| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Laundry detergent was stored on top of the washer/dryer in an unlocked laundry room on site. The staff kitchen contained mouthwash, hand lotion, and cans of chafing gel accessible to individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Upon identification of the violation, the laundry detergent located on top of the washer/dryer was immediately removed and placed in a locked storage area inaccessible to individuals. The mouthwash, hand lotion, and cans of chafing gel located in the staff kitchen were also removed and placed in secured storage inaccessible to individuals when not in use.
The CEO/Director conducted a facility-wide review of the program site to identify any additional poisonous or potentially harmful materials that could be accessible to individuals. Any identified items were immediately secured.
All staff will be retrained on the requirements of 55 PA Code Chapter 2380.53(a), which requires poisonous materials to be kept locked or made inaccessible to individuals when not in use. Staff will be educated on identifying potentially poisonous materials and the requirement to return these items to secured storage immediately after use.
Documentation of staff retraining will be maintained by the facility. |
08/18/2026
| Implemented |
| 2380.89(a) | Fire drills were conducted quarterly, recorded as performed on dates 08/05/2025, 11/05/2025, 02/06/2026, and 05/06/2026. 2380 regulations require drills to be conducted monthly. | An unannounced fire drill shall be held at least once a month. | The facility identified that fire drills had been conducted quarterly rather than monthly as required by 55 PA Code Chapter 2380.89(a).
The CEO/Director reviewed the fire drill requirements with the staff responsible for conducting and documenting fire drills. Effective immediately, the facility will conduct an unannounced fire drill at least once each month in accordance with 55 PA Code Chapter 2380.89(a).
Staff responsible for fire drills will be retrained on the Chapter 2380 fire drill requirements, including the requirement that drills be conducted monthly and remain unannounced to individuals.
A monthly fire drill schedule and tracking log will be established to ensure that a fire drill is completed and properly documented during each calendar month. Documentation of the corrective action and staff retraining will be maintained by the facility. |
08/18/2026
| Implemented |
| 2380.181(a) | Individual 1 did not have record of an initial assessment on file. Individual 2 did not have an initial or annual assessment on file. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | The CEO/Director will ensure that the deficiencies identified during the licensing inspection are corrected for both individuals.
An assessment will be completed for Individual 1 and maintained in the individual's record. The required assessment for Individual 2 will be completed and maintained in the individual's record.
The CEO/Director will also conduct a review of all individuals currently enrolled in the program to verify compliance with 55 PA Code Chapter 2380.181(a). Each individual's record will be reviewed to verify that an initial assessment was completed within the required timeframe and that an updated assessment has been completed annually thereafter.
If any additional missing or overdue assessments are identified during the facility-wide review, the required assessment will be completed and placed in the individual's record.
Staff responsible for completing and maintaining assessments will be retrained on 55 PA Code Chapter 2380.181(a). The training will include the requirement that each individual have an initial assessment completed within 1 year prior to or within 60 calendar days after admission and an updated assessment completed annually thereafter.
Documentation of completed assessments, the facility-wide record review, and staff retraining will be maintained by the facility.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
09/18/2026
| Implemented |
| 2380.21(u) | Individual 1 and 2's rights statements are based upon 6 PA Code §11.9, rather than 55 PA Code §2380.21 and do not cover all rights ensured by ODP regulations. | The facility 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 facility and annually thereafter. | The CEO/Director will revise the facility's Individual Rights Statement to ensure that it reflects the rights required under 55 PA Code Chapter 2380.21 and includes the process for reporting a rights violation.
The previous rights statement based upon 6 PA Code § 11.9 will no longer be used as the facility's Chapter 2380 Individual Rights Statement.
The corrected Individual Rights Statement will be reviewed and explained to Individual 1 and Individual 2. The process for reporting a rights violation will also be explained. Documentation acknowledging that the rights were reviewed and explained will be signed and maintained in each individual's record.
The CEO/Director will conduct a review of all current individual records to determine whether any other individual received the previous rights statement. Each affected individual will be provided the corrected Chapter 2380 Individual Rights Statement. The rights and process for reporting a rights violation will be explained to the individual and persons designated by the individual as applicable.
Staff responsible for admissions, annual individual rights reviews, and maintenance of individual records will be retrained on 55 PA Code Chapter 2380.21, including the requirement to inform and explain individual rights upon admission and annually thereafter.
The CEO/Director will be responsible for ensuring completion of this corrective action and maintaining documentation of the completed reviews. |
08/18/2026
| Implemented |
| 2380.36(b) | CEO performs Fire Safety training for staff, but did not have Fire Safety Expert credentials. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The facility acknowledges that annual fire safety training was previously conducted by the CEO without documentation establishing the CEO as a qualified fire safety expert as required by 55 PA Code Chapter 2380.36(b).
The facility will obtain the services of a qualified fire safety expert to provide the required annual fire safety training to all program specialists and direct service workers.
