| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff Four and Five were hired on 8/15/24, yet Criminal History was not requested until 11/7/24. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| The agency acknowledges the delay in requesting the background checks for Staff #4 and #5. This issue occurred due to an administrative oversight during onboarding. Once identified, the agency took immediate corrective action to ensure compliance. Pennsylvania State Police and FBI background checks were promptly initiated and have since been successfully completed. Both staff members were cleared and deemed eligible to continue providing direct support services. Documentation of their clearance results has been added to their personnel files, and the agency confirmed that there were no incidents during the interim period. Moving forward, the agency has taken steps to prevent similar lapses, as outlined below. |
06/22/2025
| Implemented |
| 6400.68(b) | The running water of the kitchen and bathroom returned with temperatures of 145.1F and 145.5F respectively, exceeding the allowable threshold of 120F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Daily water temperature checks are conducted by staff as part of the agency¿s routine environmental safety protocol. On April 30, 2025, staff recorded elevated hot water temperatures at the residence, which triggered an automated alert in the agency¿s internal monitoring system. In response, a maintenance request was promptly submitted to the apartment complex administration to lower the water heater setting. The apartment¿s maintenance team is currently addressing the issue. Additionally, the agency has requested that faucet limiters be installed at frequently used taps to restrict hot water output, and the front office has confirmed that this request is in progress.
To ensure the immediate safety of Individual #3, a temporary safety protocol has been implemented. Staff are required to manually test water temperature at all faucets before use and assist the individual as needed to prevent accidental exposure to excessively hot water. All temperature logs, maintenance communications, and staff instructions have been documented and are available for review. Staff have also received re-training on water safety procedures and the importance of promptly reporting and escalating temperature concerns. |
06/24/2025
| Implemented |
| 6400.111(f) | The fire extinguisher in the kitchen (on the wall) did not have a inspection tag verifying that it has been checked annually. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The agency identified in December 2024 that the wall-mounted fire extinguisher provided by the apartment complex lacked a valid inspection tag and could not be confirmed as having been inspected by a certified fire safety expert. Since the extinguisher was not under the agency¿s control, a proactive decision was made at that time to purchase a new, agency-owned fire extinguisher that had been properly inspected and certified in accordance with 55 PA Code Chapter 6400.111(f). This compliant extinguisher was placed on the kitchen countertop in December 2024 and was already present in the apartment at the time of the annual inspection. To prevent confusion, the original wall-mounted extinguisher was subsequently removed and returned to the apartment complex after the inspection and following the exit meeting. The residence now contains only one fire extinguisher, which is properly certified, inspected, and fully compliant with regulatory requirements. |
06/17/2025
| Implemented |
| 6400.46(d) | The following Staff One was not trained in CPR/FA: | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Upon review, it was determined that Staff One had not completed the required CPR, First Aid, and Heimlich maneuver training within the mandated time frame. As corrective action, the staff member was immediately scheduled for and completed an in-person CPR/First Aid training conducted by a certified instructor affiliated with a recognized health care training organization. Certification credentials have been received and are available for licensing verification. Staff One is now in full compliance with the regulation. |
06/16/2025
| Implemented |
| 6400.46(d) | CPR records for the following staff two and three did not include an in-person training component | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Upon discovering that Staff Two and Staff Three did not complete the required in-person CPR/First Aid training, the agency conducted a comprehensive review of all staff CPR certifications. It was determined that additional staff across the agency had also completed only online CPR/First Aid courses without the required hands-on, in-person component.
As a corrective measure, all affected staff, including Staff Two and Staff Three, were immediately scheduled and brought in for in-person CPR, First Aid, and Heimlich maneuver training conducted by a certified instructor affiliated with a recognized healthcare organization. All participants successfully completed the training and were issued updated certification verifying in-person instruction. These credentials have been reviewed and filed in each employee¿s personnel record and are available for licensing verification.
Going forward, in-person CPR/First Aid training is now mandatory for all agency staff who provide direct support or supervision to individuals. Online-only certifications will no longer be accepted. This ensures full compliance with 55 PA Code Chapter 6400.46(d) and reinforces the agency¿s commitment to the safety and well-being of the individuals we serve. |
06/19/2025
| Implemented |