| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | Individual #1's record content did not include a completed hearing examination for 2024 and 2025. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 has a hearing examination scheduled for 12/8/2025. This appointment is scheduled with Gilmore Audiology LLC. Individual #1 will continue to attend annual appointments with his new audiologist due to PCP being unable to perform a hearing exam. |
12/08/2025
| Implemented |
| 6400.216(a) | On 11/5/25 at 12:04 PM, a binder containing Individual #1's personal identifiable information, assessment, Service Plan, and most recent physical examination as well as dental examination forms was unlocked and unattended on a desk in the staff office. | An individual's records shall be kept locked when unattended.
| On 11/5/2025 the individuals records were locked in the home so there is only staff access. If records are unattended staff will keep the records locked. |
11/05/2025
| Implemented |
| 6400.32(r)(1) | On 11/5/2025 at 11:47 AM, there was a turn locking mechanism on the inside with a pinhole access point on the outside of the door leading to Individual #1's bedroom. Individual #1 has not been provided with a designated locking mechanism to lock and unlock their bedroom door independently. [Repeated Violation-12/3/24, et al] | 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. | Individual #1's doorknob has been replaced with a doorknob that does not have a locking mechanism. The individual has declined to want a lock on their bedroom. The new doorknob does not have the pin hole locking mechanism. |
11/14/2025
| Implemented |
| 6400.52(c)(2) | On 11/29/24, Program Specialist #1 did not complete annual training for the 2024 calendar year in the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse, as the material was self-read, and there was no documented trainer. The source for this training read, "reading materials, questions." | The annual training hours specified in subsections (a) and (b) 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. | On 12/3/2025 Training Manager trained Program Specialist #1 in person covering the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse |
12/03/2025
| Implemented |
| 6400.52(c)(3) | On 4/29/24, Program Specialist #1 did not complete annual training for the 2024 calendar year regarding individual rights, as the material was self-read, and there was no documented trainer. The source for this training read, "reading materials, questions." | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | On 12/3/2025 Training Manager trained Program Specialist #1 in person regarding individual rights |
12/03/2025
| Implemented |
| 6400.52(c)(4) | On 3/28/24, Program Specialist #1 did not complete annual training for the 2024 calendar year in recognizing and reporting incidents, as the material was self-read, and there was no documented trainer. The source for this training read, "reading materials, questions." | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | On 12/3/2025 Training Manager trained Program Specialist #1 in person in recognizing and reporting incidents |
12/03/2025
| Implemented |
| 6400.52(c)(5) | On 7/31/24, Program Specialist #1 did not complete annual training for the 2024 calendar year on the safe and appropriate use of behavior supports, as the material was self-read, and there was no documented trainer. The source for this training read, "reading materials, questions." | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | On 12/3/2025 Training Manager trained Program Specialist #1 in person on the safe and appropriate use of behavior supports |
12/03/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. The most recent review of Individual #1's psychiatric medications was completed on 7/10/25. | 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. | This Psychiatric evaluation had been completed on 9/11/2025. At the time UCIP was trying to reach the psychiatric doctor to receive the form, but was unable to reach the doctor until the individuals next appointment. The individual was seen on 11/24/2025 and UCIP received the completed appointment form showing that the individual had an appointment on 9/11/2025 and that medications were reviewed. |
11/24/2025
| Implemented |
| 6400.166(a)(5) | On 11/5/25, Individual #1's November 2025 Medication Administration Record did not include the strength for the prescribed, Fluticasone 50MCG Nasal Spray. [Repeated Violation-12/3/24, et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | On 11/5/2025 Individual #1's November 2025 Medication Administration record was updated to include the strength for the prescribed, Fluticason 50MCG Nasal Spray. |
11/05/2025
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Bisacodyl 5MG Tablets with instructions to, "take one tablet by mouth once daily as needed for no bowel movement for three days (do not crush)." Individual #1's November 2025 Medication Administration Record states, "insert one suppository rectally daily as needed if no moderate or large bowel movement." [Repeated Violation-12/3/24, et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | On 11/5/2025 Individual #1's November 2025 Medication Administration Record was updated to match the label of the Bisacodyl 5MG Tablets with instructions to "take one tablet by mouth once daily as needed for no bowel movement for three days (do not crush)." |
11/05/2025
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Bisacodyl 5MG Tablets with instructions to, "take one tablet by mouth once daily as needed for no bowel movement for three days (do not crush)." Individual #1's November 2025 Medication Administration Record states, "insert one suppository rectally daily as needed if no moderate or large bowel movement." [Repeated Violation-12/3/24, et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | On 11/5/2025 Individual #1's November 2025 Medication Administration Record was updated to match the label of the Bisacodyl 5MG Tablets with instructions to "take one tablet by mouth once daily as needed for no bowel movement for three days (do not crush)." |
11/05/2025
| Implemented |
| 6400.166(a)(14) | Individual #1 is prescribed Ketoconazole 2% Cream. The medication label states, "Apply Topically to affected area twice a day for fungal infection." Individual #1's November 2025 Medication Administration Record states, "Apply topically to affected area two times a day until lesions cleared plus one more week." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | On 11/5/2025 individual #1's prescribing doctor was contacted to receive clarification. The doctor updated the ketoconazole 2% cream to state "Apply topically twice a day to lesions until cleared for fungal infection plus one more week". At this time the old medication was taken to the pharmacy to replace the medication and update the current medication with this wording on the label. The medication label and the medication administration record currently match. |
11/05/2025
| Implemented |
| 6400.207(5)(II) | Staff interviews revealed that Individual #1 wears a Mixed Martial Arts helmet and medical hand mittens with Velcro straps for the wrists when engaging in self-injurious behaviors. Individual #1 does not have a current order from their physician with a medical diagnosis for the helmet and mittens. Individual #1's Service Plan, last updated 10/29/25, and their most recent assessment, did not address if the individual can easily remove the helmet and mittens or if they are removed by a staff person immediately upon the request or indication by the individual for periodic relief to allow freedom of movement. [Repeated Violation-12/3/24, et al] | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | On 11/24/2025 Daniel saw his psychiatric doctor. The Psychiatric doctor signed a form stating "Dan has padded gloves that he likes to wear when experiencing SIB. These gloves lessen the blows. Dan can ask to have them on or off. Dan can take them off and put them on himself. Dan may need assistance at times with taking them off or putting them on, at which time staff will assist Dan, with the task." UCIP will request that the helmet and glove approval is signed at each medication evaluation appointment occurring at least every three months. |
11/24/2025
| Implemented |