| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #2's Service Plan, last updated 5/9/25, explains that "all poisonous items are kept locked in a closet and monitored at the residence. [Individual #2] requires supervision with all potentially hazardous materials/ chemicals." At 12:50 PM on 9/4/25, unlocked and accessible underneath the sink in the full bathroom located on the home's main level were the following poisonous cleaners: a 25-ounce can of Scrubbing Bubbles Bathroom Cleaner; a 24-ounce jug of Great Value Toilet Bowl Cleaner; a 32-ounce jug of Lysol Toilet Bowl Cleaner; and a one pound, 6.4-ounce can of Member's Mark Disinfectant Wipes. | Poisonous materials shall be kept locked or made inaccessible to individuals. | DHS staff will ensure that all poisonous and hazardous chemicals be kept locked in a secured closet or other locked location in the home. |
10/31/2025
| Implemented |
| 6400.65 | At 12:18 PM on 9/4/25, the full bathroom located in the home's basement did not have a mechanical exhaust fan or an operable window for ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| DHS will have the proper ventilation in all areas of the home. This will be made possible by using the appropriate windows or otherwise mechanical devices. DHS will contact our contractor to complete this task. |
10/31/2025
| Implemented |
| 6400.72(b) | At 12:07 PM on 9/4/25, the screen in the window facing the rear of the home in the dining room had linear-shaped tear in its center, measuring two feet in length by one-quarter inch wide. | Screens, windows and doors shall be in good repair. | DHS staff will contact our contractor to complete the necessary repairs on the windows and other structures. The Director has a meeting with our contractor on 9/24/25 to set a schedule to fix the window. |
10/31/2025
| Implemented |
| 6400.80(b) | At 12:20 PM on 9/4/25, the exterior walkway and steps leading from the attached garage's swing door were covered with several candy wrappers, a piece of tissue paper, a crushed plastic container, an empty 14-ounce plastic jug of Autz Halloween Cheese Balls as well as thick layers of foliage and brush. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | DHS staff will conduct exterior house and yard checks to ensure that our homes are free from any debris or in need of repair. |
10/31/2025
| Implemented |
| 6400.106 | The agency had furnace inspections and cleanings for this home conducted on 7/15/24, and then again on 8/18/25. | 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.
| DHS staff schedule the cleanings of the furnaces on a yearly basis. Staff will make the upcoming appointment at the previous appointment if applicable. If this is not possible we will do so within the appropriate time frame. |
10/31/2025
| Implemented |
| 6400.113(a) | Individual #1 completed annual fire safety training on 6/14/24, and then again on 8/1/25. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | DHS staff will conduct initial and yearly fire safety training with our individuals that include general fire safety as well any evacuation procedures and designated areas in the event that the individual smokes. |
10/31/2025
| Implemented |
| 6400.142(d) | Individual #1 had dental examinations completed on 4/19/24, and then again on 2/15/25. However, both of these examinations did not include documentation of teeth cleanings. | The dental examination shall include teeth cleaning or checking gums and dentures. | DHS staff will ensure that all dental exams are completed in their entirety and that the necessary aspects of the exam have been followed. |
11/07/2025
| Implemented |
| 6400.151(a) | Direct Service Worker #3's most recent physical examination was completed on 9/15/22. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | DHS staff will have a current physical examination and will have one completed every two years. |
10/31/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's current assessment, completed on 1/17/25, did not include their functional strengths, needs, and preferences, as the corresponding fields were either missing or unaddressed elsewhere in the document. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment must include the following information: the individual's functional strengths, needs, and preferences. |
10/31/2025
| Implemented |
| 6400.181(e)(2) | Individual #1's current assessment, completed on 1/17/25, did not include their interests, as the corresponding field was either missing or unaddressed elsewhere in the document. | The assessment must include the following information: The likes, dislikes and interest of the individual. | DHS staff will complete the individual assessments with our individuals and ensure that no fields are left unaddressed. If needed, we can also include family members to assist. |
10/31/2025
| Implemented |
