| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 7/21/2026, at approximately 1:30pm, the basement door leading to the garage had a deadbolt lock with the key side inside the garage. The garage does not have a swing door leading to the outside of the home. This is an entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On July 26th 2026, Provider removed the deadbolt that was on the door going from basement to the garage. Now, there is a door knob that safely opens and closes without any chance of risk of entrapment to Individuals or Staff members. |
07/26/2026
| Implemented |
| 6400.52(a)(1) | Direct service worker #1 had 10.5 hours of documented annual training in the annual training year, dated 7/1/25 through and including 6/30/26. Direct service worker #1 did not complete 24 hours of training during the training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | On 8/16/2026, a new training syllabus was created for all existing staff, except for new hires. This syllabus has a minimum of 24 hours annual training hours on it that must be maintained in order to keep compliance and employed. DSP #1 was notified of this plan of correction and policy by the CEO on 8/19/2026. |
08/19/2026
| Implemented |
| 6400.52(c)(2) | Direct service worker#1 did not complete the following annual training in the annual training year, dated 7/1/25 through and including 6/30/26: 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. | On 8/16/2026, a new training syllabus was created for all existing staff, including new hires. This syllabus has a focus on the annual training of prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.§§ 10225.101-102255102), the Child Protective Service Law (23 Pa.C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704) and applicable adult protective services regulations. DSP #1 was notified of this plan of correction and policy by the CEO on 8/19/2026. |
08/19/2026
| Implemented |
| 6400.52(c)(3) | Direct service worker #1 did not complete the following annual training during the annual training year, dated 7/1/2025 through and including 6/30/26: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | On 8/16/2026, a new training syllabus was created for all existing staff, including new hires. This syllabus has a focus on the completion of annual training of Individual Rights. DSP #1 was notified of this plan of correction and policy by the CEO on 8/19/2026. |
08/19/2026
| Implemented |