| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | There was a total of 22 hours of training done on 03/26/25 for staff member 1.
There was a total of 22.5 hours of annual training done on 03/27/25 for staff member 2.
Training dated 12/1/2024 and 12/02/2024 exceeds the 8-hour work day for staff member 4.
The training hours for the staff members exceed the normal workday. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Company training & orientation policies have been updated to reflect allowable daily limit on training/orientation. |
11/14/2025
| Implemented |
| 6400.66 | The exterior light at front door entrance is detached from the wall and does not turn on. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Proper & sufficient lighting has been installed in every room, hallway, stairway, doorway, porch, ramp, fire escape and every other room/operable area of the house. |
10/20/2025
| Implemented |
| 6400.151(a) | There was no physical exam prior to 08/28/24 for staff member 2. | 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. | Staff member 2 has put in a request with their doctor's office for a copy of their annual physical conducted between 08/27/2023 & 08/27/2024. Staff members' records are also being audited to ensure that any staff who comes into direct contact with individuals or provides any applicable services, have documentation of annual physical exams within 12 months prior to employment and every 2 years thereafter. |
10/20/2025
| Implemented |
| 6400.151(b) | The 09/14/25 physical exam for staff member 3 was performed by a chiropractor and not a licensed physician, certified nurse practitioner or licensed physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff member 3 has scheduled a physical examination to be performed by a licensed physician. |
11/14/2025
| Implemented |
| 6400.52(c)(2) | Staff member 1 did not complete the prevention, detection and reporting of abuse, suspected abuse and alleged abuse training. | 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. | Staff member 1 has completed the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse training. |
11/14/2025
| Implemented |
| 6400.52(c)(4) | Staff member 1 did not complete the recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff member 1 has completed the recognizing and reporting incidents training. |
11/14/2025
| Implemented |