| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 5/4/2026 at 1:30 PM, the empty attic space measuring approximately 4-feet in height, which is accessible via a retractable ladder in the hallway near Individual #1's and Individual #2's bedrooms, was observed without a light source. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| CLASS corrected by having the facilities department assure that the light was illuminated in the attic. This fix was in place on 6/11/26. |
06/16/2026
| Implemented |
| 6400.71 | On 5/4/2026 at 1:12 PM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or near the cordless phone that was located on the television stand in the living room. At 1:37 PM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or near the cordless phone that was located on the nightstand in the Individual #3's bedroom. | 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.
| CLASS corrected by replacing telephone numbers near each telephone. This fix was in place on 5/19/2026. |
06/16/2026
| Implemented |
| 6400.82(f) | On 5/4/2026 at 1:39 PM, the half-bathroom adjacent to the laundry room did not contain a wall mirror. | 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. | CLASS corrected by assuring that a mirror was added to the half bathroom have a mirror. This fix was in place on 5/19/2026. |
06/16/2026
| Implemented |
| 6400.110(a) | On 5/4/2026 at 1:30 PM, the empty attic space measuring approximately 4-feet in height, which is accessible via a retractable ladder in the hallway near Individual #1's and Individual #2's bedrooms, was observed without an automatic smoke detector. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | CLASS corrected by installing an operable automatic smoke detector in the attic of this home. This fix was in place on 5/19/2026. |
06/16/2026
| Implemented |
| 6400.111(a) | On 5/4/2026 at 1:30 PM, the empty attic space measuring approximately 4-feet in height, which is accessible via a retractable ladder in the hallway near Individual #1's and Individual #2's bedrooms, was observed without a fire extinguisher with a minimum 2-A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | CLASS corrected by installing an operable fire extinguisher with a minimum 2-A in the attic of the home. This fix was in place on 6/9/2026. |
06/16/2026
| Implemented |
| 6400.141(a) | Individual #3 most recently had an annual physical examination completed on 1/8/2025. This exceeds the annual requirement. [Repeat violation 09/24/25, et. al.] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | CLASS recognizes that we cannot correct this violation. |
06/16/2026
| Implemented |
| 6400.141(c)(4) | Individual #1's current physical examination, completed on 7/10/2025, did not include vision and hearing screenings; however, the attending physician noted on this physical examination that Individual #1 was due for an annual vision examination. This physical examination's supplemental "Progress Notes" also indicated an HEENT examination was completed with the following results: ": Panic membranes are clear bilaterally, hemianopsia, no lymphadenopathy or thyromegaly;" however, this physical examination included no documentation of a hearing screening. Individual #1s content of records did not include documentation demonstrating that Individual #1 had an annual vision examination completed. Individual #2's current physical examination, completed on 2/26/2026, did not include vision and hearing screenings. This physical examination's supplemental "Progress Notes" indicated only a general physical examination was performed on the eyes and ears. Actual vision and hearing screenings or examinations evaluating Individual #2's eyesight and auditory capabilities, were not conducted, as the comments read: "Pupils react equally to light and accommodation, wears glasses," and "Ears normal," respectively. Individual #3 last had an annual physical examination completed on 1/8/2025 that did not include vision and hearing screenings. Individual #3's content of records did not include documentation demonstrating that Individual #3 had annual vision and hearing examinations completed in 2025. [Repeat violation 09/24/25, et. al.] | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | CLASS recognizes that we cannot correct this violation. |
06/16/2026
| Implemented |
| 6400.144 | On 5/4/2025 at 1:26 PM, Individual #1's bed was observed with a medical assist bar which the individual utilizes when getting into and out of their bed. The order for the medical assist bar was obtained from Individual #1's physician on 5/6/2025 at 1:01 PM; therefore, the agency failed to obtain an order for the adaptive equipment prior to use. Individual #1 had a dental appointment completed on 10/14/2025 that included the attending physician's prescribed health recommendations for Individual #1 to complete a follow-up appointment in three months; however, the health services were not arranged for or provided. Individual #3 had an optometrist appointment completed on 9/10/2025 that included the attending physician's prescribed health recommendations for Individual #3 to complete a follow-up appointment with a glaucoma specialist. The agency submitted documentation from Individual #3's MyUPMC Portal showing that this follow-up appointment is scheduled for 6/9/2026 at 8 AM with the UPMC Vision Institute. Consequently, this follow-up appointment with a glaucoma specialist was neither yet provided, nor arranged for in a timely manner, as the scheduled appointment date of 6/9/2026 comes nine months after such prescribed health recommendations were made on 9/10/2025. In addition, Individual #3 had a three-month psychotropic medication review completed on 10/29/2025 that included the attending physician's prescribed health orders for bloodwork labs to be completed; however, the agency did not present documentation that such health services were arranged for or provided. [Repeat violation 09/24/25, et. al.] | 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.
