| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The background check for Staff Person #1 was requested on 5/7/2024 despite a hire date of 4/29/2024. | 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.
| The citation was caused by a failure to follow the agency¿s internal procedure for timely background check submission. This occurred because the background check process was not consistently enforced as a prerequisite before assigning training or confirming employment. To address the issue, the HR Manager and Administrator conducted a review of the cited record and initiated a full audit of all staff hired since January 2024. The Administrator and HR Manager have been retrained on the staff qualification policy, with an emphasis on submitting background checks before assigning any training or hire dates. Going forward, the Administrative Assistant will submit the Pennsylvania criminal background check on or before the confirmed hire date, and the HR Manager will verify and upload the submission record to the personnel file within 24 hours. |
05/05/2025
| Implemented |
| 6400.65 | The bathroom window is bolted down, and the room has no exhaust fan for ventilation | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| To correct the issue, the bathroom window was unbolted, repaired, and restored to full operability, allowing for proper ventilation. The repair was completed by maintenance and confirmed by the House Manager to meet regulatory requirements under 55 PA Code Chapter 6400.65. |
04/14/2025
| Implemented |
| 6400.72(c) | The middle lock on the back door does not lock when you turn the knob. The basement has a sliding bolt on the door. | Outside doors shall have operable locks. | To correct the issue, the middle lock was promptly repaired and is now fully operable. The lock was tested post-repair to ensure it engages securely and meets the requirements of 55 PA Code Chapter 6400.72(c), |
04/12/2025
| Implemented |
| 6400.73(a) | The basement has no rails and the steps are cracked. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The citation was issued due to the absence of handrails and the presence of cracked steps in the basement. However, it is important to clarify that the basement is not part of the licensed living space or our leased premises accessible to individuals. As an added safety measure, a locking mechanism with a key has been installed on the basement door to prevent any individual from gaining access to the area. This effectively restricts entry and removes the area from routine use by residents or staff. |
04/12/2025
| Implemented |
| 6400.76(a) | The corner cabinet in the kitchen (AKA Lazy Susan) door does not close | Furniture and equipment shall be nonhazardous, clean and sturdy. | To address this, the cabinet door was immediately repaired to ensure that it closes securely and functions properly. The repair was completed by maintenance and verified by the House Manager and administrator to confirm it meets regulatory expectations. |
04/12/2025
| Implemented |
| 6400.80(b) | The fence in the backyard needs to be replaced. The sidewalk in the backyard is cracked and need replacement. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | As the property is managed by a landlord, the issue was reported immediately. The landlord has since completed all required maintenance, including replacing the damaged fencing and addressing the cracked sidewalk to ensure the area is safe and in good repair. These corrections have been verified by the House Manager and Administrator |
04/12/2025
| Implemented |
| 6400.216(a) | Individual Daily books sitting on table in living room unlocked. | An individual's records shall be kept locked when unattended.
| This occurred due to a lapse in staff practice and lack of reinforcement around confidentiality protocols. To correct the issue, the records were immediately removed from the common area and secured in a locked storage cabinet. All staff present were reminded that individual records must be locked when unattended at all times. |
05/05/2025
| Implemented |
| 6400.52(a)(1) | Training hours not compliant for year 2024 for Staff Person #1. 13.5 total training hours were counted for the period of 1/1/2024-12/31/2024. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | This gap was due to a lack of automated tracking and follow-up during the year. To correct this, the remaining training hours have been scheduled and are set to be completed during the week of May 5, 2025. The training plan includes job-related topics aligned with regulatory expectations and will be logged upon completion. The Program Supervisor and Training Coordinator will verify and document completion in the staff training file. |
05/09/2025
| Implemented |
| 6400.166(a)(11) | The prescribed medication Nystatin 100000 ointment has no diagnosis on the MAR for Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | To correct the issue, the MAR has been updated to include the required diagnosis, and it now matches the information listed on the medication label. The correction was completed immediately upon discovery and verified by the Program Nurse. |
04/11/2025
| Implemented |