| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | All poisons must be stored in original containers. An unidentified poison was found under the sink in an unlabeled container. | Poisonous materials shall be stored in their original, labeled containers. | 1. The plan of correction is to store all poisonous materials in designated, locked cabinets that clearly labeled as hazardous material storage.
2. Keep poisonous materials in their original containers whenever possible; if transferred, use containers that are equally secure and properly labeled.
3. Restrict access to staff only. |
01/27/2026
| Implemented |
| 6400.82(f) | There was no soap in the bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | On 09/29/2025, Program Specialist and staff put soap in the bathroom.
FYI: There was soap in the home but locked in the cabinet. |
01/27/2026
| Implemented |
| 6400.151(a) | Bi-annual compliance with physicals cannot be determined for Staff #2 as the previous one is not dated. | 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. | On 09/30/2025, Program Specialist provided Staff#2 the physical form for doctor to fill out the previous year date that was (04/01/2023). |
01/27/2026
| Implemented |
| 6400.151(c)(3) | The physical of staff #2 does not include a signed statement that the staff member is free from 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. | On 09/30/2025, Program Specialist contacted PCP, to signed statement on physical form regarding communicable diseases. |
01/27/2026
| Implemented |
| 6400.212(a) | Individual #1 ISP found in another individual's program book.
Individual #1 medical appointment summary found in individual #2 medical book. Individual #2 was referred to as individual #1 in the lifetime medical review. | A separate record shall be kept for each individual.
| On 09/29/2025, the Director reviewed the individual's records to ensure that no other individual's information was mixed with their personal information. |
01/27/2026
| Implemented |
| 6400.52(c)(2) | Staff #1 and #2 did not complete training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act for the 2024 training year | 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 09/30/2025, Director scheduled staff#1 and staff#2 for the completion of the trainings.
Please find attached completion of training. |
01/27/2026
| Implemented |
| 6400.52(c)(4) | Staff #1 and staff #2 did not complete training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act for the 2024 training year | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | On 09/30/2025, Director scheduled staff for completion of all the missing trainings. |
01/27/2026
| Implemented |