| CLASS recognizes that we cannot correct this violation. |
06/16/2026
| Implemented |
| 6400.171 | On 5/4/2026 at 1:09 PM, the following expired foods unprotected from contamination were on-site in the residential home: a 1-pound container of Hillshire Farms Honey Ham with a use-by-date of 4/27/2026 was observed in the top crisper drawer of the refrigerator; a 1-pound container of Hillshire Farms Honey Ham with a use-by-date of 4/21/2026 was observed in the top crisper drawer of the refrigerator; an 8-ounce package of Great Value Sliced Provolone Cheese with a best-if-used-by-date of 3/29/2026 was observed in the top crisper drawer of the refrigerator; and a 1-head bag of Mann's Green Leaf Lettuce with brown, slimy, wilting leaves was observed in the bottom crisper drawer of the refrigerator. In addition, at 1:09 PM, the following foods were observed open and unprotected from contamination in the residential home: a pan of homemade peanut butter fudge was uncovered on the second shelf from the top in the refrigerator; a partially used stick of butter was uncovered on the top shelf of the interior door of the refrigerator; and a 28.22-ounce bag of DeWaffel Bakkers Mini Pancakes was left open on the top shelf inside the freezer. [repeat violation 09/24/25 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| CLASS corrected by disposing of expired foods and ensuring all opened food is being stored properly. This fix was in place on 5/5/26. |
06/16/2026
| Implemented |
| 6400.214(b) | On 5/4/2026 at 1:05 PM, the following content from Individual #1's, Individual #2's, and Individual #3's records were not available on-site (either in hardcopy or electronic formats) in the residential home: incident reports relating to the individuals, physical examinations, dental examinations, dental hygiene plans, assessments, individual support plans, and psychological evaluations. According to agency staff, all individual charts had been temporarily relocated to the agency office to complete compliance reviews. [Repeat violation 9/24/2025, et. al.] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| CLASS corrected by having the record information in individual's binders in the home on 6/16/2026. |
06/16/2026
| Implemented |
| 6400.163(h) | Individual #1 was previously prescribed, Tolnafate Pow 1%, with instructions to "Apply topically to area of rash daily for fungal infection." This medication was discontinued by Individual #1's physician on 1/9/2026; however, on 5/4/2026 at 2:19 PM, the medication was observed on-site in the residential home. [Repeat violation 09/24/25, et. al.] | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | CLASS immediately removed expired and/or discontinued medications from the home. This was completed on 5/4/26 |
06/16/2026
| Implemented |
| 6400.165(c) | Individual #2 is prescribed, Albuterol HFA 90mcg, with instructions to "Inhale 2 puffs every 6 hours if needed for wheezing." On 5/4/2026 at 1:56 PM, this life sustaining medication was not available on-site in the residential home. According to agency staff, this medication has been ordered but was not currently available for Individual #2's use. | A prescription medication shall be administered as prescribed. | CLASS corrected this by having a new prescription sent to pharmacy and delivered to the home with 2 refills. This was corrected on 5/13/26. |
06/16/2026
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed medical marijuana; however, their May 2026 Medication Administration record did not include the name of this medication. This medication was omitted entirely from Individual #1's May 2026 Medication Administration Record. [Repeat violation 09/24/25, et. al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | CLASS is aware we cannot fix this violation. However, CLASS Nurse is working with Individual #1's family member and pain management doctor to develop a way to document medical marijuana vape pen on the Medication Administration Record. |
06/16/2026
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed medical marijuana; however, their May 2026 Medication Administration record did not include the strength of this medication. This medication was omitted entirely from Individual #1's May 2026 Medication Administration Record. [Repeat violation 09/24/25, et. al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | CLASS is aware we cannot fix this violation. However, CLASS Nurse is working with Individual #1's family member and pain management doctor to develop a way to document medical marijuana vape pen on the Medication Administration Record. |
06/16/2026
| Implemented |
| 6400.166(a)(7) | Individual #2 is prescribed, Diclofenac Sodium 1%, with instructions to "Apply 2 grams topically daily as needed for pain." On 5/4/2026 at 1:59 PM, the pharmacy-issued medication label indicated that the prescribed dose of this medication was 2 grams; however, Individual #2's May 2026 Medication Administration Record indicated that the prescribed dose of this medication was 4 grams. [Repeat violation 09/24/25, et. al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | CLASS corrected this by updating the medication record. |
06/16/2026
