| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | On 09/11/25 at 11:31 AM the hot water temperature measured at the bathroom bathtub measured 124.5 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water tank dial was turned down. |
10/30/2025
| Implemented |
| 6400.46(b) | Program Specialist #1 was trained in general fire safety on 09/02/23, and then again on 01/15/25. This exceeds the annual requirement. Direct Service Worker #2 was trained in general fire safety on 06/22/23, and then again on 12/11/24. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All certifications including Fire Safety are uploaded in to On target clinical and entered onto a Training Tracker for all DSPS and Administrative staff. An email is generated and sent to all staff a month in advance of their certification expiring. All Certifications reports are sent to Program director on a monthly basis for review. |
10/30/2025
| Implemented |
| 6400.52(c)(2) | Direct Service Worker #2's annual training year from 07/01/24 to 06/30/25 did not include the following area: Prevention, detection, and reporting of abuse. [Repeat Violation 9/18/24 et. al.] | 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. | All certifications including 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. are uploaded in to On target professional and entered onto a Training Tracker for all DSPS and Administrative staff. An email is generated and sent to all staff a month in advance of their certification expiring. All Certifications reports are sent to Program director on a monthly basis for review. |
10/31/2025
| Implemented |