| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | Direct Service Worker #4, date of hire 10/28/24, had a Pennsylvania State Police criminal history check completed on 2/24/25. This exceeds within 5 working days after date of hire. On 11/14/25, Chief Executive Officer #1 provided documentation via e-mail that a Pennsylvania State Police criminal history check was also completed on 02/25/24 for Direct Service Worker #4. The criminal history check conducted on 02/25/24 was not available for review during the inspection on 11/13/25; therefore, compliance could not be measured. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | Office Administrator and CFO were retrained on 11/17/2025 on items that need to be completed prior to staff members being hired. CEO created a form for pre-employment items needed prior to someone working with our individuals. Within this form items are listed along with dates to measure compliance. |
11/17/2025
| Implemented |
| 2380.20(c) | Direct Service Worker #3, date of hire 4/14/25, had a Pennsylvania State Police criminal history check completed on 8/29/23. This exceeds more than 1 year prior to date of hire. | Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire. | Office Administrator and CFO were retrained on 11/17/2025 on items that need to be completed prior to staff members being hired. CEO created a form for pre-employment items needed prior to someone working with our individuals. Within this form items are listed along with dates to measure compliance. A Pennsylvania State Police criminal history check was also done on 11/17/2025 |
11/17/2025
| Implemented |
| 2380.59(b) | At 12:11 PM, the water temperature measured 128.3 Fahrenheit at the men's restroom sink.
At 12:13 PM, the water temperature measured 130.4 Fahrenheit at the women's restroom sink.
At 12:15 PM, the water temperature measured 128.8 Fahrenheit at the men's restroom sink. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | To correct the non-compliance with 2380.59 regarding hot water temperature, the facility immediately adjusted the building's hot water heater on 11/13/2025 at 230pm. All staff responsible for maintenance have been retrained on 11/17/2025 on the required water temperature range and documentation procedures. The Maintenance Supervisor will oversee and ensure ongoing compliance with this regulation. |
11/17/2025
| Implemented |
| 2380.113(a) | Direct Service Worker #2, date of hire 09/15/25, had an initial physical examination completed on 09/16/25. This is not prior to employment. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Office Administrator was retrained on 11/17/2025 on items that need to be completed prior to staff members being hired. This will ensure documentation is done prior to someone being hired and starting orientation. |
11/17/2025
| Implemented |
| 2380.113(c)(3) | Chief Executive Officer #1 had a physical examination completed on 04/22/25. The physical examination did not include a signed statement that the staff person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions). This section of the physical was left blank. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | To correct the non-compliance, CEO #1 will return to the medical provider to obtain a signed statement confirming that the staff person is free of serious communicable diseases as required by 28 Pa. Code §27.2. Once obtained, the completed statement will be placed in the CEO's personnel file by 12/15/2025. To prevent this issue from occurring in the future, Trusted Living care has updated its Physical Examination Form Checklist to include a required verification line for the communicable disease statement. The office admin/ CEO will now review all physical examinations for completeness prior to allowing an employee to begin or continue work. CEO has received refresher training on documentation requirements on 11/17/25. |
11/17/2025
| Implemented |