| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | There were no criminal history background checks for staff members 1, 2, 3, 4, 5, and 6.
The criminal history background check for staff member7 was not done within 5 working days after the date of hire. (Repeat Violation) | 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.
| Criminal history background checks were obtained and completed for staff members 1, 2,3,4,6, and-6.
The background check for staff member 7 was completed and documented.
All documentation has been placed in the employee files and verified for compliance.
A review of all personnel files was conducted to ensure all staff now meet background check |
03/30/2026
| Implemented |
| 6400.21(b) | There is no attestation of PA residency for the past 2 years for staff members 5, 8, 9, 10, and 11. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| ASO will update the employee application to include an attestation verifying Pennsylvania residency for the past two years.
Attestation forms will be completed for staff members 5, 8, 9, 10, and 11 and placed in their personnel files.
All personnel files will be reviewed to ensure required documentation is complete and compliant. |
03/30/2026
| Implemented |
| 6400.77(b) | There is no thermometer available in the home. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | ASO replaced the missing thermometer in the first aid kit.
The first aid kit was reviewed to ensure all required items are present and complete. |
01/21/2026
| Implemented |
| 6400.112(d) | Fire drill dated 11/5/2025-evacuation time 4min 0 seconds, 1/7/2026 -- evacuation time 3min 10 seconds | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | ASO reviewed fire drill procedures and evacuation expectations with all staff.
Staff were retrained on emergency evacuation protocols, with emphasis on client safety, prompt response, and proper exit procedures.
Additional guidance was provided on reducing evacuation time while maintaining safety and accountability of all individuals.
A follow-up drill was conducted to reinforce training and ensure improved performance. |
01/30/2026
| Implemented |
| 6400.151(c)(3) | Staff member 14's Physical exam did not have a signed statement that the staff person is free of communicable diseases. | 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. | ASO will request updated documentation from the medical provider/clinic to obtain a signed statement verifying that staff member 14 is free from communicable disease.
The completed documentation will be placed in the employee's personnel file.
A review of all employee health records will be conducted to ensure all required physical exam documentation is complete and compliant.
HR managers and administrative staff will be retrained on documentation requirements and the importance of maintaining complete medical records to ensure client health and safety. |
04/02/2026
| Implemented |
| 6400.151(c)(4) | Staff member 14's Physical exam did not address information of medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | ASO will request updated medical documentation from the clinic/medical provider to ensure the physical examination includes a statement addressing any medical conditions that may interfere with the health of individuals served.
The completed and compliant documentation will be placed in the employee's personnel file.
A comprehensive review of all staff physical examination records will be conducted to ensure all required components are complete and compliant.
HR managers and administrative staff will be retrained on documentation requirements, including ensuring all physical exams address communicable diseases and any medical conditions that may impact client safety. |
04/30/2026
| Implemented |
| 6400.34(a) | Individual Rights -there was no signature and not everything that need to be there included for individual 2 | 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. | ASO will update staff records to ensure all required information is complete and properly documented, including all necessary signatures.
Missing documentation will be obtained and verified for accuracy.
The Training/Compliance Officer and HR managers will be instructed and retrained on documentation requirements, emphasizing the importance of complete and accurate records to support client safety.
A full review of all personnel files will be conducted to ensure compliance across all staff records. |
04/30/2026
| Implemented |
| 6400.46(a) | The last fire safety training done for staff member 14 was on 01/13/25. | 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. | ASO will schedule and complete updated fire safety training for staff member 14.
Training records will be updated and placed in the employee's personnel file.
The Training/Compliance Officer and HR managers will be instructed and retrained on tracking staff training requirements, ensuring timely completion and proper documentation.
Staff will be educated on the importance of fire safety procedures and client safety during emergencies.
A review of all staff training records will be conducted to ensure all required trainings are current and compliant. |
04/30/2026
| Implemented |
| 6400.52(a)(3) | Staff member 13 completed 8 hours of annual training and 24 training hours were required. (Repeat Violation) | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | ASO will ensure staff member 13 completes the remaining required training hours to meet the 24-hour annual training requirement.
Training records will be updated and placed in the employee's personnel file.
The Training/Compliance Officer and HR managers will be instructed and retrained on tracking training requirements and ensuring timely completion.
A review of all staff training records will be conducted to ensure all employees meet annual training requirements.
Staff will be educated on the importance of training in maintaining client safety and quality care. |
04/30/2026
| Implemented |
| 6400.52(b)(1) | Staff member 12 completed 6-1/2 training hours of annual training and 12 training hours were required. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | ASO will ensure staff member 12 completes the remaining required training hours to meet the 12-hour annual training requirement.
Training records will be updated and placed in the employee's personnel file.
The Training/Compliance Officer and HR managers will be instructed and retrained on tracking training requirements, ensuring timely completion and accurate documentation.
A review of all staff training records will be conducted to ensure all employees meet required annual training hours.
Staff will be educated on the importance of training in maintaining client safety and quality care. |
04/30/2026
| Implemented |
| 6400.52(c)(2) | Staff member 12 did not complete the required annual training: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | 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. | ASO will ensure staff member 12 completes required training on abuse prevention, detection, and reporting.
Training records will be updated and placed in the employee's personnel file.
The Training/Compliance Officer and HR managers will be instructed and retrained on monitoring required training completion, ensuring all staff meet mandatory training requirements.
A comprehensive review of all staff training records will be conducted to ensure all employees have completed required abuse-related training.
Staff will be educated on the importance of protecting individuals, recognizing signs of abuse, and following proper reporting procedures. |
04/30/2026
| Implemented |
| 6400.52(c)(3) | Staff member 13 did not complete the required annual training: Individual rights. (Repeat Violation) | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | ASO will ensure staff member 13 completes the required annual individual rights training.
Training records will be updated and placed in the employee's personnel file.
The Training/Compliance Officer and HR managers will be instructed and retrained on tracking required trainings, ensuring all staff complete mandatory training in a timely manner.
A comprehensive review of all staff training records will be conducted to ensure all employees are compliant with individual rights training requirements.
Staff will be educated on the importance of respecting and protecting the rights of individuals served. |
04/30/2026
| Implemented |
| 6400.52(c)(4) | Staff member 14 did not complete the required annual training: Recognizing and reporting incidents. (Repeat Violation) | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | ASO will ensure staff member 14 completes required training on recognizing and reporting incidents.
Training records will be updated and placed in the employee's personnel file.
The Training/Compliance Officer and HR managers will be instructed and retrained on tracking required training completion, ensuring all staff meet mandatory training requirements.
A comprehensive review of all staff training records will be conducted to ensure all employees are compliant with incident reporting training requirements.
Staff will be educated on the importance of timely and accurate incident recognition and reporting to ensure client safety. |
04/30/2026
| Implemented |
| 6400.213(1)(i) | Religion was left blank on face sheet in Binder . | Each individual's record must include the following information: Personal information, including: (iv) The religious affiliation. | ASO updated the individual's face sheet to include the required information regarding religion, ensuring the record is complete and accurate.
The binder was reviewed to confirm all required elements are properly documented and compliant.
The Training/Compliance Officer and HR managers were instructed and retrained on documentation requirements, emphasizing the importance of maintaining complete and accurate records to support individual rights and person-centered care. |
01/21/2026
| Implemented |