| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was a bottle of dish detergent in the kitchen that falls under the standard of having poisonous ingredients. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The bottle of dish detergent containing poisonous ingredients was immediately removed from an accessible area and secured in a locked cabinet designated for hazardous substances. Staff were reminded of the requirement to store all cleaning and potentially harmful products in locked areas, in accordance with 55 PA Code Chapter 6400 regulations. |
04/04/2025
| Implemented |
| 6400.64(e) | The trash cans kept outside of the home did not have lids. | Trash receptacles over 18 inches high shall have lids. | Lids were purchased and immediately placed on all outdoor trash cans to comply with sanitation and safety regulations. |
04/04/2025
| Implemented |
| 6400.67(a) | The following areas of the home are in need of repair:
-The left closet door in Individual #2's room was off the track and the right door would not open.
-The bathroom appears to have been plastered on the inside and is peeling.
The dishwasher had a black substance consistent with mold, in the bottom. | Floors, walls, ceilings and other surfaces shall be in good repair. | The left closet door in Individual #2¿s room has been placed back on the track, and the right door has been repaired to open and close properly.
The bathroom walls have been cleaned, sanded, and repainted to address the peeling plaster.
The dishwasher was thoroughly cleaned and sanitized to remove any mold or buildup, and a cleaning solution safe for regular use was implemented to prevent recurrence. |
04/04/2025
| Implemented |
| 6400.81(k)(2) | The bed in Individual #1's room did not have a solid foundation. The boxspring appears to be in a slanted position indicating an unsteady foundation. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | The bed in Individual #1¿s room was immediately inspected. The box spring and bed frame were replaced to ensure a solid and stable foundation. |
04/04/2025
| Implemented |
| 6400.81(k)(6) | The were no mirrors present in any of the bedrooms. | In bedrooms, each individual shall have the following: A mirror. | Mirrors have been installed in all bedrooms to meet personal grooming and environmental standards. |
04/04/2025
| Implemented |
| 6400.101 | The locking mechanism on the back door requires a key to exit creating a potential fire hazard for exiting. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The current back door lock, which requires a key to exit, will be replaced with a code-compliant, single-action lock that allows for immediate egress without a key |
04/04/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's annual physical dated 10/7/24 did not include information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1¿s primary care provider was contacted, and an updated physical form was requested and obtained to include pertinent diagnosis information required in the event of an emergency. The revised physical was reviewed and placed in the individual¿s medical file. |
04/04/2025
| Implemented |
| 6400.34(a) | Individual #1's current rights documents was not updated to include R through S. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual #1¿s rights document will be updated immediately to include sections R through S. The corrected document will be reviewed and re-signed with the individual to ensure full understanding and compliance. |
04/04/2025
| Implemented |
| 6400.141(d) | Individual #1's annual physical dated 10/7/24 did not include a TB test. As James was recently admitted to the agency the TB testing was required. | Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. | James is scheduled for a TB test for 4/10/25 10am to ensure compliance with admission health requirements. |
04/04/2025
| Implemented |