| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Regarding poisonous substances, Individual #2's Service Plan, last updated 8/6/25, states that "[Individual #2] is unable to read warning labels and see danger signs [and] [that] these [poisonous] substances are not left where [Individual #2] would come in contact within daily living." However, at 9:54 AM on 11/5/25, unlocked and accessible underneath the sink of the full bathroom located in the bedroom hallway on the home's main level was a 19-ounce can of Lysol Disinfectant Spray with directions to call Poison Control if ingested or absorbed. At 10:18 AM, unlocked and accessible in the storage closet located near the home's entry door in the living room were the following poisonous materials: a 16 fluid-ounce bottle of API Quick Start Fish Water Tank Cleaner; a 1.3-ounce jar of API Bottom Feeder Fish Food Pellets; and a 16.9 fluid-ounce bottle of Tetra Easy Balance Plus Fish Tank Water Optimizer. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 11/5/2025 a 19-ounce can of Lysol Disinfectant Spray with directions to call Poison Control if ingested or absorbed, a 16 fluid-ounce bottle of API Quick Start Fish Water Tank Cleaner; a 1.3-ounce jar of API Bottom Feeder Fish Food Pellets; and a 16.9 fluid-ounce bottle of Tetra Easy Balance Plus Fish Tank Water Optimizer were all locked up with the other poisons. |
11/05/2025
| Implemented |
| 6400.67(b) | At 9:54 AM on 11/5/25, the basement's sewer drain located next to the laundry tub was missing a drain grate cover, exposing a circular hole, measuring 13 inches in diameter, and posing a tripping hazard. In addition, the laundry tub, located in the basement and adjacent to this sewer drain, was disconnected from the drain, itself, exposing a rusted, sharp metal end. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 11/14/2025 maintance added a drain grate cover to cover a circular hole measuring 13 inches in diameter, that had been posing a tripping hazard. UCIP maintenance also removed the laundry tub that was located in the basement and adjacent to this sewer drain. Since this has been removed it is no longer exposing a rusted, sharp metal end. |
11/14/2025
| Implemented |
| 6400.104 | The home's Fire Department Notification Letter, dated 1/2/25, did not indicate that Individual #1 requires assistance in evacuating. However, according to the written fire drill record submitted from 11/1/24 to 10/1/25, the following drills documented that Individual #1 needed evacuation assistance: 2/4/25; 3/5/25; 8/2/25; 9/2/25; and 10/2/25. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| On 11/13/2025 UCIP updated the local fire department notification letter with the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. UCIP also sent the local fire department notification letter on 11/13/2025. |
11/13/2025
| Implemented |
| 6400.105 | At 9:58 AM on 11/5/25, leaning against the front of the gas hot water tank located in the home's basement was a plastic 2.5-gallon storage bucket. In addition, taped to the side of this hot water tank was a laminated paper agency memo that read: "Staff are not permitted to change the temperature on the hot water tank. Any staff found changing the temperature on these tanks will be terminated immediately. If you have any problems with the temperature on your tank, please contact your supervisor. Thank you for your cooperation." | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| On 11/5/2025 the plastic 2/5 gallon storage bucket leaning against the front of the gas hot water tank in the home's basement was removed. The laminated paper agency memo that read: "Staff are not permitted to change the temperature on the hot water tank. Any staff found changing the temperature on these tanks will be terminated immediately. If you have any problems with the temperature on your tank, please contact your supervisor. Thank you for your cooperation." has been removed. |
11/05/2025
| Implemented |
| 6400.32(r)(1) | At 9:42 AM on 11/5/25, Individual #2's bedroom door was equipped with a lock requiring a key to operate it from the outside. During an interview, Individual #2 stated that they do not have a key to their bedroom. Individual #2 also informed that last week, they had requested a replacement key from Program Specialist #2 since Individual #2 had misplaced it. Individual #2 revealed that the agency has yet to respond. Furthermore, Individual #2 exclaimed that they would like the Department to inform the agency again regarding this matter so that Individual #2 can lock and unlock their bedroom door. [Repeated Violation-12/3/24, et al] | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Individual #2 has been given a replacement key to their bedroom. In addition UCIP DSP's that are working in the home have been given a key that they will carry on their person while working in the home. UCIP Program Specialist for the home has been given a back up key if the individual or staff were to misplace the one they have. If one is missplaced UCIP will give the Program Specialist key to the home and contact maintenance to replace the backup Program Specialist key. |
11/14/2025
| Implemented |
| 6400.52(c)(1) | On 9/23/24, Executive Director #1 did not complete annual training for the 2024 calendar year in the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships, as the material was self-read, and there was no documented trainer. | 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. | On 12/1/2025 UCIP Training Manager completed training in person for executive director #1 including application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. |
12/01/2025
| Implemented |
| 6400.52(c)(2) | On 9/23/24, Executive Director #1 did not complete annual training for the 2024 calendar year in the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse, as the material was self-read, and there was no documented trainer. | 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. | On 12/1/2025 UCIP Training Manager completed training in person for executive director #1 in prevention, detection and reporting of abuse, suspected abuse, and alleged abuse. |
12/01/2025
| Implemented |
| 6400.52(c)(3) | On 9/23/24, Executive Director #1 did not complete annual training for the 2024 calendar year regarding individual rights, as the material was self-read, and there was no documented trainer. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | On 12/1/2025 UCIP Training Manager completed training in person for executive director #1 regarding individual rights. |
12/01/2025
| Implemented |
| 6400.52(c)(4) | On 9/23/24, Executive Director #1 did not complete annual training for the 2024 calendar year in recognizing and reporting incidents, as the material was self-read, and there was no documented trainer. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | On 12/1/2025 UCIP training manager completed training in person for executive director #1 recognizing and reporting incidents |
12/01/2025
| Implemented |