| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.14(a) | The agency did not possess a valid certificate of occupancy for any of its homes or an applicable letter from the corresponding municipality or township, indicating that a certificate of occupancy is not required. | If the home is located outside Philadelphia, Scranton or Pittsburgh and serves four or more individuals or if the home is located in a multiple family dwelling, the home shall have a valid fire safety occupancy permit listing the
appropriate type of occupancy from the Department of Labor and Industry or the Department of Health. If the home is located in Philadelphia, Scranton or Pittsburgh,
the home shall have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton, if required by State law or regulation or local codes. Source: Records. | The Provider will contact the homeowner of this residence and assist in any way in obtaining an occupancy permit from Smithton Borough officials or any other Borough governmental entity. |
10/24/2025
| Implemented |
| 6400.64(a) | At 10:27 AM on 9/4/25, the center interior base of the oven was coated with blackened grease and several charred food particles. At 11:00 AM, the base of the walk-in shower stall located in the home's basement was lined throughout its entirety with debris, pinkish-colored water stains, and a multitude of dead insects. The interior sink adjacent to the shower stall located in the home's basement was coated with a black substance in a large area surrounding its drain, appearing to be mold and/ or mildew. At 11:10 AM, in the full bathroom located on the home's main level, the caulking surrounding the entire walk-in shower base as well as the caulking applied to its adjoining walls was covered significantly in several portions with a blackish substance, appearing to be mold and/or mildew. | Clean and sanitary conditions shall be maintained in the home. | The Site monitor, DSP staff will clean the oven after each prepared meal to ensure that it remains clean.
The Site Monitor and DSP staff will clean and sanitize the unused basement bathroom in its' entirety and adding the basement bathroom to the scheduled house cleaning.
The Site Monitor contacted the Landlord and he agreed to make the caulking repairs to remove blackish substance appearing to be mold or mildew. |
10/24/2025
| Implemented |
| 6400.67(b) | At 10:53 AM on 9/4/25, located at the bottom of the basement steps, was a dryer exhaust vent pipe extending six inches inward towards the basement from the wall, with exposed, sharp metal edges. The dryer exhaust vent pipe was stuffed with a cloth rag to prevent the basement from exposure to outside elements. At 11:18 AM, the carpet in the area in front of Individual #3's dresser was frayed, exposing carpet padding in an area measuring two feet by one and one-half inches. This section of carpeting was also creased and raised from the rest of the level flooring in seven areas, each measuring in lengths of two feet, one foot, four feet, one and one-half feet, four and one-half feet, and two and one-half feet, respectively, posing as tripping hazards. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Provider contacted the landlord. The landlord agreed to make the repairs, but to cut and cap the exposed interior dryer vent.
Site Monitor contacted Landlord; Landlord agreed to replace the flooring in accordance with regulations. |
10/24/2025
| Implemented |
| 6400.80(a) | At 10:44 AM on 9/4/25, the top step of the set of three, leading from the basement to the exterior sidewalk adjacent to the detached garage, was missing a large piece of structural concrete in an area measuring approximately two feet in length. This broken step area missing concrete structure was outlined on both sides with jagged edges of remaining concrete, posing a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The Provider has contacted the owner of this residence and has been given preliminary approval to complete these tasks. The Director has made contact with our agency contractor and will meet with him on September 24, 2025, at 10:00 a.m. to develop a plan to address these issues. |
10/31/2025
| Implemented |
| 6400.101 | At 10:50 AM on 9/4/25, the interior basement door leading to the attached garage was equipped with a deadbolt lock, requiring a key to disengage it from the garage side. The attached garage did not have an exterior swing door to prevent entrapment. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| DHS currently rents the Smithton home, and we have contacted the owner. We have addressed the issue with the door and the deadbolt lock. A swing door will be provided for our individuals, or the dead bolt will be removed to ensure that there is no entrapment. |
10/31/2025
| Implemented |
| 6400.111(a) | At 11:00 AM on 9/4/25, there was no operable fire extinguisher with a minimum 2-A rating on the home's basement level. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The Provider will have a minimum 2-A-rated Fire Extinguisher located and accessible in the basement. |
10/31/2025
| Implemented |
| 6400.112(c) | According to the written fire drill record submitted from 11/16/24 to 8/21/25, the drill conducted on 8/21/25 did not document the time that it took place, as the corresponding field was left blank. [Repeated Violation-11/13/24, et al] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The fire drill trainings will be monitored and documented correctly by DHS staff to ensure the training is completed in its entirety. |
10/31/2025
| Implemented |
| 6400.151(a) | Director/ Chief Executive Officer Designee #1's date-of-hire to this position is 8/22/25. Through interviews conducted on 9/3/25, Director/ Chief Executive Officer Designee #1 revealed that they have contact with the individuals for more than five days in a six-month period. Director/ Chief Executive Officer Designee #1's content of records included only a physical examination completed on 9/4/25, as there was no documentation of a prior physical examination having been completed before their appointment to this position on 8/22/25. | 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. | The Director completed his physical examination on September 4, 2025. In the future, the Director will remain in compliance by having a physical exam completed well within the two-year limit. |
10/31/2025
| Implemented |
| 6400.171 | At 10:35 AM on 9/4/25, the following perishable food items in the refrigerator were unprotected from contamination: a 22-ounce package of Member's Mark Rotisserie Season Chicken Breast Lunch Meat with a best-if-used-by-date of 7/22/25; a 22-ounce package of Member's Mark Seasoned Angus Roast Beef Lunch Meat with a best-if-used-by-date of 7/2/25; and a 22-ounce package of Member's Mark Uncured Honey Ham Lunch Meat with a best-if-used-by-date of 7/9/25. | Food shall be protected from contamination while being stored, prepared, transported and served.
