| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home did not complete a self-assessment within the required timeframe. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The CEO will complete self-assessments in the March-May timeframe in order to ensure compliance |
09/09/2026
| Accepted |
| 6400.15(c) | The self-assessment did not include a complete summary of corrections. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| CEO will ensure that self-assessment's and subsequent self-violations have appropriate plans of correction. |
09/09/2026
| Accepted |
| 6400.21(a) | Staff #4's date of hire was 04/02/26 and they did not have a criminal history check until 08/29/26, which was not within 5 working days after the person's date of hire. | 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.
| Business manager will submit an application for Pennsylvania criminal history immediately after hire |
09/11/2026
| Accepted |
| 6400.22(e)(3) | There are no receipts for the following transaction for Individual #1:
On Individual #1's Debit card- 08/10/26 for pizza in the amount of $16.13 and 08/24/26 at The Net for drinks in the amount of $60.
On the Individual's Credit Card-
08/25/26 at Best buy in the amount of $63.59
08/26/26 at Weis for a gift card in the amount of $50.00
08/26/26 from Amazon in the amount of $15.88
08/26/26 from Amazon in the amount of $96.60
08/27/26 from Door Dash in the amount of $57.61
08/27/26 from Issac's in the amount of $28.18
08/27/26 from Amazon in the amount of $19.99
08/28/26 from Door dash in the amount of $73.63
08/29/26 from Amazon in the amount of $46.98
08/29/26 from Amazon in the amount of $26.96
08/30/26 from Target in the amount of $43.67 | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Program specialist will retrain staff in financial record keeping. If Individual 1 does not get or provide a receipt, then one will be written out and signed by individual one and placed in financial book |
09/18/2026
| Accepted |
| 6400.64(a) | At the time of the 09/02/26 inspection, there was a mold-like substance on the bottom of the safety bar in the main bathroom. | Clean and sanitary conditions shall be maintained in the home. | House manager removed bar and cleaned the mold like substance. |
09/03/2026
| Accepted |
| 6400.111(f) | The fire extinguisher inspections were not provided so it is uncertain if the fire extinguishers were inspected annually. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | CEO was not able to verify credentials of who tagged fire extinguisher. Fire extinguisher has been switched and taken to Clark fire prevention to be tagged and inspected. |
09/22/2026
| Accepted |
| 6400.151(a) | Staff #3 date of hire was 5/19/26 but they did not have a physical until 5/20/26 which was not within 12 months prior to employment.
Staff #4's date of hire was 4/2/26 but they did not have a physical until 4/17/26 which was not 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. | CEO will change orientation process of new hires. They will be sent for Physical and TB test before completing orientation |
09/09/2026
| Accepted |
| 6400.151(b) | Staff #2 had a physical on 1/15/26 and the physician did not sign and date the physical form | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff #2 will obtain a signed and dated copy of Physical from 1/15/26 |
09/02/2026
| Accepted |
| 6400.151(c)(3) | Staff #2 had a physical on 1/15/26 and the physical form did not identify if the staff person was free of communicable disease. | 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. | Staff #2 will obtain a copy of physical stating free from communicable disease |
09/02/2026
| Accepted |
| 6400.211(b)(3) | Individual #1's face sheet did not document the name, address, and phone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| House manager has updated face sheet to include the name, address and phone number of who can give consent for emergency medical treatment |
09/08/2026
| Accepted |
| 6400.213(3) | Individual #1's face sheet does have a line for identifying marks but it is documented as N/A. This is applicable to the individual and if there are not any identifying marks, it needs to say none.
Individual #1's face sheet does have a line for religion but it is documented as N/A. This is applicable to the individual and if the individual does not have a religion, it needs to say none. | Each individual's record must include the following information: Identifying Marks and Religion. | House manager has updated Face Sheets changing the N/A for Identifying marks to Yes to reflect Tattoos. House manager has also updated face sheet for religion from N/A to a no as requested by Individual 1 |
09/18/2026
| Accepted |
| 6400.46(a) | Staff #4's fire safety training was not provided so it is uncertain if they completed the fire safety training before working with individuals. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Director of training has Sent fire training, conducted by a fire safety expert to Staff Number 4 for immediate completion. |
09/25/2026
| Accepted |
| 6400.46(b) | Staff # 2's fire safety trainings were not provided so it is uncertain if they completed the fire safety training annually.
