| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff #1 indicated that they lived outside of Pennsylvania within the last two years prior to being hired on 3/16/25. The FBI criminal check was not completed until 5/16/25, which exceeded the 5-day required timeframe | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| The agency routinely completes a Federal Bureau of Investigation (FBI) criminal history record check for new employees who have not lived in the Commonwealth for the two years preceding their application date and within five working days after their date of hire, before working with individuals. During the licensing inspection on 8/05/2025, the Staff member's records indicated that the FBI check was conducted after the 5-day after-hire window. The staff misread the screening question on the application and indicated that they had lived in PA in the previous 2 years. However, later, the agency program specialist realized it was inaccurate, as the staff had not lived in PA for the last 2 years prior, which necessitated an FBI check in addition to the criminal background check already completed at hire. The FBI's records showed no criminal occurrences.
As a corrective action to prevent recurrence, the Director of Quality Management (DQM) implemented a new-hire checklist that includes a verbal check with new applicants, in addition to the screening form on how long they have lived in the Commonwealth, to ensure new staff are screened appropriately. Education and training on compliance with 55 PA Code Chapter 6400.21(a) emphasizes the need for HR personnel to ensure new hires who have not lived in the commonwealth for two years before application undergo a Federal Bureau of Investigation (FBI) criminal history record check before being hired. |
09/02/2025
| Implemented |
| 6400.141(c)(10) | Individual #1 Physicals dated 2/6/2024 & 10/18/2024 does not indicate that the individual is free from communicable disease | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | During a licensing inspection on 8/05/2025, it was identified that the consumer's primary care provider (PCP) failed to mark in the Annual Health Physical Record that the consumer was free from communicable disease. But there is documentation in the individual's Health record stating the individual is free from communicable disease. According to the inspector, the failure of the PCP to indicate that the individual is free of communicable disease in the Annual Health Physical Record violates the documentation expectation, which states: The physical examination shall include Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The agency Director of Quality Management (DQM) or designee will check all completed annual health physical records to ensure that consumers' PCPs have completed all sections of the form. |
09/02/2025
| Implemented |
| 6400.151(a) | Staff #2 , was hired on 12/4/21 and should have had a physical completed in December 2023 to meet the two-year regulatory requirement. The physical on file for this staff was not completed until 7/25/25. | 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. | As a standard, the agency routinely requests that potential hires complete a health physical before hiring, in alignment with 55 PA Code Chapter 6400.151(a). and thereafter annually. Following the conference call regarding the licensing inspection on 8/05/2025, the inspector informed Agency leaders that a staff member's 2024 completed Health physical Record was missing. Just as she was about to leave the premises, the administrator provided her with the 2024 staff member's physical health record, informing her that it may have been overlooked in the employee's file. Since this is still cited as a violation, the agency is addressing it accordingly. |
09/02/2025
| Implemented |