| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The individual #1's bedroom contained both open and empty food containers on the floor | Clean and sanitary conditions shall be maintained in the home. | Individual #1 agreed to allow staff to assist him with the upkeep of his personal bedroom. The open and empty food containers observed on the bedroom floor were removed immediately, and the area was cleaned. Individual #1's assessment will be updated and shared with the planning team to reflect his refusal to allow staff in his room, and sometimes his home, to assess cleanliness and help him clean, refusal of medication, refusal to go for medical appointments, refusal of furnishings, and Individual #1's desire to exercise his choices and rights in areas which may be detrimental to his health and safety (Such as refusal to take prescribed medication, medical assessments, and/or unsanitary bedroom). |
04/02/2026
| Implemented |
| 6400.66 | The office did not have lighting at the beginning of inspection. The permanent light fixture in the office is not operable. Near the end of the inspection, Individual #1 brought in a floor lamp from the living room to light the room. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A floor lamp was purchased on April 2, 2026, since the office does not have overhead lights. |
04/02/2026
| Implemented |
| 6400.71 | The telephone below the window in the office did not have emergency phone numbers posted in the area. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency telephone numbers were immediately posted near the office telephone located below the window upon identification of the issue on 4.2.2026. |
04/02/2026
| Implemented |
| 6400.72(a) | The office window was propped open and did not have a screen to keep out insects or wildlife.
The office and Individual #1's bedroom windows were propped open with wooden blocks, as the window ballasts no longer function properly. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Upon identification, the office and individual windows that were propped open with wooden blocks were closed to address the safety concern. A room air conditioner was installed in individual #1's bedroom to provide cool air on 4.2.2026. Maintenance was notified, and repairs were initiated to correct the non functioning window balance mechanisms. KenCCID is in the process of replacing the windows and expects to have the windows replaced by May 30, 2026 |
04/02/2026
| Implemented |
| 6400.76(a) | Individual #1's mattress and boxspring were soiled and not stable.
There was kitchen cabinet in the home missing a face. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Individual #1's bedroom was cleaned on April 2, 2026, including the mattress and boxspring. A new bed along with mattress, boxspring and bed cover was delivered to the home on April 15, 2026.
On April 2, 2026, the kitchen cabinet face was replaced. |
04/02/2026
| Implemented |
| 6400.76(c) | Individual #1's mattress sits on a boxspring, unaligned, on the floor. An invoiced was provided for a new queen bed. The order isn't itemized to determine if the individual will receive an exact replacement or homelike furniture. | Furniture shall be comfortable and home-like. | Individual #1 received his new queen size bed with a headboard and frame on 4/15/2026 |
04/15/2026
| Implemented |
| 6400.77(b) | The thermometers in the first aid kit did not contain batteries. The batteries stored with the first aid kit were not the necessary size to power the thermometers. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The first aid kit was immediately updated with the correct size batteries, and the thermometers were tested to ensure they were fully operational on 4/2/2026. |
04/02/2026
| Implemented |
| 6400.82(f) | The bathroom did not contain paper towels/hand towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Paper towels were immediately placed in the bathroom to support proper hand hygiene on 4.2.2026. |
04/02/2026
| Implemented |
| 6400.105 | Bagged rock salt and mops/ mop buckets were stored against the furnace and hot water heater.
The filter for the furnace (located on the dining room wall) was completely covered in a thick layer of dust and lint. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Upon discovery on 4.2.2026, all items were removed from the closet that house the furnace/hot water tank and stored in a separate location. |
04/02/2026
| Implemented |
| 6400.144 | The following PRN medications were missing from the medications: Milk of Magn Sus 1200/15; Diphenhydramine 50 mg CAP; Refresh Tear Dro 0.5% OP for Individual #1. Proof the medications were ordered in March was provided but as of 4/2/2026 if the Individual needed the medication, it could not be administered. There were no substitutes provided or correspondence from the prescribing doctor authorizing any alternatives. | 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 PRN for individual #1 was refilled by the pharmacy and delivered to the home on April 7, 2026. |
04/07/2026
| Implemented |
| 6400.24 | PA Code 284.412(b) requires regulated medical waste to be stored in a manner that minimizes exposure and vectors. The Sharps Container in the office closet was filled with regulated medical waste above the maximum fill line listed on the container. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On the same day the violation was identified (4.2.2026), the overfilled sharps container was properly disposed of and was immediately replaced with a new sharps container per protocol |
04/02/2026
| Implemented |
| 6400.163(h) | The following medications: PRN Acetaminophen 500mg tab; Nicotine TD Dis 21mg/24 were found with the medications but not listed on the MAR for Individual #1.
There was an expired blister pack of Ibuprofen 400 mg included with the medications that stating use by 3/21/2026 on the medication label for Individual #1. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Upon discovery on 4/2/2026, the discontinued medication was removed from the home and disposed of per policy. |
04/02/2026
| Implemented |
| 6400.166(c) | The provider is documenting refusals as a missed dose on the MAR. Specifically, the April 2, 2026, 8am doses for Cicloprioz Cre 0.77% and Lidocaine 5% pad were recorded as missed doses. Staff stated that Individual #1 stated he would take the medications later in the day. There is no documentation explaining if the prescriber permits late administration. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | KenCCID uses an electronic MAR system; which key code documents the refusal as an 'O'and lists the 'refusal' in the medication notes section. This symbol populates and the key code indicates " Not administered". The symbol noted on the electronic MAR for an omission is '/'. KenCCID is working with ACCUflo to make changes to the electronic MAR. On 4/2/2026 it was clarified to staff that medication may only be administered within the hour before and one hour after the administration time window and cannot be administered without written authorization from the prescribing physician. Individual #1 and his assigned nurse will confer with his prescribing physicians for standing late administration times specific to his needs by May 30, 2026. |
04/02/2026
| Implemented |