| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The Criminal History Record Checks for Staff #2, Staff #3, and Staff #4 noted a "Record"; however, documentation was not on file to show that an internal review was completed to determine eligibility of hire. | 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.
| August 31, 2026 HR staff was retrained on the regulation 6400.21 regarding criminal history checks and on how to navigate the PA Criminal website and the difference between the final report and a pending report. Staff #2 & #4 were terminated prior to this correction for other reasons. A determination was conducted on staff #3 (8/29/26) and the Determination form was completed. It was determined to continue employment. |
09/15/2026
| Implemented |
| 6400.112(e) | Fire Drills were held during asleep hours on 04/01/26 and 09/14/25, which exceeds the 6-month minimum requirement for drills during sleep hours. | A fire drill shall be held during sleeping hours at least every 6 months. | Overnight fire drills will be conducted in the month of September, by the 15th day. Supervisor's will be conducting the drills at WF, CYP & WS2 within 30 minutes after the individuals have gone to be or 30 minutes before they wake. A new fire drill schedule has been created for all drills and identifying sleep hours for the 3 programs that are in bed by 8pm and rise by 7am daily. The Fire Drill policy was updated to indicate that there must be 2 overnight drills per year and those drills must be 6 months apart. |
09/15/2026
| Implemented |
| 6400.165(g) | Individual #2 's psychotropic medication reviews for 01/09/26 and 10/01/25 did not clearly state the medication and the dosage. The form the company is using separates the two items and therefore makes it unclear which dosage is for which medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Updated the 3-month med review form and submitted it to the Psychiatrist for a review. |
09/10/2026
| Implemented |