| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | The following staff members would need an FBI Criminal Background check because the agency did not obtain documentation that the staff members resided in the state of Pennsylvania for at least 2 years prior.
- Staff #1
- Staff #2
- Staff #3
- Staff #4
- Staff #5
- Staff #6 | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| To correct the noncompliance, We Care For All will submit FBI Criminal Background Checks for Staff #1 through Staff #6 within the required timeframe. Although addresses were previously verified using identification cards or driver¿s licenses, we did not obtain documentation confirming that these staff members resided in Pennsylvania for at least two years prior to hire. All six staff members have since signed a We Care For All address attestation form to confirm their residency history, and FBI background checks will now be completed to meet regulatory requirements. |
07/28/2025
| Implemented |
| 6400.43(b)(1) | 1. Any staff member who has a criminal background needs to have their offenses reviewed and documented on a case by case basis. The staff members who need this review completed are as follows:
- Staff #3
- Staff #4
- Staff #6
The 2/13/25 signed room & board contract for individual #2 does not have a designated amount written on it. Selection #1 is circled on the form, but the amount is left blank. The agency had the individual sign a contract where any amount could then be written in later. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | We Care For All has developed a Background Review Form and implemented a policy for hiring individuals with a criminal background. For staff members with criminal background records (Staff #3, Staff #4, and Staff #6), a case-by-case background review will be completed within 48 hours of receiving the background check results to determine hiring eligibility.
We also completed the SSI Room and Board contract for Individual #2 based on the confirmed rate provided by the representative payee, Advocacy Alliance. However, we acknowledge that the 2/13/25 signed contract did not include a designated amount. |
07/28/2025
| Implemented |
| 6400.62(a) | There were unlocked poisons in the home at the time of inspection (Antibacterial Soap) | Poisonous materials shall be kept locked or made inaccessible to individuals. | We Care For All will ensure that all poisonous materials, including toiletries, are properly locked and inaccessible to individuals. Following the inspection, the antibacterial soap and any other items labeled as hazardous were secured in locked storage. |
07/28/2025
| Implemented |
| 6400.111(f) | The Fire Extinguisher in the basement of the home was most recently inspected in Feb 2024 which is more than 1 year | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | We Care For All has scheduled an immediate inspection of the basement fire extinguisher by a certified fire safety expert to bring it into compliance. Once inspected and approved, the updated inspection tag will be affixed to the extinguisher to clearly show the current date. |
07/28/2025
| Implemented |
| 6400.112(a) | The agency did not provide any documentation that any fire drills were conducted at this location in the last year. | An unannounced fire drill shall be held at least once a month. | We Care For All acknowledges that documentation of fire drills for this location was not available at the time of inspection. Going forward, we will ensure that fire drill records are completed immediately after each drill and kept in the home¿s safety binder for review during inspections |
07/28/2025
| Implemented |
| 6400.141(a) | The physicals for individual #2 were not completed annually (within one year) as required by regulation. Dates of the physicals are 4/16/24 and 6/18/25. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | We Care For All acknowledges that Individual #2¿s physical examination was not completed within the required 12-month timeframe. The most recent physical was completed on 6/18/25, which has brought the individual back into compliance. |
07/28/2025
| Implemented |
| 6400.141(c)(4) | There was no record that individual #2 had a hearing or vision exam. The yes or no boxes on the form designated for this information on the form was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | We Care For All acknowledges that the physical examination form for Individual #2 did not include documentation of a vision or hearing screening, and the designated yes/no boxes were left blank. We have since contacted the physician to update the physical form to reflect the results of the vision and hearing screenings, ensuring the record is now complete |
07/28/2025
| Implemented |
| 6400.141(c)(14) | The 6/18/25 physical for individual #2 is missing medical information pertinent to diagnosis and treatment in case of emergency. The line designated for this information on the form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | We Care For All acknowledges that the 6/18/25 physical for Individual #2 was missing medical information pertinent to diagnosis and treatment in case of emergency. We have since scheduled a follow-up appointment with the individual¿s physician to have the required information completed and documented on the physical form. |
07/28/2025
| Implemented |
| 6400.32(r) | Individual #3 did not have a lock on their door and there was no documentation stating that they did not want one installed. | An individual has the right to lock the individual's bedroom door. | We Care For All acknowledges that Individual #3 did not have a lock on their bedroom door, and there was no documentation stating they did not want one installed. We have since installed a lock on the individual¿s bedroom door to ensure their right to privacy is upheld. |
07/28/2025
| Implemented |
| 6400.34(a) | The individual rights form signed on 1/1/25 for individual #2 does not include the right to lock the bedroom door. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | We Care For All acknowledges that the individual rights form signed on 1/1/25 for Individual #2 did not include the right to lock their bedroom door. To correct this, Individual #2 has since signed a new individual rights form that includes this right. |
07/28/2025
| Implemented |
| 6400.34(a) | An annual assessment for a different individual residing within the same home was found in the record for individual #2. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | We Care For All acknowledges that an annual assessment for a different individual was mistakenly filed in Individual #2¿s record. The incorrect document has since been removed, and the correct annual assessment for Individual #2 has been placed in their file. |
07/28/2025
| Implemented |
| 6400.169(a) | There was no record of staff member #1 completing the required medication practicums following the initial 10/9/24 medication administration training. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | We Care For All acknowledges that there was no record of Staff Member #1 completing the required medication practicums after the 10/9/24 medication administration training. The practicum was completed, but the documentation was not provided to Staff Member #1 for their file. The missing form has since been obtained and added to their personnel file to ensure compliance. |
07/28/2025
| Implemented |
| 6400.169(b)(2) | Individual #2 is prescribed Ozempic Inj. however the staff in the home do not have the department approved diabetes patient training. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | We Care For All acknowledges that Individual #2 is prescribed Ozempic injections; however, staff in the home have not yet completed the Department-approved diabetes patient education program required to administer injectable medications. Staff are scheduled to complete the required injectables training. Until training is complete, only properly trained personnel or the prescribing healthcare professional will administer Ozempic to Individual #2. |
07/28/2025
| Implemented |