| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | At 12:36PM, an unlabeled spray bottle containing an unidentifiable liquid and a spray bottle containing a bluish gray liquid with "Do not use on mirrors" handwritten on masking tape on one side and "antibacterial bathroom" handwritten on the other side, were stored with a variety of other cleaning supplies. | Poisonous materials shall be stored in their original, labeled containers. | Admin 1 removed the unlabeled bottles and the concentrated cleaning chemical from the site on 5/28/2025
All agency staff received a retrain on poisons (55 PA Code 6400.62
Physical site checklist updated to highlight the infraction for staff to check monthly
Admin 1 will do quarterly checks to ensure all poisons are labeled and in their original container |
06/06/2025
| Implemented |
| 6400.74 | At 12:13PM, the outside steps from the porch in the rear of the home did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Admin 1 added nonskid strips to the stairs on 5/29/2025
Physical site checklist updated with inclusion of out door stairs- check for deterioration of non skid strips and notify Admin 1 if need replacing. This form is turned in at the end of every month and is filled in by the staff whose shift falls on the last day of the month. |
06/06/2025
| Implemented |
| 6400.80(b) | At 12:13PM, the handrails, on either side of the six outside steps in the rear of the home, were overgrown with shrubbery obstructing safe use of the handrails posing a falling risk. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Shrubs were immediately removed by Admin 1 and Program specialist on 5/29/2025
Staff retrained on Fire drills which included a discussion of the importance of clear egress for our individual's safety. |
06/06/2025
| Implemented |
| 6400.101 | At 10:45AM, the front door was equipped with a chain lock posing an obstructed egress when engaged. At 12:04PM, the outside door in the garage was equipped with a foot operated latch lock at the bottom an obstructed egress when engaged. At 12:10PM, the basement door was equipped with a sliding bolt lock posing an obstructed egress when engaged. In addition, at 12:10PM, the four outside steps and the outside area at the basement door egress was obstructed by and contained multiple tripping, slipping and falling hazards to include a garden hose strewn across the four outside steps, overgrown plants, dirt, leaves, sticks, mossy areas, a loose red brick and a full size portable basketball hoop. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Chain lock removed by Program Specialist on 5/28/2025. Foot latch removed by Program specialist on 5/28/2025. Admin 1 removed the sliding bolt on basement door on 5/28/2025. Admin 1 removed debris, moss and overgrown plants from basement door egress on 5/29/2025. Admin 1 moved hose to far end of the house where the water nozzle is and placed on a hose stand on 5/29/2025. Basket ball hoop was removed by Program Specialist on 5/29/2025 |
06/06/2025
| Implemented |
| 6400.110(b) | At 12:15PM, the closest smoke detector was twenty feet-four inches from Individual #1's bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Program specialist added a new smoke detector in the hallway directly outside of individual 1's bedroom door(within 6 feet) |
05/29/2025
| Implemented |