| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature in the bathroom was 129 degrees | Hot water temperatures in bathtubs and showers may not exceed 120°F. | IN accordance with 55 PA Code Chapter 6400.68(b), the maintenance manager will ensure that a contractor adjusts the temperature at the water heater at the residence. The executive director will ensure that the maintenance manger is retrained on the "Home Maintenance Checklist" that currently includes checking that water temperatures do not exceed 120F. |
02/13/2026
| Implemented |
| 6400.112(d) | The fire drill which occurred on 9/5/25 took 4min 15 seconds for the individual to evacuate. | 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. | In accordance with 55 PA Code Chapter 6400.112(d), the executive director will update the agency's fire drill logs to include a section labeled for followup drills for any drill times exceeding the allowable threshold of 2.5 minutes. The Program Specialist will be retrained on this section of the regulation in order to ensure compliance |
02/28/2026
| Implemented |
| 6400.32(h) | There were cameras present in the common areas of the home, however there was no documentation of informed consent from the individual acknowledging their presence. | An individual has the right to privacy of person and possessions. | In accordance with 55 PA Code Chapter 6400.32(h), the program specialist will ensure that individuals in the program will have the reason for cameras in common areas and have individuals sign statements of permission if they choose. |
02/28/2026
| Implemented |