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed medical marijuana; however, their May 2026 Medication Administration record did not include the frequency of administration for this medication. This medication was omitted entirely from Individual #1's May 2026 Medication Administration Record. [Repeat violation 09/24/25, et. al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | CLASS is aware we cannot fix this violation. However, CLASS Nurse is working with Individual #1's family member and pain management doctor to develop a way to document medical marijuana vape pen on the Medication Administration Record. |
06/16/2026
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed medical marijuana; however, their May 2026 Medication Administration record did not include the diagnosis or purpose for prescribing this medication. This medication was omitted entirely from Individual #1's May 2026 Medication Administration Record. [Repeat violation 09/24/25, et. al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | CLASS is aware we cannot fix this violation. However, CLASS Nurse is working with Individual #1's family member and pain management doctor to develop a way to document medical marijuana vape pen on the Medication Administration Record. |
06/16/2026
| Implemented |
| 6400.166(b) | On 5/4/2026, Individual #1's prescribed medications including, but not limited to the following, were not initialed by staff as having been given as reflected on Individual #1's March 2026 Medication Administration Record for the corresponding time and dates: Aspirin Low Tab. 81 MG EC with instructions to "Take 1 tablet by mouth daily for blood thinner;" Mag. Oxide Tab. 400 MG with instructions to "Take 1 tablet by mouth daily for supplement;" and Venlafaxine Cap. ER 150 MG with instructions to "Take 1 capsule by mouth every morning for mood" at 8 AM on 3/9/2026, 3/16/2026, 3/23/2026, and 3/30/2026. In addition, Individual #1's prescribed medications including, but not limited to the following, were not initialed by staff as having been given as reflected on Individual #1's April 2026 Medication Administration Record for the corresponding time and dates: Aspirin Low Tab. 81 MG EC with instructions to "Take 1 tablet by mouth daily for blood thinner;" Mag. Oxide Tab. 400 MG with instructions to "Take 1 tablet by mouth daily for supplement;" and Venlafaxine Cap. ER 150 MG with instructions to "Take 1 capsule by mouth every morning for mood" at 8 AM on 4/6/2026 and 4/22/2026.
On 5/4/2026, Individual #2's prescribed medications including, but not limited to the following, were not initialed by staff as having been given as reflected on Individual #2's March 2026 Medication Administration Record for the corresponding times and dates: Acetamin Tab. 500 MG with instructions to "Take 2 tablets (1000 MG) by mouth three times a day for pain/ discomfort" at 2 PM on 3/2/2026, 3/5/2026, 3/9/2026, 3/19/2026, and 3/25/2026; Aripiprazole Tab. 30 MG with instructions to "Take 1 tablet by mouth daily for mood" at 8 AM on 3/9/2026, 3/16/2026, 3/23/2026, and 3/30/2026; and Citalopram Tab. 40 MG with instructions to "Take 1 tablet by mouth daily for mood" at 8 AM on 3/9/2026, 3/16/2026, 3/23/2026, and 3/30/2026. In addition, Individual #2's prescribed medications including, but not limited to the following, were not initialed by staff as having been given as reflected on Individual #2's April 2026 Medication Administration Record for the corresponding time and dates: Acetamin Tab. 500 MG with instructions to "Take 2 tablets (1000 MG) by mouth three times a day for pain/ discomfort" at 8 AM on 4/6/2026, 4/13/2026, and 4/22/2026; Aripiprazole Tab. 30 MG with instructions to "Take 1 tablet by mouth daily for mood" at 8 AM on 4/6/2026, 4/13/2026, and 4/22/2026, and 3/30/2026; and Citalopram Tab. 40 MG with instructions to "Take 1 tablet by mouth daily for mood" at 8 AM on 4/6/2026, 4/13/2026, and 4/22/2026.
On 5/4/2026, Individual #3's prescribed medications including, but not limited to the following, were not initialed by staff as having been given as reflected on Individual #3's March 2026 Medication Administration Record for the corresponding time and dates: Aspirin Low Tab. 81 MG EC with instructions to "Take 1 tablet by mouth daily for blood thinner;" Citalopram Tab. 40 MG Tab with instructions to "Take 1 tablet by mouth daily for mood;" and Divalproex DR 500 MG Tab with instructions to "Take 1 tablet by mouth twice a day for seizure/mood" at 8 AM on 3/9/2026, 3/16/2026, 3/23/2026, and 3/30/2026. In addition, Individual #3's prescribed medications including, but not limited to the following, were not initialed by staff as having been given as reflected on Individual #3's April 2026 Medication Administration Record for the corresponding time and dates: Aspirin Low Tab. 81 MG EC with instructions to "Take 1 tablet by mouth daily for blood thinner;" Citalopram Tab. 40 MG Tab with instructions to "Take 1 tablet by mouth daily for mood;" and Divalproex DR 500 MG Tab with instructions to "Take 1 tablet by mouth twice a day for seizure/mood" at 8 AM on 4/6/2026, 4/13/2026; 4/21/2026, and 4/22/2026. [Repeat violation 9/24/25, et. al.] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | CLASS recognizes that we cannot correct this violation |
06/16/2026
| Implemented |