| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | The criminal history form for Staff #2 was not completed timely. Staff #2's hire date was 6/20/2023 and the criminal history form was not requested until 6/4/2024. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | Upon preparing for licensing, we identified Staff 2 did not have a criminal background check in her file and immediately ordered a new one. This was completed on 6/4/2024. |
06/04/2024
| Implemented |
| 2380.20(b) | The addendum to verify residency was not completed (circled) in its entirety for Staff #1 who was a new hire. | If a prospective employe who will have direct contact with individuals resides outside of 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. | Employee 1 edited the document during the time of licensing (6/10/2024) by circling ¿yes¿ she lived in PA for the past two years. On the Employee Agreement, page 6, there is a question under the birthday that reads: ¿Have you resided in the state of Pennsylvania for the past two years?¿ with a yes or no option to circle. |
06/10/2024
| Implemented |
| 2380.53(a) | A container of bubbles solution was found unlocked in the craft room. The label indicates to contact medical assistance if ingested deeming it a poison that needs to be locked up. Additionally, hand soap on the counter in the first and second level bathrooms are also considered poisons and need to be locked up as well. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The Supervisor of Day Services threw away the old soap on 6/10/2024 and purchased new soap that was non-toxic and placed it in all bathroom and kitchen areas.
The bubbles were also removed by the Supervisor of Day Services, from the arts and crafts room and locked in the kitchen cabinet on the day of licensing 6/10/2024. |
06/10/2024
| Implemented |