| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff 1's background check was not completed until 06/27/2026, their start date was 09/15/2025. Staff 2's background check was completed 07/23/2026, their date of hire was 03/27/2026. Staff 3's criminal history check was requested 07/23/2026 -- their hire date was 06/01/2026. [REPEAT VIOLATION] | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Staff 1 had a background check om 08/25/25 before their hire date with our agency hence we didn't see a need to repeat it on 09/15/25 until the following year. Pls see shared folder for their previous background check. |
08/14/2026
| Implemented |
| 6400.64(b) | Rodent droppings were observed in the kitchen cabinets. | There may not be evidence of infestation of insects or rodents in the home. | House has been fumigated and staff have cleaned out the droppings (see shared folder) |
08/14/2026
| Implemented |
| 6400.67(a) | The front door to the residence had loose/hanging weather stripping, missing door handle, and trimming with sharp edges. The dresser in the occupied bedroom was missing knobs [REPEAT VIOLATION]. | Floors, walls, ceilings and other surfaces shall be in good repair. | We accept responsibility for our carelesnness with the door knob. Door handle and sripping has now been repaired |
08/14/2026
| Implemented |
| 6400.71 | The emergency contacts listed hospitals that were closed. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| An updated emergency contact list was placed in the houses (see shared folder) |
08/14/2026
| Implemented |
| 6400.151(a) | Staff 3's physical exam is dated 06/29/2026, after their start date of 06/01/2026. | 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. | We accept our carelessness on this issue and have developed a more thorough employee compliance checklist tracker to monitor compliances.
The issue of non-compliance with recruitment requirements at hire date were discussed at the management review meeting post inspection, held 08/18/2026. A quarterly QA&R was set up by the prog director to audit all hiring and training compliances with HR department. (see shared folder) |
09/04/2026
| Implemented |
| 6400.151(c)(2) | Staff 3's TB test is dated 07/03/2024, more than one year prior to their hire date of 06/01/2026. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Chest xray done on 7/03/24, had ruled out TB and all TB test were negative and still within the two yr mark prior to hire date of 6/1/26 that's why we didnt require a review until next annual was due. But we take responsible and will review our policy to reflect same. they have been asked to submit a new TB clearance, unfortunately they've been out of the office due to a family emergency. |
09/04/2026
| Implemented |
| 6400.51(a)(1) | Staff 1 did not complete the following orientation topics within the first 30 days of employment: Person-centered Practices, Detection, Reporting, and Preventing Abuse, Incident Management, and Fire Safety. Their start date was 06/01/2026, and the trainings were completed 07/26/2026, 07/22/2026, 07/15/2026, and 08/03/2026 respectively. [REPEAT VIOLATION] | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | it was an oversight on our part. staff 1 hired 9/10/26 completed all inhouse trainings and job-related training but we didn't realize until we sought counsel that as the nurse they needed to complete the odp training as well, hence the delay. (see shared folder)
However, from the hire date you indicated above you probably are referring to staff 3 who was hired 6/1/26. we take responsibility for the oversight which was partly due to their many days out because of their dying brother |
08/20/2026
| Implemented |