Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(c) | Staff #1 was hired by the provider effective 04/29/2024. There was no record that a request for a criminal history record check was submitted to the Pennsylvania State Police (PSP) within 1 year prior to or within 5 working days of the staff's date of hire by the provider. There was a criminal history record check located within the staff record; however, this document was dated 12/07/2021, which was more than 1 year prior to the staff's hire date. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| A background check was completed for Staff # 1 on 5/30/2025. |
05/30/2025
| Implemented |
6400.64(a) | The home was unclean in two areas:
1. The top of the home's kitchen refrigerator was coated in a thin, tacky, clear substance to which dust was visibly adhered.
2. There were tiny, gritty chunks of an unidentifiable, hard, white substance as encircling the bathtub drain. There were also numerous stray hairs adhered to the area of the bathtub surrounding the drain. | Clean and sanitary conditions shall be maintained in the home. | The refrigerator including the top and bathtub including the drain area were both cleaned at the home by staff. |
06/02/2025
| Implemented |
6400.67(b) | The lower interior surface of the home's oven was peppered with small, blackish, charred detritus consistent with the burnt leavings of food. There were areas coated in a shiny, black substance consistent in appearance with burnt oils or grease from cooking. The four stovetop burner guards contained blackened, charred crumbs. The condition of this home's oven and stovetop increased the risk of a fire occurring in the home, constituting a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Program Director will be cleaning the oven and stovetop to ensure both are maintained in a clean and sanitary condition. This cleaning will be completed by 6-4-25, and ongoing oversight will be conducted to ensure regular maintenance moving forward. |
06/04/2025
| Implemented |
6400.72(a) | The window located above the home's kitchen sink, which was cracked open at the time of inspection, lacked a window screen. There was no screen located within the home that could be securely inserted into this window's frame. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | A new screen was ordered by the Property Maintenance Technician on 5/30/2025 and will be installed upon arrival. |
06/13/2025
| Implemented |
6400.72(b) | The window located above the home's kitchen sink was designed such that it could be opened and closed via a crank mechanism. At the time of inspection, this window was cracked open approximately one-half inch. The crank handle was not attached to the window crank and could not be located within the home. | Screens, windows and doors shall be in good repair. | The window crank for the window was ordered and will be fixed by the Property Maintenance Technician upon arrival. |
06/13/2025
| Implemented |
6400.24 | Staff #2 was hired effective 06/15/2024. Staff #2 completed hiring paperwork to state that they were not a resident of Pennsylvania for at least 2 years prior to hire; however, an FBI background check was not completed for Staff #2 as required. The provider is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Administrative staff set up a new FBI Background check for staff #2. |
06/04/2025
| Implemented |
6400.46(b) | Staff #1 was hired by the provider effective 04/29/2024 and began working directly with individuals on 05/13/2024. Per the staff training record, this staff did not receive training in Fire Safety until 07/23/2024. This staff did not receive training in Fire Safety topics prior to working directly with individuals as required. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All rehires will receive new hire training which includes fire safety training before working directly with individuals. |
06/02/2025
| Implemented |