| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment of the home, completed by the agency on 4/24/2025, did not address regulations 6400.151a-152c. This section was left blank. [Repeated violation: 9/25/2024 et al] | 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.
| LIIs will be completed by Program Specialists between 2/23/26 and 3/23/26. Director and QCC will review by 4/15/26 to ensure completion. Shared calendar invites have been created for both timeframes. |
10/13/2025
| Implemented |
| 6400.21(a) | Direct Service Worker #1, date of hire 12/9/2024, had an application for a Pennsylvania criminal history record check submitted to the State Police on 12/4/2024. The criminal history record check indicated that Direct Service Worker #1 had a criminal record; however, the agency did not document their review of Direct Service Worker #1's record check and the agency's decision-making process for hiring. | 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.
| HR Director will complete a Statement of Suitability: Individualized Assessment of Criminal Findings Review for any employee with a criminal record within 10 business days of receiving results. |
10/13/2025
| Implemented |
| 6400.106 | The furnace in the home was cleaned and inspected by a professional furnace cleaning company on 4/17/2024 and then again on 8/7/2025. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace inspections will be scheduled by the Director of Facilities 10 months from the date of the previous inspection. A reminder has been added to shared calendars including the QCC, Director of Residential, Executive Director and CFO. |
10/13/2025
| Implemented |
| 6400.112(d) | The fire drill conducted on 9/17/2024 had a documented evacuation time of 4 minutes and 50 seconds. The fire drill conducted on 12/12/2024 had a documented evacuation time of 4 minutes and 16 seconds. The fire drill conducted on 4/30/2025 had a documented evacuation time of 4 minutes and 20 seconds. The fire drill conducted on 5/2/2025 had a documented evacuation time of 4 minutes and 41 seconds. The fire drill conducted on 6/12/2025 had a documented evacuation time of 5 minutes and 24 seconds. The fire drill conducted on 7/1/2025 had a documented evacuation time of 6 minutes and 10 seconds. The fire drill conducted on 8/12/2025 had a documented evacuation time of 3 minutes and 10 seconds. The home does not have documentation of an extended evacuation time written by a fire safety expert within the last year. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A meeting with a local fire inspector was held on 9/29/25 to begin the process of inspections of all homes, with the first inspection being completed on the same date. Once all homes are completed, information and recommendations will be reviewed. |
09/29/2025
| Implemented |
| 6400.112(e) | For the fire drill records that were reviewed from 9/17/2024 to 8/12/2025, the only drill that was conducted during sleeping hours was held on 12/12/2024. [Repeated violation: 9/25/2024 et al] | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight fire drill will be conducted by the 15th of the month. |
10/15/2025
| Implemented |
| 6400.141(a) | Individual #1's most recent physical examination was completed on 8/15/2024. [Repeated violation: 9/25/2024 et al] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 had a physical completed on 10/7/25. |
10/13/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's most recent hearing screening was completed on 8/15/2024. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 had a physical completed on 10/7/25, which included a hearing screening. |
10/13/2025
| Implemented |
| 6400.141(c)(7) | Individual #1's gynecological examinations were completed on 4/12/2024 and then again on 5/30/2025. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 has a gynecological exam completed on 5/30/25. |
10/13/2025
| Implemented |
| 6400.18(a)(5) | Enterprise Incident Management incident #9660005 had a due date for the Incident First Section of 7/20/2025 at 11:42pm. The Incident First Section was submitted by the agency on 7/21/2025 at 12:27pm.
Enterprise Incident Management incident #9659950 had a due date for the Incident First Section of 7/20/2025 at 11:42pm. The Incident First Section was submitted by the agency on 7/21/2025 at 12:25pm. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| All residential employees will be retrained on the agency Incident Management Policy, including recognition of reportable incidents, definition of time of discovery and timeframes for reporting. |
10/31/2025
| Implemented |
| 6400.18(a)(6) | Enterprise Incident Management incident #9659912 had a due date for the Incident First Section of 7/9/2025 at 9:32am. The Incident First Section was submitted by the agency on 7/21/2025 at 2:28pm. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Exploitation
. | All residential employees will be retrained on the agency Incident Management Policy, including recognition of reportable incidents, definition of time of discovery and timeframes for reporting. |
10/31/2025
| Implemented |
| 6400.18(i) | Enterprise Incident Management incident #9659912 had a due date of 8/7/2025 for the Provider Certified Investigation, Administrative Review, and Incident Final Section. The Provider Certified Investigation Was submitted by the agency on 8/8/2025 at 11:00am, the Administrative Review Section was submitted by the agency on 8/8/2025 at 11:15am, and the Incident Final Section was submitted by the agency on 8/8/2025 at 11:16am. No extensions were filed by the agency.
Enterprise Incident Management incident #9660005 had a due date of 8/18/2025 for the Administrative Review Section. The Administrative Review Section was submitted by the agency on 8/22/2025 at 2:05pm. No extensions were filed by the agency.
Enterprise Incident Management incident #9659950 had a due date of 8/18/2025 for the Administrative Review and 9/1/2025 for the Incident Final Section. The Administrative Review Section was submitted by the agency on 8/22/2025 at 3:10pm and the Incident Final Section was submitted by the agency on 9/15/2025 at 3:05pm. No extensions were filed by the agency. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Point person(s) will notify the QCC of incidents upon submission of the initial section. QCC will schedule an administrative review for 10 business days from the date of discovery. QCC will create a calendar invite including point person, Director and Executive Director for 21 days from date of discovery as a reminder that an incident is coming due to close. |
10/13/2025
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication reviews completed on 9/20/2024, 11/15/2024, 1/23/2025, 3/12/2025, 4/28/2025, 6/11/2025, and 8/5/2025 did not include the diagnosis or purpose of their prescribed medications or the need to continue their medications. [Repeated violation: 9/25/2024 et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 has a psychiatric medication review completed on 10/7/25. |
10/13/2025
| Implemented |
| 6400.207(5)(III) | On 9/25/2025 at 11:15am, Individual #1's bed contained bedrails that restricted the movement or function of the individual's body. The agency did not have a prescription for the equipment from the individual's physician. Individual #1's most current assessment dated 8/8/2025 did not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's individual support plan, last updated 5/21/2025, did not include periodic relief of the device to allow freedom of movement. [Repeated violation: 9/25/2024 et al] | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | An order for bedrails, including related diagnosis and instructions for periodic relief was obtained on 9/30/25. Individual #1's assessment has been updated to include bedrail usage. The updated assessment was sent to members of the team on 10/13/25. An email was sent to Individual #1's supports coordinator on 10/13/25 to request revisions to reflect the order and updated assessment. |
10/13/2025
| Implemented |