| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(b) | On 4/22/2026 at 10:35AM, an unlabeled, plastic spray bottle with a clear substance and "Bleach" hand-written on it and an unlabeled, plastic spray bottle with a purple substance and "Speedball" hand-written on it was in the locked bin under the sink in the kitchen on the first floor of the facility. | Poisonous materials shall be stored in their original, labeled containers. | Unlabeled plastic spray bottles were dumped and thrown away on 4/22/2026 with inspector present. |
05/08/2026
| Implemented |
| 2380.59(a) | On 4/22/2026 at 10:39AM, the hot water temperature measured 64.7F at the sink in the kitchen on the first floor of the facility. At 10:47AM, the hot water temperature measured 90.1F at the sink in the men's bathroom on the first floor of the facility. | The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas. | The property manager at the site came in on 4/29/26 and adjusted the water heater. The temperature measured at 119.7 at 3:27 PM on 4/29/26. |
05/08/2026
| Implemented |
| 2380.70(d) | On 4/22/2026 at 10:55AM, there was no thermometer in the first aid kit. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | A thermometer was purchased and added to this first aid kit on 4/22/26. Inspector was present. |
05/08/2026
| Implemented |
| 2380.111(c)(3) | Individual #2, date of admission 10/1/2026, completed a Tetanus vaccination on 9/30/2015, and not again until 10/3/2025. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The tetanus vaccination was completed on 10/3/25. The Program Specialist who was responsible no longer works over this program, however, the current Program Specialist was also retrained on 2380.111(c)(3). All charts have been reviewed to ensure that there are no other violations under the same code. The Program Specialist has been given guidance on cyclical date tracker monitoring requirements as noted below. |
05/07/2026
| Implemented |
| 2380.111(c)(4) | Individual #1, date of admission 10/2/2025, had a physical examination on 7/30/2025 that did not include a hearing and vision screening. These fields stated, "Refused," on the form. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The program received the evaluation documentation for Individual 3 on 4/27/26. All charts have been reviewed to ensure there are no additional violations under this same regulatory code. The Program Specialist was trained on 111(c)(4) regulation.
The Program Specialist was specifically trained that no blanks are permitted on the physical form, as any blank indicates missing required information. All sections of the form are regulated, including any areas marked as "refused." |
05/07/2026
| Implemented |
| 2380.111(c)(6) | Individual #2, date of admission 10/1/2025, completed a physical examination on 10/29/2025. The physical examination did not indicate that the individual was free from communicable disease. This section was left blank. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | The 2025 physical was returned on 4/30/26 and has been corrected, with no remaining blanks. The Program Specialist previously responsible for this area is no longer assigned to the program. However, the current Program Specialist has been retrained on regulation 2380.111(c)(6), including the required steps to take if a physical form is returned incomplete or with blanks.
The Program Specialist was specifically trained that no blanks are permitted on the physical form, as any blank indicates missing required information, and all sections of the form are regulated. Additionally, all charts have been reviewed to ensure there are no other violations under this same regulatory code. |
05/07/2025
| Implemented |