| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There were spider webs throughout basement.
The bathroom toilet bowl was dirty.
The bathtub was dirty with a dead insect inside of it.
The kitchen windows in between window and screen are dirty. | Clean and sanitary conditions shall be maintained in the home. | The basement was thoroughly cleaned immediately upon identification of the deficiency. All spider webs were removed from walls, ceilings, corners, and other affected areas. |
04/01/2026
| Implemented |
| 6400.64(e) | There was no outside trash receptacle. | Trash receptacles over 18 inches high shall have lids. | An appropriate outdoor trash receptacle with a secure lid has been purchased and placed at the exterior of the home to ensure proper waste disposal. |
04/01/2026
| Implemented |
| 6400.66 | The outside backdoor light was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The deficiency regarding the outside backdoor light being inoperable was corrected immediately upon discovery. The light fixture was inspected, and the nonworking bulb was replaced to restore proper lighting. Staff also verified that the fixture was functioning correctly after replacement. |
04/01/2026
| Implemented |
| 6400.68(a) | The kitchen sink has a very poor stream of water flow. | A home shall have hot and cold running water under pressure. | Faucet and aerator inspected and cleaned/replaced as needed
- Plumbing assessed and repairs completed
- Water pressure restored for both hot and cold water
- All fixtures tested for compliance |
04/01/2026
| Implemented |
| 6400.73(a) | The handrail to the back porch is on the right of the steps; however, the back door opens to the right and blocks the handrail to the point that the handrail cannot be used to assist with descending to the second step. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The deficiency regarding the handrail at the back porch being obstructed by the door was addressed immediately upon identification. The door swing and handrail accessibility were evaluated to ensure safe use of the steps. Adjustments were made to eliminate the obstruction, ensuring that the handrail is fully accessible and can be used effectively when ascending and descending the steps. |
04/01/2026
| Implemented |
| 6400.110(e) | There is a basement, first floor and second floor of the property and the smoke detectors are not interconnected, although there are operable smoke detectors on each level. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The deficiency regarding the smoke detectors not being interconnected throughout the basement, first floor, and second floor was addressed immediately upon identification. Although operable smoke detectors were present on each level, they were not interconnected as required. A licensed professional was contacted to install an interconnected smoke detection system throughout the home to ensure that all alarms sound simultaneously and are audible throughout the residence.
The installation of the interconnected smoke detector system ensures compliance with regulatory requirements for homes serving four or more individuals or homes with three or more stories. The system was tested after installation to confirm proper functionality and audibility across all levels of the home. |
04/01/2026
| Implemented |
| 6400.32(h) | All three bedrooms have blinds and window coverings that are damaged, which limits privacy. | An individual has the right to privacy of person and possessions. | The deficiency regarding damaged blinds and window coverings in all three bedrooms was corrected immediately upon identification. The damaged blinds were removed and replaced with new, fully functional window coverings to ensure each individual's right to privacy is maintained at all times.
All newly installed blinds/window coverings were inspected to ensure proper functionality, full coverage, and ease of use for the individuals residing in the home |
04/01/2026
| Implemented |
| 6400.46(b) | There was no documentation that staff member 2 has completed fire safety training from a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The deficiency regarding the lack of documentation confirming that Staff Member 2 completed annual fire safety training by a fire safety expert was addressed immediately upon identification. Staff Member 2 was scheduled for and completed fire safety training conducted by a qualified fire safety expert. Documentation of the completed training has been obtained and placed in the employee's personnel file.
All required training topics, as outlined in regulatory requirements, were covered during the training to ensure compliance and staff competency in fire safety procedures |
04/01/2026
| Implemented |
| 6400.52(c)(1) | Staff member 1 & 2 have not completed the application of person-centered practices, community integration, etc. training for the training year. | 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 deficiency regarding Staff Members 1 and 2 not completing the required annual training in the application of person-centered practices, community integration, individual choice, and supporting individuals was addressed immediately upon identification. Staff Members 1 and 2 have been scheduled for and have completed the required training. Documentation verifying completion has been obtained and placed in the employee's personnel file.
The training completed included all required components in accordance with subsections (a) and (b), including the application of person-centered practices, promotion of community integration, support of individual choice, and assisting individuals in developing and maintaining meaningful relationships. |
04/01/2026
| Implemented |
| 6400.52(c)(2) | Staff members 1 and 2 have not completed the prevention, detection and reporting of abuse, suspected abuse and alleged abuse training for the training year. | 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 deficiency regarding Staff Members 1 and 2 not completing the required annual training in the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse was addressed immediately upon identification. Staff Members 1 and 2 have been scheduled for and have completed the required training. Documentation verifying completion has been obtained and placed in the employee's personnel file.
The completed training encompassed all required components in accordance with subsections (a) and (b), including the prevention, detection, and reporting of abuse in compliance 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 all applicable protective services regulations. |
04/01/2026
| Implemented |