| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | At the time of the inspection, located on the corner of the sink next to the dryer in the basement was a square clear plastic container with a gray lid that contained an unidentifiable green liquid coating the bottom of the container. The container did not have a label on it, and it could not be determined what the green substance was. Once the Licensing Representative pointed out the container the staff threw the container away in the garbage. | Poisonous materials shall be stored in their original, labeled containers. | The container was disposed of in the trash at the time of the inspection. |
09/01/2025
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. At the time of the inspection, the ceiling vent located in the bathroom located in the basement had a significant amount of dust/debris on all four sides of it. | Clean and sanitary conditions shall be maintained in the home. | Effective 7/19/2025, the ceiling vent located in the bathroom in the basement was cleaned of all dust/debris. The monthly home inspection form will be updated with enhanced details for site expectations prior to 08/01/2025. |
09/01/2025
| Implemented |
| 6400.67(b) | At the time of the inspection, the bathroom door located in the basement would stick when you would attempt to exit the room. The Licensing Representative (LR) had to use their shoulder and force to push the door open when the door was closed. The sticking door poses a hazard as an individual or anyone could become stuck/trapped inside the bathroom. One of the lightbulbs in bathroom located in the basement was missing from the light fixture above the mirror. An empty socket can expose live electrical terminals increasing the risk of accidental shocks or burns is someone touches it, and an empty socket can create a fire hazard if dust debris enter the socket and creates a spark or short circuit. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Effective 7/19/2025, the bathroom door was repaired so that it no longer sticks and the lightbulb was replaced in the light fixture above the mirror in the basement bathroom. The monthly home inspection form will be updated with enhanced details for site expectations prior to 08/01/2025. |
09/01/2025
| Implemented |
| 6400.73(a) | There are 3 steps that lead from the basement sliding door to the concrete patio area/yard outside. 2 concrete steps and then the 1 step to enter the home, and it did not have a handrail at the time of the inspection. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Effective 7/19/2025, a handrail was installed from the basement sliding door to the concrete patio area/yard outside. The monthly home inspection form will be updated with enhanced details for site expectations prior to 08/01/2025. |
09/01/2025
| Implemented |
| 6400.77(b) | At the time of the inspection, the first aid kit did not contain tweezers. | 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. | Effective 07/23/2025, the tweezers were replaced in the first aid kit. The monthly home inspection form will be updated with enhanced details for site expectations prior to 08/01/2025. |
09/01/2025
| Implemented |
| 6400.141(c)(4) | Individual #5's physical examination dated 2/11/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | An addendum form for the annual physical, was created to specifically address pertinent information to diagnosis and treatment in case of an emergency. Prior to 09/01/2025, the addendum form will be completed for Individual #5 by their Primary Care Physician to add to current annual physical in the file. |
09/01/2025
| Implemented |
| 6400.151(a) | 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. Staff #5's date of hire is 6/6/25 and their physical examination was dated 6/27/25. This exceeds the requirement. | 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. | A pre-employment checklist will be created |
09/01/2025
| Implemented |
| 6400.211(b)(3) | Individual #5's record did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Effective 7/16/2025, Individual #5¿s record was updated to include the name, address, and telephone number of the person able to give consent for emergency medical treatment. |
09/01/2025
| Implemented |
| 6400.52(c)(5) | There was no record or documentation that Staff #3 and Staff #4 received annual training in the safe and appropriate use of behavior supports during the training year 7/1/24-6/30/25. The agency provided a document titled "Residential Program Staff meeting agenda" for 4/22/25 at 1pm via email to the Licensing Representative (LR) on 7/16/25 that included Behavior Charting and daily documentation, however there was no record of a sign in sheet of who attended the training therefore the Licensing Representee cannot determine if Staff #3 and Staff #4 attended the meeting. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Effective 7/21/2025, Staff #3 and Staff #4 received annual training in safe and appropriate behavior supports. |
09/01/2025
| Implemented |
| Article X.1007 | Staff #5's date of hire is 6/6/25 and their Pennsylvania (PA) crime check date of request was completed 7/15/2025, which was the date of the inspection. The Older Adult Protective Services Act (OAPSA) requires that PA State Police criminal history record checks must be completed on or before a staff member's first day of work. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | A pre-employment checklist will be created |
09/01/2025
| Implemented |