| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was baked in grime in the kitchen's oven. | Clean and sanitary conditions shall be maintained in the home. | The oven was deep-cleaned immediately. |
06/25/2025
| Implemented |
| 6400.71 | There were no emergency telephone numbers by the basement telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency contact numbers were printed and posted next to the basement phone. |
06/25/2025
| Implemented |
| 6400.77(b) | There was no thermometer in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A thermometer was added to the first aid kit immediately and checked against the required inventory. |
06/25/2025
| Implemented |
| 6400.105 | The lint trap of the dryer was not cleaned of its lint. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The lint trap was cleaned during the inspection. All staff were retrained on daily dryer maintenance. |
06/25/2025
| Implemented |
| 6400.110(a) | The first floor and basement smoke detectors were inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Both smoke detectors were replaced and tested successfully. A video was sent to the auditor for confirmation. |
06/25/2025
| Implemented |
| 6400.112(c) | -January and December drills did not have exit route documented.
April and February did not have evacuation times documented. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drill logs were updated for accuracy. Staff were retrained on documentation requirements for time, exit route, and alarm operability. |
06/25/2025
| Implemented |
| 6400.112(f) | May, April, March and February drills listed all same exit route of front door. Alternate exits need to be used. | Alternate exit routes shall be used during fire drills. | A revised drill schedule was created to rotate exit routes. Upcoming drills will utilize rear and basement exits where applicable. |
06/25/2025
| Implemented |
| 6400.24 | There was no access to a locked bathroom in the basement. 55 Pa code § 20.34 states: The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The basement bathroom was unlocked immediately following the inspection. A written directive was issued to all staff to ensure access is never restricted during inspections. |
06/25/2025
| Implemented |