| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was installed on 8/22/24 and not cleaned until 9/12/2025. Needs to be completed annually. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Wheelhouse failed to have a tickler system in place to serve as a reminder for the annual furnace cleaning.
On 10/14/25, the Executive Director contacted Topline to put in a reminder for July 2026 to conduct an annual inspection and cleaning of the central air unit. |
10/14/2025
| Implemented |
| 6400.34(a) | The individual rights were not signed in the record. | 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. | On 2/7/25, the agency's individual rights attestation form did not contain a space for the individual, family or guardian to date the form.
10/14/25, individual #1 dated the individual's right attestation form. Wheelhouse pulled the individual's right attestation form from rotation and placed the updated copy in the folder to be used agency wide. |
10/14/2025
| Implemented |
| Article X.1007 | Wheelhouse is required to maintain criminal history checks and hiring policies for the hiring, retention, and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15).
According to OAPSA regulations, Criminal Background checks must be completed on or before the staff members' first day working with individuals. Staff person #3 was hired on 2/20/2025 and their first day working with individuals was 2/22/2025, but their criminal background check was not completed until 2/26/2025. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | The human resource department failed to complete staff person #1 criminal history check within five days of employment.
On 10/14/25, the Executive Director re-educated the human services department on the regulatory for completing staff members criminal history. The human resource has completed an internal audit all criminal history background check for employees is within their dates of hire. |
10/14/2025
| Implemented |