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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:53 AM on 3/5/26, the interior finish of the back wall, side walls, center base, and ceiling of the kitchen's microwave was delaminated in several areas and contaminated with oxidation. | Clean and sanitary conditions shall be maintained in the home. | A new microwave was purchased. |
03/16/2026
| Implemented |
| 6400.104 | The agency did not submit written notification to the local fire department for this home to address the following: the home's address; the home's capacity; a description and/or diagram of the home's general layout; a general description of the mobility needs of the individual(s) served; and the exact bedroom location(s) of any individual(s) who require assistance to evacuate in an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| New fire department notification letters were prepared and sent on 3/5/26. |
03/05/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's current assessment, completed on 8/29/25, did not address their preferences, as there was no corresponding field or relative language present throughout the entire document. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment will be revised to include a preferences section to meet the requirement of 6400.181(e)(1). |
04/03/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment, completed on 8/29/25, did not address their supervision needs within the home and lacked information to indicate the overall length(s), time(s), and/or type(s) of monitoring required. | The assessment must include the following information: The individual's need for supervision.
| The assessment will be revised to include the individual's supervision needs to meet the requirement of regulation 6400.181(e)(4). |
04/03/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed on 8/29/25, did not include specific areas of training, programming, and services. [Repeated Violation- 3/11/25, et al.] | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment will be revised to include specific areas of training, programming, and services to meet the requirements of regulation 6400.181(e)(12). |
04/03/2026
| Implemented |
| 6400.165(f) | Individual #1 is currently prescribed psychotropic medications to treat symptoms of a diagnosed psychiatric illness. Individual #1's content of records included an undated behavior support plan within their current Service Plan, last updated 2/6/26, that addressed their social, emotional and environmental needs relative to the symptoms of the psychiatric illness. For the prior year, the agency provided an exclusive social, emotional, and environmental needs plan that was undated and written independently of Individual #1's Service plan. In addition, Individual #1's only Service Plan written in 2025, with an update date of 3/19/25, included the same undated behavior support plan embedded in Individual #1's current Service Plan, last updated 2/6/26, as both behavior support plans were identical word-for word. Therefore, compliance demonstrating that such a plan was re-written annually for Individual #1 could not be measured. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | All Program Specialists were retrained by the Residential Directors on regulation 6400.165(f). |
03/16/2026
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 2/6/26, contained the following discrepancies between their current assessment, completed on 8/29/25, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Service Plan, last updated 2/6/26, contained no language or guidance on Individual #1's ability to use or avoid poisonous materials. However, Individual #1's assessment, completed on 8/29/25, indicated, "No, [Individual #1] cannot be safe around unlocked poisons."; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 2/6/26, contained no guidance or language addressing Individual #1's ability to sense and quickly move away from such heat sources. However, Individual #1's assessment, completed on 8/29/25, provided a "V," meaning Individual #1 requires verbal prompting to recognize and quickly move away from dangerous heat sources; regarding water safety, Individual #1's Service Plan, last updated 2/6/26, did not address their ability to swim and explained that "[Individual #1] must be supervised at all times when around bodies of water, such as a pond or a pool, by [their] residential staff or natural supports. [Individual #1] can become overstimulated with water, which may cause [Individual #1] to vomit. [Individual #1] enjoys being in the pool, and [Individual #1] uses a life jacket." In contrast, Individual #1's assessment, completed on 8/29/25, provided a "T," denoting that Individual #1 needs total assistance in order to swim; and regarding supervision needs within the home, Individual #1's Service Plan, last updated 2/6/26, explained that "[Individual #1] [is] monitored by staff and family at all times when···in [their] home or residence" with an awake overnight staff indicated. The Service Plan also stated that "[Individual #1] cannot be left alone due to health and safety concerns." However, Individual #1's assessment, completed on 8/29/25, did not address their supervision needs in the home and lacked information to indicate the overall length(s), time(s), and/or type(s) of monitoring required. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Program Specialists were retrained on regulation 6400.182(c) by the Residential Directors, along with the process for documenting conversations with the Supports Coordinator when requests for updates to the plan are made. |
03/16/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | The "Rights" forms, signed by Individual #1 on 7/25/14, and Individual #2 on 11/24/14, did not state the full rights per regulation 33(e) regarding privacy and regulation 33(j) regarding voting.
Per 6400.33(e), "An individual has the right to privacy in bedrooms, bathrooms and during personal care." Individual #1 and Individual #2's signed statements include "Each individual will be given privacy during treatment and care of personal needs."
Per 6400.33(j), "An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections." Individual #1 and Individual #2's signed statement does not include this statement. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Quality Assurance Director revised the Client Rights to include "each individual has the right to privacy in bedrooms, bathrooms, and during personal care" and "each individual who is of voting age has the right to vote and will be assisted to register and vote in the elections." The Program Specialist will have client #1 and #2 and/or parent/guardian sign the revised rights by January 6, 2015. The Administrative Assistant will send the revised Client Rights to all clients and/or parent guardian by January 15, 2015. The Program Specialist will ensure the Client Rights are reviewed and the Acknowledgement Form signed by the client and/or parent/guardian annually and filed in the client's Program Book. |
12/29/2014
| Implemented |
| 6400.103 | The written emergency evacuation procedures do not include the means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Quality Assurance Director revised the Emergency Evacuation Plan on 12/24/14 to include that the means of transportation will be by Agency and Staff vehicles and that the emergency shelter location are the Avalon Hotel on 16 West 10th Street, Erie, PA 16501, client family member's, or staff member's homes. The revised Emergency Evacuation Plan will be distributed to all group homes by january 1, 2015. |
12/29/2014
| Implemented |
| 6400.106 | The furnace has not been inspected and cleaned for several years by a professional furnace cleaning company or trained staff person. | 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.
| The Maintenance Manager will schedule the furnace cleaning and inspection with a professional cleaning company by January 16, 2015. The Maintenance Manager will schedule the cleaning and inspections to be done by a professional cleaning company annually. The Program Specialist will receive a copy of the cleaning and inspection reports to ensure they were done by the professionally cleaning company annually. |
12/29/2014
| Implemented |
| 6400.216(a) | Individual #1 and #2's medical record including labwork sheets were unlocked on the bulletin board in the garage. | An individual's records shall be kept locked when unattended. | The Program Specialist removed the posted Lab work for Client's #1 and #2 on 12/2/2014. The Program Specialist and Nurse Manager will reminded all the nurses and staff members that all client records must be locked at all times. The Program Specialist will conduct Confidentiality Training for the staff members on January 15, 2015. The Program Specialists of each facility will check throughout each shift she/he works to ensure client records are locked and remain confidential effective January 1, 2015. |
12/29/2014
| Implemented |
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