| 6400.181(e)(10) | Individual # 1's current assessment, completed on 1/17/25, did not include a lifetime medical history, as it was located in a separate record binder entitled, "[Individual #1]: Confidential." Furthermore, Indivudal#1's lifetime medical history was not sent on 5/26/25 to the plan team with their current assessment. | The assessment must include the following information: A lifetime medical history. | DHS staff will include any and all pertinent lifetime medical history when completing the individual's assessments, keeping the documentation together. The lifetime medical history will be made available to the plan team. |
10/31/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed on 1/17/25, did not precisely address recommendations for specific areas of training, programming, and services, as the corresponding field read as follows: "Training: [Individual #1] will continue to receive regular trainings for fire safety; Programming: [Individual #1] attends a day program 5 days a week and states that [they] enjoy going. [Individual #1] does not want anything to change at the present time; and Services: [Individual #1] states [they] [are] happy with all current services." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | DHS staff will complete the individual assessments with our individuals and ensure that no fields are left unaddressed. If needed, we can also include family members to assist. |
10/31/2025
| Implemented |
| 6400.15(b) | The agency used the Department's licensing inspection instrument modified in June 2018 to complete the self-assessment for this home. The current licensing inspection summary instrument for the community homes regarding individuals with intellectual disability or autism regulations was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | DHS has updated our department's licensing inspection form to the 2020 model. This updated form will allow us to be in compliance. |
10/31/2025
| Implemented |
| 6400.32(r)(1) | At 12:32 PM on 9/4/25, Individual #2's bedroom door was equipped with a privacy lock having a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #2 with a unique mechanism in which to lock and unlock their bedroom door. | 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. | DHS Site Monitors will be asking each individual to confirm whether they want a lock on the door. Review the Individual and Basic rights. In addition, staff will adjust the locks to be suitable for the individual's ability or, if desired, not lock the mechanism at all. |
10/31/2025
| Implemented |
| 6400.32(r)(3) | Individual #1's current assessment, completed on 1/17/25, states that "[Individual #1] has a privacy lock on [their] [bedroom] door that unlocks from the inside. [Individual #1] cannot operate the lock. [Individual #1] does not have the fine motor skills to operate a keypad lock, privacy lock, or deadbolt." At 12:33 PM on 9/4/25, Individual #1's bedroom door was equipped with a privacy lock having a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. However, assistive technology was not provided by the agency to allow Individual #1 to lock and unlock their bedroom door without assistance. | Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. | DHS Site Monitors will be asking each individual to confirm whether they want a lock on the door. Review the Individual and Basic rights. In addition, staff will adjust the locks to be suitable for the individual's ability or, if desired, not lock the mechanism at all. |
10/31/2025
| Implemented |
| 6400.32(r)(4) | At 12:32 PM on 9/4/25, Individual #2's bedroom door was equipped with a privacy lock having a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. At 12:33 PM on 9/4/25, Individual #1's bedroom door was equipped with a privacy lock having a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | DHS Site Monitors will be asking each individual to confirm whether they want a lock on the door. Review the Individual and Basic rights. In addition, staff will adjust the locks to be suitable for the individual's ability or, if desired, not lock the mechanism at all. |
10/31/2025
| Implemented |
| 6400.46(a) | Direct Service Provider #3's annual fire safety training was completed on 6/14/24, and then again on 8/21/25. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | DHS staff will be trained on a yearly basis for fire safety and evacuation procedures. This shall encompass the use of fire extinguishers and safety areas inside or outside of the home. In addition, the fire alarms and local fire departments will also be notified. |
10/31/2025
| Implemented |
| 6400.46(d) | Direct Service Provider #3 was trained in cardiopulmonary resuscitation on 6/22/22, and then again on 2/5/25. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | DSP staff will take part and be certified in cardiopulmonary resuscitation in a timely manner following the initial date of employment as well as yearly afterwards. This training will be conducted by a recognized care organization. |
10/31/2025
| Implemented |
| 6400.51(b)(1) | Direct Service Provider #1's date-of-hire is 1/6/25. Their orientation did not include documentation of completing required training on the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | DHS has updated our orientation package to include the application of person-centered practices along community integration and individua choice. |
