Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00284854 Renewal 01/22/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Water in kitchen was 125 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. WHO: Administrative Staff WHAT: The water in the kitchen was 125 degrees. WHEN and HOW · Adjusted the water temperature There is no other violation · Target dates:1/22/26 · Specific dates:1/22/26 2. A plan to prevent future occurrences · By regularly checking thermostatic mixing valves and documenting routine temperature monitoring to keep hot water at or below 120°F. 01/22/2026 Implemented
6400.142(g)There was no dental hygiene plan for individual 2.A dental hygiene plan shall be rewritten at least annually. WHO: Program specialist WHAT: There was no dental hygiene plan for individual 2. WHEN and HOW · Dental Hygiene plan retrieved from the individual's Dentist reflecting a full dental plan There is no other violation · Target dates:1/22/26 · Specific dates:2/25/26 2. A plan to prevent future occurrences · By requiring documentation of a written dental hygiene plan for each individual or written interdisciplinary team confirmation of dental hygiene independence. 02/25/2026 Implemented
6400.181(e)(3)(ii)The 09/01/25 annual assessment does not mention that individual 2 is nonverbal and communicates with an IPAD. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. WHO: Program Specialist WHAT: The 09/01/25 annual assessment does not mention that individual 2 is nonverbal and communicates with an IPAD. WHEN and HOW · Assessment was updated with Individual's method of communication information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(5)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information:  The individual's ability to self-administer medications.WHO: Program specialist WHAT: The individual's ability to self-administer medications WHEN and HOW · Assessment was update with Individual's self-administer medications information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(6)The 09/01/25 assessment does not discuss individual 2's ability to safely use or avoid poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. WHO: Program specialist WHAT: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. WHEN and HOW · Assessment was updated with Individual's safely use or avoid poisonous materials, when in the presence of poisonous materials information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(10)The lifetime medical history section of the 09/01/25 assessment for individual 2 does not mention the individual's seizure disorder and surgeries to reduce muscle tension in legs.The assessment must include the following information: A lifetime medical history. WHO: Program specialist b. WHAT: A lifetime medical history. c. WHEN and HOW · Assessment was updated with Individual's seizure history There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(12)The 09/01/25 assessment for individual 2 does not discuss recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. WHO: Program specialist b. WHAT: Recommendations for specific areas of training, programming, and services c. WHEN and HOW · Assessment was updated with Individual's recommendations for specific areas of training, programming and services There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(i)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. WHO: Program specialist b. WHAT: The assessment must include the following information: Health. c. WHEN and HOW · Assessment was updated with Individual's Progress over the last 365 calendar days and current level in the following areas: Health. There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(ii)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. a. WHO: Program specialist b. WHAT: The assessment must include the following information: ii. Motor and communication skills. c. WHEN and HOW · Assessment was updated with Individual's Motor and communication skills information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(iii)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. . WHO: Program specialist b. WHAT: The assessment must include the following information: iiI. Activities of individual living. c. WHEN and HOW · Assessment was updated with Individual's Activities of residential living information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(iv)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. . WHO: Program specialist b. WHAT: The assessment must include the following information: vi. Personal adjustment. c. WHEN and HOW · Assessment was updated with Individual's Personal adjustment information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(vi)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. HO: Program specialist b. WHAT: The assessment must include the following information: vi. Recreation. c. WHEN and HOW · Assessment was updated with Individual's progress over the last 365 calendar days and current level in the following areas: Recreation information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(vii)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. a. WHO: Program specialist b. WHAT: The assessment must include the following information: vii. Financial independence. c. WHEN and HOW · Assessment was updated with Individual's progress over the last 365 calendar days and current level in the following areas: Financial independence information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(viii)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. a. WHO: Program specialist b. WHAT: The assessment must include the following information: viii. Managing personal property. c. WHEN and HOW · Assessment was update with Individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.181(e)(13)(ix)The 09/01/25 assessment for individual 2 does not address the individual's progress over the last 365 calendar days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.a. WHO: Program specialist b. WHAT: The assessment must include the following information: ix. Community integration. c. WHEN and HOW · Assessment was updated with Individual's progress over the last 365 calendar days and current level in the following areas: Community-integration information There is no other violation · Target dates:1/22/26 · Specific dates:2/2/26 2. A plan to prevent future occurrences · Ensuring all individual assessments includes complete information needed to understand each person's needs and protect their health and safety. A new assessment template was created using PA Chapter 6400 regulations. Capturing each requirement. 02/02/2026 Implemented
6400.217Individual 2's parent signed off on the release forms and there are no court papers showing that they are the individual's legal guardian.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. a. WHO: Program specialist b. WHAT: Individual 2's parent signed off on the release forms and there are no court papers showing that they are the individual's legal guardian. c. WHEN and HOW · Individual legal guardian submitted prove of guardianship Similar violation occurred with individual 4 and it's been resolved · Target dates:1/22/26 · Specific dates:1/22/26 A plan to prevent future occurrences · Modify the intake process to require submission of documentation verifying legal guardianship by anyone claiming to be the individual's legal guardian. If no such documents in provided, the individual will assume their responsibility for signing all required documents. 01/22/2026 Implemented
6400.32(t)The individual rights form for individual 2 has precautions for individuals with Prader-Willi Syndrome, and the individual does not have Prader-Willi Syndrome. The individual's rights form does not stipulate that the individual has the right to access food at any time.An individual has the right to access food at any time.a. WHO: Administrative Staff b. WHAT: An individual has the right to access food at any time. c. WHEN and HOW · Information was included in the rights package There is no other violation · Target dates:1/22/26 · Specific dates:3/25/26 2. A plan to prevent future occurrences · By updating the rights package to clearly include the individual's right to access food at any time and reviewing it with all individuals and staff. 03/25/2026 Implemented