| All perishable food will be wrapped and labeled with a use-by date. Additionally, Staff will place food in see-through containers to ensure that we can better prevent contamination. |
10/31/2025
| Implemented |
| 6400.214(b) | At 10:10 AM on 9/4/25, neither hard nor electronic copies of the following regarding Individual #1's most current records were kept at the home: an assessment, an applicable social, emotional, and environmental needs plan, which was dated 5/14/23, and incident reports. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The Provider will confirm that the necessary paperwork is current and up to date on all of our individuals and that incident reports are completed in their entirety and available in hard and electronic copies. |
10/31/2025
| Implemented |
| 6400.216(a) | At 10:05 AM on 9/4/25, the following of Individual #1's and former resident, Individual #2's records were unlocked and in plain view on an open shelf in the staff office area located on the home's main level:
a blue binder, entitled, "[Individual #2]---Medical Documentation Papers," containing demographic information, medical appointments dating from 6/22/16 to 6/1/20, and physician orders; a black binder entitled, "[Individual #2] and [Individual #1] goals," containing Individual Support Plan outcome goals for Individual #2 dating from 12/16/22 to 7/15/23, several receipts for purchases by Individual #2 made in 2022, Individual Support Plan outcome goals for Individual #1 dating from 1/16/23 to 10/15/23; and a black binder, entitled, "[Individual #1]---Medical Documentation," containing demographic information, medical appointments dating from 3/23/16 to 7/28/20 as well as a Health Risk Screening Tool completed on 12/28/19. | An individual's records shall be kept locked when unattended.
| All individual documentation will be secured in a locked box and placed in an additional locked container to ensure it's confidentiality. To further ensure compliance, these documents will be removed from common areas and put in a secure, designated area. |
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. | DH S has begun to use the Department's Licensing inspection form for 2020. |
10/31/2025
| Implemented |
| 6400.18(g) | Enterprise Incident Management #: 9657592 for exploitation, involving theft/ misuse of funds, was discovered on 7/15/25 at 12:00 AM and reported on 7/16/25 at 4:16 PM. The agency assigned Certified Investigator #2 on 7/15/25 at 9:00 AM. However, Certified Investigator #2's first witness statement was not gathered until 7/17/25 at 10:00 AM with the testimony of Individual #1's relative. Furthermore, Certified Investigator #2 did not make a notation in the Certified Investigator's Report about the reason for this delay in capturing testimonial evidence under the corresponding filed entitled, "Summary of Relevant Information from Witness and Attempts at Interview." | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | DHS has trained CLA staff to conduct these investigations within the 24-hour timeframe. In addition, we will be using a binder and cataloging the time and date of any incident, and the confirmation of the certified investigator beginning the process within these 24 hours |
10/31/2025
| Implemented |
| 6400.20(b) | The agency did not review, analyze, conduct, and document a trend analysis of incidents at least every three months for its homes during the following time periods: 7/1/24 to 1/31/25 and 6/1/25 to 9/3/25. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | The Provider will complete quarterly data reports on incidents to ensure that these target dates are met and that we can easily access the necessary information. |
10/31/2025
| Implemented |
| 6400.32(r)(1) | At 11:17 AM on 9/4/25, Individual #3's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #3 with a unique mechanism in which to lock and unlock their bedroom door. At 11:26 AM on 9/4/25, Individual #1's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #1 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. | The Provider will review the Individual and Basic Rights to confirm whether they want a lock on the door. Additionally, staff will change the locks if the individual chooses to have locks installed on the door. We will also be discussing this matter with the homeowner, as DHS does not own this home. |
10/31/2025
| Implemented |
| 6400.32(r)(4) | At 11:17 AM on 9/4/25, Individual #3's bedroom door was equipped with a privacy lock having a pop button 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 11:26 AM on 9/4/25, Individual #1's bedroom door was equipped with a privacy lock having a pop button 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. | The Provider will inquire with the individuals to confirm if they want locks on their doors. If, in fact, the individual wishes to have a lock, we will change the locks to comply with regulatory standards. |
10/31/2025
| Implemented |
| 6400.51(b)(4) | Program Specialist #3's date-of-hire is 11/11/24. Program Specialist #3's orientation record did not include required training on recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | New hires will complete the necessary training within the first week of employment. The employee will have a checklist in their respective employee file that needs to be signed off on by their direct supervisor. |
10/31/2025
| Implemented |
| 6400.51(b)(5) | Program Specialist #3's date-of-hire is 11/11/24. Program Specialist #3's orientation record did not include all job-related knowledge and skills. | The orientation must encompass the following areas: Job-related knowledge and skills. | The Provider will have all new hires complete their orientation packets in their entirety. DHS will add any relevant paperwork to these documents, including job-related skills and knowledge. |
10/31/2025
| Implemented |
| 6400.163(d) | At 10:00 AM on 9/4/25, the home's first aid kit included the following unlocked, accessible over-the-counter medications: seven packets of Antacid, each containing two 420 MG tablets; two packets of Aspirin, each containing two 325 MG tablets; and two packets of Ibuprofen, each containing two 200 MG tablets. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All unnecessary medications and syringes will be removed from the first aid kits and be placed in locked containers. |
10/31/2025
| Implemented |