| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | There is a signed Room and Board contract between the provider and Individual #1, dated 04/04/2025; however, expense records and receipts show that Individual #1 was charged for multiple grocery purchases in July and August 2025. As part of the Board agreement, the provider is responsible for these types of purchases. | Individual funds and property shall be used for the individual's benefit. | The individual was never billed or held financially responsible for groceries. The provider has adhered to the requirements of the signed Room and Board agreement. To strengthen compliance and enhance documentation practices moving forward, the provider will ensure that financial records and supporting documentation clearly reflect that grocery purchases are covered by the agency in accordance with the contract. The Chief Executive Officer will monitor this process and is responsible for ensuring continued compliance. |
08/18/2025
| Implemented |
| 6400.22(e)(3) | For July and August 2025, the provider was unable to provide documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of Individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The provider will ensure that all purchases exceeding $15 made on behalf of Individual #1 are supported by an original receipt or verifiable expense record. Effective immediately, staff will be required to submit receipts for all purchases at the time of transaction. Administrative staff will maintain these records in the individual¿s financial file, in accordance with 55 Pa. Code Chapter 6400 regulations. |
08/25/2025
| Implemented |
| 6400.43(b)(1) | There is a signed Room and Board contract between the provider and Individual #1, dated 04/04/2025; however, expense records and receipts show that Individual #1 was charged for multiple grocery purchases in July and August 2025. As part of the Board agreement, the provider is responsible for these types of purchases. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The individual was never billed or financially responsible for groceries. The provider has adhered to the requirements of the signed Room and Board agreement. To strengthen compliance and enhance documentation practices moving forward, the provider will ensure that financial records and supporting documentation clearly reflect that grocery purchases are covered by the agency in accordance with the contract. |
08/25/2025
| Implemented |
| 6400.64(a) | Throughout the basement, baseboards and various parts of drywall closest to the basement floor were discolored and appeared to be water damaged.
Additionally, there were two (2) chairs in the basement with cushions covered in a spotted, mold-like substance. | Clean and sanitary conditions shall be maintained in the home. | The provider has removed and disposed of the two (2) chairs with mold-like substance to eliminate any potential health and safety risk. The affected baseboards and sections of drywall were inspected, cleaned, and replaced where necessary. A licensed contractor was engaged to assess and remediate the water damage and ensure the area is safe and sanitary. |
08/18/2025
| Implemented |
| 6400.64(f) | The trash receptacle in the backyard did not have a cover/lid. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The provider immediately replaced the trash receptacle with one that includes a secure cover/lid to prevent pest access and maintain sanitary conditions. |
08/15/2025
| Implemented |
| 6400.67(b) | Broken tiles were found on the edge of the stairwell landing leading from the top of the 2nd floor down to the 1st floor. The broken floor tiles present a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The provider immediately removed and replaced the broken floor tiles on the stairwell landing to eliminate the tripping hazard and ensure a safe walking surface. A maintenance inspection was completed to verify that the repair met safety standards. |
08/18/2025
| Implemented |
| 6400.70 | The home was not equipped with an operable, non-coin-operated telephone with an outside line that is easily accessible to individuals and staff. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The provider immediately added a cordless, non¿coin-operated landline telephone with an outside line to the home to ensure accessibility for both individuals and staff. The phone has been installed in a common area that is easily reachable and will remain operable at all times. |
08/18/2025
| Implemented |
| 6400.71 | Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center could not be found posted on or near a telephone or in the home. | 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.
| The provider immediately posted the emergency telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center in a visible location near the home¿s landline telephone. The posting is clear, legible, and accessible to both staff and individuals in the event of an emergency. |
08/18/2025
| Implemented |
| 6400.72(a) | The window covering on the first-floor bathroom window was torn and no longer covered the full window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The provider immediately removed the damaged window covering and replaced it with a new, fully functional covering that ensures the window is completely covered and privacy is maintained at all times. |
08/19/2025
| Implemented |
| 6400.76(a) | Dining room chair legs on one (1) chair were loose and not stable enough to safely sit in the chair. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The provider immediately removed the unstable dining room chair from use. The chair was repaired to restore stability and safety, and the dining area was re-inspected to ensure all other chairs and furniture are secure and safe for use. |
08/19/2025
| Implemented |
| 6400.80(b) | Trash, debris, and discarded furniture were observed throughout the backyard area. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The provider immediately removed all trash, debris, and discarded furniture from the backyard. The area was cleaned and restored to a safe and sanitary condition. |
08/15/2025
| Implemented |
| 6400.111(a) | All floors of the home, including the basement, were equipped with fire extinguishers that do not meet the minimum required 2-A rating for each floor. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | All floors of the home, including the basement, were equipped with fire extinguishers that meet the minimum required 2-A rating for each floor. |
08/18/2025
| Implemented |
| 6400.111(c) | The kitchen was not equipped with an operable fire extinguisher that meets the minimum required 2A-10BC rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The provider immediately removed the non-compliant fire extinguishers and replaced them with fire extinguishers that meet or exceed the minimum 2-A rating requirement for every level of the home, including the basement. Documentation of purchase and installation has been retained in agency records. |
08/18/2025
| Implemented |