| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 6/26/2025 at 10:44AM, there was a swing bar lock on the inside of the door leading to the front exit of the home causing an obstructed egress when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Swing Bar Lock was removed during the inspection on 6/26/25 after the home was notified of the violation. Later that same day, a picture of the unobstructed door was forwarded to the inspector on to substantiate compliance. |
06/26/2025
| Implemented |
| 6400.112(e) | The agency has only conducted one fire drill during the sleep hours in the past 12 months. The fire drill was dated 5/13/2025 and conducted at 12:13am. | A fire drill shall be held during sleeping hours at least every 6 months. | House manager will continue to notify staff during their shift when to conduct unannounced fire drill during the regulated sleeping hours of 11p-7a. |
08/06/2025
| Implemented |
| 6400.151(a) | Direct Service Worker (DSW) #2, date of hire 1/7/2025, had a physical examination completed 1/10/2025. The physical examination was not completed within 12 months prior to employment. | 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. | This was an oversight on the part of the PS, the worker was hired on 12/24, completed initial requirements to include training and physical with TB on 1/10/25, before their initial first workday with clients on the evening of 1/10/25. |
08/06/2025
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #2, date of hire 1/7/2025, had a Tuberculin skin testing by Mantoux method with negative results completed 1/10/2025. The Tuberculin skin testing was not completed within 12 months prior to employment. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | This was an oversight on the part of the PS, the worker was hired on 12/24, completed initial requirements to include training and physical with TB on 1/10/25, before their initial first workday with clients on the evening of 1/10/25. |
08/06/2025
| Implemented |
| 6400.171 | On 6/26/2026 at 10:42AM, a carton of eggs with a best by date of 6/8/2025 and a package of strawberries with what appears to be mold were in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Checklist has been prepared which highlights each staff persons responsibility during their shift. This will help ensure staff are completing their tasks including checking dates on food for expiration and best used by dates. |
08/06/2025
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 10/10/2024, does not include Individual #1's dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | This was an oversight, the assessment for Individual #1 dated July 12, 2024 included dislikes. Assessments currently identify (in accordance with 6400.181e(1-14) all areas to be addressed. Assessment has been revised to include dislikes. |
08/06/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 10/10/2024, does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The inspector provided additional clarification as to information that should be included in section 6400.181(e)(10) during the inspection. Assessment has been updated to include the details of lifetime medical history. |
08/06/2025
| Implemented |
| 6400.52(b)(1) | Chief Executive Officer #1 did not complete 12 hours of training during the last completed annual training year, dated 7/1/2023 - 6/30/2024. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | Training was completed during the required 2023-2024 training year. During the inspection, program specialist was not aware training records of CEO were needed since s/he no longer provides direct care so the records available at the inspection site. Inspector was made aware the CEO received the required training. Documentation was forwarded to the inspector on 7/21/25 once POC was made available to the agency. [Immediately, the agency will ensure that all training documentation for all staff is available to the Department for review when requested. DPOC by HDKP, HSLS, on 9/19/25]. |
07/22/2025
| Implemented |
| 6400.52(c)(1) | Chief Executive Officer #1 did not complete the following training topic during the last completed annual training year dated 7/1/2023 - 6/30/2024: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | PS showed the log demonstrating completion of the training to the inspector. CEO completed training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships as required on 2/23/24. Substantiation was emailed to the inspector on 7/21/25. [Immediately, the agency will ensure that all training documentation for all staff is available to the Department for review when requested. DPOC by HDKP, HSLS, on 9/19/25]. |
07/22/2025
| Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1 did not complete the following training topic during the last completed annual training year dated 7/1/2023 - 6/30/2024: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | PS showed the log demonstrating completion of the training to the inspector. CEO completed training on The prevention, detection and reporting of abuse as required on 2/23/24. Substantiation was emailed to the inspector on 7/21/25. [Immediately, the agency will ensure that all training documentation for all staff is available to the Department for review when requested. DPOC by HDKP, HSLS, on 9/19/25]. |
07/22/2025
| Implemented |
| 6400.52(c)(3) | Chief Executive Officer #1 did not complete the following training topic during the last completed annual training year dated 7/1/2023 - 6/30/2024: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | CEO completed annual training year dated 7/1/2023 - 6/30/2024 for Individual rights on 2/23/24. Substantiation was emailed to the inspector on 7/21/25. [Immediately, the agency will ensure that all training documentation for all staff is available to the Department for review when requested. DPOC by HDKP, HSLS, on 9/19/25]. |
07/22/2025
| Implemented |
| 6400.52(c)(4) | Chief Executive Officer #1 did not complete the following training topic during the last completed annual training year dated 7/1/2023 - 6/30/2024: Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | CEO completed training within the 7/1/2023 - 6/30/2024 training year for Recognizing and reporting incidents. The training was completed on 2/23/24. [Immediately, the agency will ensure that all training documentation for all staff is available to the Department for review when requested. DPOC by HDKP, HSLS, on 9/19/25]. |
08/06/2025
| Implemented |