| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(c) | The background check for staff number one on file was completed on 5/17/2023 and the DOH 7/29/2024, which exceeds the one-year window to be utilized prior to date of hire without completing a new criminal history check. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| The Executive Director failed to ensure that staff member #1 PSP criminal history clearance was within the one year window.
On 3/11/25, a new criminal history clearance was completed for staff #1. |
03/11/2025
| Implemented |
| 6400.112(e) | There was no overnight drill completed in a six-month time frame. Drills conducted the following dates at the following times: 10/19/24 (7:31pm), 9/3/24 (7:00pm), 8/5/24 (6:30pm), 7/12/24 (6:27pm), 6/20/24 (7:11pm), 5/2/24 (2:00pm). | A fire drill shall be held during sleeping hours at least every 6 months. | The house supervisor failed to ensure that an overnight fire drill was conducted every six month per regulatory compliance.
On 3/13/25, an overnight fire drill was completed for residential site.
The house supervisor was reeducated on the time frames for overnight fire drills. |
03/13/2025
| Implemented |
| 6400.151(a) | No physical on file for staff number one who began employment on 7/29/2024. | 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. | At the time of inspection staff #1 physical was provided to the Department for determine compliance.
Staff #1 physical exam was completed on 11/17/24. A copy of staff #1 physical exam was provided to the Department. |
11/17/2024
| Implemented |
| 6400.46(b) | 6400.46 (b) No record of annual training staff number one by 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 Executive Director failed to ensure that staff #1 received fire safety training.
On 3/14/25, J-30 Solutions has contracted with Elsevier Direct Course training course for all staff to be able to complete the Department approved fire safety online training course. |
03/14/2025
| Implemented |