All applicable staff who previously received fire safety training from the CEO will complete fire safety training provided by the qualified fire safety expert.
Prior to conducting the training, the CEO/Director will obtain and maintain documentation verifying the fire safety expert's qualifications or credentials.
Documentation of the corrective training will include the date of training, training content, names of staff completing the training, and identification of the qualified fire safety expert who provided the training.
Copies of the fire safety expert's qualifications or credentials and staff training documentation will be maintained by the facility.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
08/18/2026
| Implemented |
| 2380.38(a)(1) | Staff 4 did not have record of completing orientation training within the first 30 days of employment. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | The CEO/Director will ensure that Staff 4 completes all required orientation training identified under 55 PA Code Chapter 2380.38 and that documentation of the completed orientation is maintained in the employee's training record.
The CEO/Director will conduct a review of all current staff training records to verify that required orientation training was completed and properly documented. Any additional staff identified as missing required orientation training will complete the required training and documentation will be maintained in their training record.
Staff responsible for hiring, onboarding, and training will be retrained on the requirements of 55 PA Code Chapter 2380.38(a)(1), including the requirement that applicable staff complete required orientation within 30 days after hire and prior to working alone with individuals.
The facility will implement a centralized new-hire training tracker that identifies each employee's date of hire, required orientation training, orientation due date, completion date, and verification of completion.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
08/18/2026
| Implemented |
| 2380.39(c)(1) | Staff members 1 and 2 did not have record of annual training on Person-Centered Practices. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The CEO/Director will ensure that Staff 1 and Staff 2 complete the required annual training in Person-Centered Practices in accordance with 55 PA Code Chapter 2380.39(c)(1). Documentation of the completed training will be maintained in each employee's training record.
The CEO/Director will conduct a review of all current staff training records to verify that applicable staff have completed the required annual Person-Centered Practices training.
Any additional staff identified as missing the required annual Person-Centered Practices training will be assigned the training for completion. Documentation of completed training will be maintained in each employee's training record.
Staff responsible for assigning, tracking, and maintaining annual training records will be retrained on the annual training requirements of 55 PA Code Chapter 2380.39.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
08/18/2026
| Implemented |
| 2380.39(c)(2) | Staff members 1 and 3 did not have record of annual training on Prevention, Detection, and Reporting of Abuse. | 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. | The CEO/Director will ensure that Staff 1 and Staff 3 complete the required annual training in Prevention, Detection, and Reporting of Abuse in accordance with 55 PA Code Chapter 2380.39(c)(2). Documentation of the completed training will be maintained in each employee's training record.
The CEO/Director will conduct a review of all current staff training records to verify that all applicable staff have completed the required annual training in Prevention, Detection, and Reporting of Abuse.
Any additional staff identified as missing the required annual training will be assigned the training for immediate completion. Documentation of completed training will be maintained in each employee's training record.
Staff responsible for assigning, tracking, and maintaining annual training records will be retrained on the requirements of 55 PA Code Chapter 2380.39, including the required annual training areas.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
08/18/2026
| Implemented |
| 2380.39(c)(3) | Staff members 1 and 2 did not have record of annual training on Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The CEO/Director will ensure that Staff 1 and Staff 2 complete the required annual training on Individual Rights in accordance with 55 PA Code Chapter 2380.39(c)(3). The training will address the individual rights requirements applicable to the facility under Chapter 2380. Documentation of the completed training will be maintained in each employee's training record.
The CEO/Director will conduct a review of all current staff training records to verify that all applicable staff have completed the required annual Individual Rights training.
Any additional staff identified as missing the required annual Individual Rights training will be assigned the training for immediate completion. Documentation of completed training will be maintained in each employee's training record.
Staff responsible for assigning, tracking, and maintaining annual training records will be retrained on the requirements of 55 PA Code Chapter 2380.39, including the requirement for annual training on Individual Rights.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
08/18/2026
| Implemented |
| 2380.39(c)(4) | Staff members 1 and 3 did not have record of annual training on Recognizing and Reporting Incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The CEO/Director will ensure that Staff 1 and Staff 3 complete the required annual training on Recognizing and Reporting Incidents in accordance with 55 PA Code Chapter 2380.39(c)(4). Documentation of the completed training will be maintained in each employee's training record.
The CEO/Director will conduct a review of all current staff training records to verify that all applicable staff have completed the required annual training on Recognizing and Reporting Incidents.
Any additional staff identified as missing the required annual training will be assigned the training for immediate completion. Documentation of completed training will be maintained in each employee's training record.
Staff responsible for assigning, tracking, and maintaining annual training records will be retrained on the requirements of 55 PA Code Chapter 2380.39, including the required annual training on Recognizing and Reporting Incidents.
The CEO/Director will be responsible for ensuring completion of this corrective action. |
08/18/2026
| Implemented |