP prior to or during the annual ISP meeting on 2/12/26 for individual #2. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | Croyle-Nielsen Therapeutic Associates (C-NTA) reviewed the licensing citation related to PA Code 55 §2380.183(a)(3), which identified that there was no documentation verifying that a Direct Support Professional (DSP) participated in the development of the Individual Support Plan (ISP) prior to or during the annual ISP meeting on 2/12/2026 for Individual #2. The regulation requires that the Individual Plan be developed by an interdisciplinary team that includes the individual's direct care staff persons.
Although DSP staff were involved in providing services to the individual, documentation verifying their participation in the ISP development process was not maintained in the individual's record.
To correct this deficiency, C-NTA implemented the following corrective actions:
· The Program Manager and Program Specialist have been retrained on the regulatory requirements under PA Code 55 §2380.183(a)(3) to ensure that direct care staff participation in ISP development is documented.
· Direct Support Professionals have been trained regarding their role and participation expectations in the ISP development process in accordance with regulatory requirements.
· The ISP development process has been updated to require documentation verifying DSP participation either through attendance at the ISP meeting or through documented input provided prior to the meeting.
· If a DSP is unable to attend the ISP meeting due to staffing ratios needing to be maintained on the program floor, written DSP input will be obtained prior to the meeting and incorporated into the ISP development process, and documentation of the DSP's contribution will be maintained in the individual's record.
These corrective actions ensure that direct care staff participation in the ISP development process is documented in accordance with PA Code 55 §2380.183(a)(3).
Date of Correction: March 2026
Person Responsible: Director of Adult Day Services |
03/17/2026
| Implemented |