10/31/2025
| Implemented |
| 6400.51(b)(2) | Direct Service Provider #1's date-of-hire is 1/6/25. Their orientation did not include documentation of completing required training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The orientation 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. | DHS will use our checklist to ensure that our orientation for new staff include the detection of reporting abuse and suspected abuse both with the adult and adolescent |
10/31/2025
| Implemented |
| 6400.51(b)(3) | Direct Service Provider #1's date-of-hire is 1/6/25. Their orientation did not include documentation of completing required training on individual rights. | The orientation must encompass the following areas: Individual rights. | DHS will utilize our updated checklist to ensure that all domains are discussed and that we have extensive training is available for individual rights. |
10/31/2025
| Implemented |
| 6400.51(b)(4) | Direct Service Provider #1's date-of-hire is 1/6/25. Their orientation did not include documentation of completing required training on recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | DHS will provide the new employees with training that covers the areas of reporting and recognizing when to report incidents. |
10/31/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Provider #1's date-of-hire is 1/6/25. Their orientation did not include documentation of completing required training on job-related knowledge and skills regarding individual-specific reviews of behavior support plans and service plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | DHS will provide training that will include topics such as job-related knowledge and skills in order to better develop a behavior support plan and service plans. |
10/31/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. However, Individual #1 did not have their medication reviewed by a licensed physician from 11/1/24 to 2/28/25. [Repeated Violation-11/13/24, 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. | The medication reviews are completed by telehealth every three months. The DHS Provider has been unable to obtain written documentation from the psych provider. DHS has been educated on how to document in the home. DHS will continue to request documentation from the psych provider while documenting the appointment date and time, medication review, and if there are medication changes. |
10/31/2025
| Implemented |
| 6400.181(f) | Individual #1's current assessment, completed on 1/17/25, was sent by Program Specialist #2 to the plan team on 5/26/25, for an annual review meeting that had already been held on 4/17/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | DHS will adhere to regulatory requirements and provide the individuals current assessment to the plan team at least 30 calendar days prior to to the annual meeting. |
10/31/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 8/18/25, contained the following discrepancies between their current assessment, completed on 1/17/25, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 8/18/25 stated that "[Individual #1] can be safely near heat sources." In contrast, Individual #1's assessment, completed on 1/17/25, indicated that "[Individual #1] is unable to sense and quickly move away from such heat sources."; regarding fire evacuation, Individual #1's Service Plan, last updated 8/18/25, explained that "Individual #1 is able to follow simple prompts to get to a safe area under 2.5 minutes. [Individual #1] does need some prompts to leave [their] belongings and evacuate." However, Individual #1's assessment, completed on 1/17/25, provided a score of "Yes/I," indicating that Individual #1 can independently evacuate in 2.5 minutes in the actual event of a fire; and regarding supervision, Individual #1's Service Plan, last updated 8/18/25, left supervision within the home completely unaddressed and indicated the following in terms of supervision in the community: Individual #1 requires a 1:3 staffing ratio with "verbal reminders to look both ways when crossing the street" and that "staff should be next to Individual #1 when [doing] [so]." In contrast, Individual #1's assessment, completed on 1/17/25, stated vaguely that Individual #1 cannot be left unsupervised at home or in the community. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | DHS will continue to update the individuals Service plan when necessary to better reflect when the abilities of our individual change .This will not only occur on an annual basis but be stressed the importance of doing so when applicable. |
10/31/2025
| Implemented |
| 6400.183(c) | Individual #1's most recent service plan annual review meeting was held on 4/17/25. However, the agency did not provide the list of attendees who participated in this meeting. | The list of persons who participated in the individual plan meeting shall be kept. | DHS will utilize our meeting checklist to ensure that a sign in sheet is available to all attendees and on site during the meeting to allow a late arrival the opportunity to sign as well. |
10/31/2025
| Implemented |