| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The staff does not have a Pennsylvania criminal history record check within 5 working days after the date of hire or no more than 1 year prior to the person's date of hire.
Staff $3 (03/13/24) DSP
Staff#7 (03/13/24) DSP
Staff #6 (03/13/24) DSP
Staff #5 (03/13/24) DSP
Staff #4 (03/19/24) DSP
Staff #2 (03/13/24) House Supervisor | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The agency failed to provide the department with a copy of the staff criminal histry check at the time of the inspection.
On 6/25/24 the Executive Director and HR complete an audit all staff files to ensure all staff working in the home had a background check completed within 5 days after the date of hire. |
06/28/2024
| Implemented |
| 6400.106 | The furnace in the home did not have inspections completed. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The agency failed to have a tickler system in place for the annual cleaning of the furnace.
On 4/15/24, the house supervisor scheduled a furnace cleaning for the home. |
06/25/2024
| Implemented |
| 6400.151(b) | Documentation that the staff has a physical examination completed within 12 months prior to employment up to and including currently was not provided. (That includes free of communicable diseases and TB testing). | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The agency failed to provide the inspector with documentation of staff physical examination.
On 4/20/24, the Executive Director provided the agency with the staff physical examination. |
06/28/2024
| Implemented |
| 6400.151(b) | Staff #3 works with individual daily and does not have a physical examination completed within 12 months prior to employment up to and including currently. (That includes free of communicable diseases and TB testing). | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The agency failed to ensure staff #3 had a completed physical examination prior to employment.
On 4/15/24, the agency human resource department completed an audit of individual #3 personnel file. Staff #3 was scheduled for a physical examination. |
06/28/2024
| Implemented |
| 6400.46(a) | The Program specialists and direct service workers were not trained before working with individuals in general fire safety by a fire safety expert. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The agency failed to provide the department with a copy of the staff fire safety training signature sheet.
On 4/15/24 the house supervisor obtain a copy of the staff fire safety training sheet from the fire safety trainer. |
06/28/2024
| Implemented |
| 6400.51(a)(1) | Staff #3 did not complete orientation prior to working with the individual within 30 days after hire, staff was hired 03/13/24. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | The house supervisor failed to document the completion of staff # 3 orientation on the agency's orientation form.
On 6/25/24, an orientation completion form was completed for staff #3 by the house supervisor. |
06/28/2024
| Implemented |
| 6400.52(a)(3) | Documentation of annual training was completed for the Staff #1 (program specialist) was not provided at time of inspection. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | The agency failed to have the program specialist's training record readily available at the time of the inspection.
On 6/5/24, program specialist training record was provided to the department. |
06/28/2024
| Implemented |