Staff #5's fire safety trainings were not provided so it is uncertain if they completed the fire safety training annually.
Staff #6 had completed their fire safety training on 6/28/26, however it is uncertain when the staff person had previously taken the fire safety training, so it is uncertain if it was completed annually. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The provider reviewed the personnel and training records for Staff #2, Staff #5, and Staff #6 to determine whether current annual fire safety training could be verified.
Because documentation verifying current annual fire safety training for Staff #2 and Staff #5 could not be produced, both staff members were required to complete fire safety training conducted by a qualified fire safety expert. Staff #2 completed the required training on 9-2-26 and Staff #5 Was out on WC and has since resigned, no training could be completed The training addressed general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, applicable smoking safety procedures, use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department.
Staff #6 completed fire safety training conducted by a qualified fire safety expert on June 28, 2026. Although the provider was unable to verify the date of Staff #6's previous annual training, the June 28, 2026 training establishes Staff #6's current annual training date. Staff #6's next fire safety training will be completed no later than June 28, 2027.
Documentation for each identified staff member, including the training date, training content, length of training, training source, name and qualifications of the fire safety expert, attendance record, and certificate of completion, was placed in the staff member's training record.
Staff #2 were not permitted to work independently with individuals until their current fire safety training was completed and documented. |
09/02/2026
| Accepted |
| 6400.46(d) | Staff #2 had completed FA/CPR training 7/9/24 and not again until 7/29/26, which is outside of the 2-year time frame that the FA/CPR certificate is to be completed. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Director of training shall keep records of all staff and dates of compliance. Training director will schedule CPR training before certification expires |
09/18/2026
| Accepted |
| 6400.52(a)(1) | Staff #6 had only completed 5 hours of training within the training year of 7/1/25-6/30/26. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Director of training will ensure all staff receive the required 24 hours of annual training during Training year. |
09/18/2026
| Accepted |
| 6400.52(c)(1) | Staff #2's annual training did not encompass Person-Centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships within the training year of 7/1/25-6/30/26.
Staff #5's annual training did not encompass Person-Centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships within the training year of 7/1/25-6/30/26.
Staff #6's annual training did not encompass Person-Centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships within the training year of 7/1/25-6/30/26. | 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. | CEO will train all staff in person -Centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships |
09/25/2026
| Accepted |
| 6400.52(c)(2) | Staff #2's annual training did not encompass the prevention, detection and reporting abuse within the training year of 7/1/25-6/30/26.
Staff #5's annual training did not encompass the prevention, detection and reporting abuse within the training year of 7/1/25-6/30/26
Staff #6's annual training did not encompass the prevention, detection and reporting abuse within the training year of 7/1/25-6/30/26. | 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. | Director of training has sent The Prevention, detection and reporting abuse training to affected staff and all other DSPs to be completed by September 25th |
09/25/2026
| Accepted |
| 6400.52(c)(3) | Staff #2's annual training did not encompass Individual Rights within the training year of 7/1/25-6/30/26.
Staff #5's annual training did not encompass Individual Rights within the training year of 7/1/25-6/30/26.
Staff #6's annual training did not encompass Individual Rights within the training year of 7/1/25-6/30/26. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Director of Training has sent Individual rights trainings to all affected staff and all other DSPs to be completed by September 25th |
09/25/2026
| Accepted |
| 6400.52(c)(4) | Staff #2's annual training did not encompass recognizing and reporting abuse within the training year of 7/1/25-6/30/26.
Staff #5's annual training did not encompass recognizing and reporting abuse within the training year of 7/1/25-6/30/26.
Staff #6's annual training did not encompass recognizing and reporting abuse within the training year of 7/1/25-6/30/26. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Director of training has sent Recognizing and reporting abuse training to all affected staff and all other DSPs with a completion date of September 25th |
09/25/2026
| Accepted |
| 6400.52(c)(5) | Staff #2's annual training did not encompass the safe and appropriate use of behavior supports within the training year of 7/1/25-6/30/26.
Staff #5's annual training did not encompass the safe and appropriate use of behavior supports within the training year of 7/1/25-6/30/26.
Staff #6's annual training did not encompass the safe and appropriate use of behavior supports within the training year of 7/1/25-6/30/26. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Director of training has sent Appropriate use of behavior supports training to all affected staff and all other DSPs with a completion date of September 25th |
09/25/2026
| Accepted |