| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | PA criminal history record checks were requested late based on the date of hire for the following staff members: #2 requested 11/11/24 under review, hired 9/1/24; #3 requested 8/1/24 cleared, hired 6/24/24; #4 requested 11/11/24 cleared, hired 7/5/24; #5 requested 9/6/24 cleared, hired 6/24/24; #1 requested 8/13/24 cleared, hired 6/24/24; #8 - hire date 6/24/24, check 7/30/2024 | 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.
| New staff employee checklist utilized for employee on board document which shows the criminal history completed within 5 days of hire. |
12/02/2024
| Implemented |
| 6400.67(a) | The dishwasher door is missing its handle. A kitchen cabinet door is missing 3 of its handles. | Floors, walls, ceilings and other surfaces shall be in good repair. | Dishwashers handle fixed/replace on 11/21/2024 & 12/15/24.
Checklist will be completed Program manager on weekly basis for physical site as of 12/15/24. |
12/15/2024
| Implemented |
| 6400.68(b) | The water temp read 136 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water temperature value fixed to regulate temperature under 120 degrees on 11/19/2024 and retested 11/26/24.
Physical site checklist will be utilized weekly to remain in compliance on all sites. |
11/19/2024
| Implemented |
| 6400.107 | There was a space heater located in the basement and being used. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The portable space heater was removed immediately from the basement it is not being used any where in the home on 11/19 and follow-up 11/26/24.
Physical site checklist will be completed weekly to assure no items are in the home that are permitted. |
11/19/2024
| Implemented |
| 6400.112(f) | The fire drill records did not show that alternate exit routes were being used for the past several months. Each month showed that only the front door was being used for evacuations. | Alternate exit routes shall be used during fire drills. | Fire drill completed on 11/19/2024 and re-run 11/26/24 to show alternate route for the evacuation of the individual within regulations.
Fire drill will be complete monthly to show alternative routes per the 6400 regulations. |
11/19/2024
| Implemented |
| 6400.141(c)(6) | Physical exam completed for individual #1 was completed on 7/3/24. The initial TB results are needed. There was no record of a Tuberculin skin testing by Mantoux method with negative results on file at the time of the review. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual #1 received their Tuberculin skin test by Mantoux method with a negative result on 6/28/2024 from previous placement.
Staff checklist developed for monthly checks to determine physicals are fully complete with TB testing every 2 years. |
11/19/2024
| Implemented |
| 6400.151(a) | Staff #1 DOH 6/24/24 -- Staff #1 did not have a physical exam on file at the time of the review. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | A physical exam completed by staff on 12/10/2024.
Staff checklist developed upon hire. Staff will have physical before working in any homes with individual. |
12/10/2024
| Implemented |
| 6400.151(c)(3) | Staff Member #6's physical does not indicate their communicable disease status. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The staff member #6 physical was completed to show the staff is free from communicable diseases on 12/10/2024
Staff checklist developed upon hire. Staff will have physical before working in any homes with individual. |
12/10/2024
| Implemented |