| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The staff member #6 was hired on December 15, 2025, but the PA Criminal Background check was not completed until April 24, 2026, which exceeded the allowable timeframe.
The staff member #7 was hired on December 15, 2025, but the PA Criminal Background check was not completed until February 17, 2026, which exceeded the allowable timeframe. | 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.
| Lifetime Skills did not maintain a pre-employment checklist or tracking system to confirm that background checks were requested within 5 working days of hire and received before the deadline, resulting in the checks for Staff Member 6 and Staff Member 7 being completed late.
LSHS's Plan of Correction: The Pennsylvania criminal history checks for Staff Member 6 and Staff Member 7 have been completed and filed in their personnel records. The agency implemented a pre-employment hiring checklist requiring that Pennsylvania criminal history record checks be submitted within 5 working days of the date of hire, with the submission date and result documented in the personnel file. Newly hired staff will not work alone with individuals until all required checks are complete. Attachment#5 |
05/26/2026
| Implemented |
| 6400.21(b) | Staff member #8 did not have an attestation of two years of residency in PA prior to hire. | 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 violation occurred because Lifetime Skills' hiring paperwork did not include a residency attestation form, so residency status was not documented at the time of hire and the agency could not demonstrate whether an FBI criminal history record check was required for Staff Member 8. The hiring process did not include a step to verify residency and trigger the FBI check submission when required. Lifetime Skills HR personnel obtained a Pennsylvania residency attestation from Staff Member 8 and filed it in the personnel record. The agency added a residency attestation form to its standard hiring packet, with a requirement that any prospective employee who has not resided in Pennsylvania for the two years preceding hire submit an FBI criminal history record check application within 5 working days after the date of hire. Attachment#6 |
07/30/2026
| Implemented |
| 6400.21(c) | The staff member #3 indicated not being a Pennsylvania resident for two years and did not have the required FBI background check (only the PA State Police (retail theft noted 2/25/19) and PA CYS checks were in the file).
The staff member #4 was hired January 10, 2026 and indicated not being a Pennsylvania resident for two years and did not have the required FBI background check (only the PA State Police and PA CYS checks were in the file).
The staff member #5 was hired on December 13, 2025, but the PA Criminal Background check was not completed until February 19, 2026, which exceeded the allowable timeframe. | 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.
| The violation occurred because Lifetime Skills' hiring paperwork did not include a residency attestation form, so residency status was not documented at the time of hire and the agency could not demonstrate whether an FBI criminal history record check was required for Staff Member #3 and #4. The hiring process did not include a step to verify residency and trigger the FBI check submission when required. Attachment#7a and 7b |
07/30/2026
| Implemented |
| 6400.151(a) | The program specialist's (Staff #1) annual physical was not current. The most recent one reviewed was dated April 26, 2022. | 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. | The Program Specialist's (Staff Member 1) physical examination was not current; the most recent physical on file was dated April 26, 2022.
LSHS did not have a tracking system in place for monitoring the due dates of staff physical examinations. As a result, the expiration of the Program Specialist's biennial physical examination was not identified, and a renewal was not scheduled during the inspection. Attachment#8 |
07/30/2026
| Implemented |
| 6400.46(b) | The program specialist's (Staff #1) annual emergency training in general fire safety was last completed on October 29, 2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | LSHS did not have a training-tracking system in place that included due dates for annual fire safety training, resulting in the absence of the Program Specialist's annual training with a fire safety expert. Staff Member 1's fire safety training has been scheduled for August 19, 2026, with the fire marshal, a fire safety expert. This training will be documented and placed in the personnel record. Annual fire safety training for program specialists and direct service workers has been incorporated into the staff compliance tracker, along with scheduled dates. Attachment#9 |
07/30/2026
| Implemented |
| 6400.46(d) | The program specialist's (Staff #1) annual emergency training was not current for first aid and techniques and cardio-pulmonary resuscitation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The Program Specialist's (Staff Member 1) training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation (CPR) was not current.
Staff Member 1 completed first aid, Heimlich techniques, and CPR training conducted by a certified trainer from a recognized health care organization, and documentation has been placed in the personnel record. These certifications have been added to the staff compliance tracker with renewal dates for all applicable staff. Moreover, Staff member #1 is train-the-trainer certified. Attachment#10 |
07/30/2026
| Implemented |
| 6400.52(a)(1) | The staff member #3 did not complete the annual 24 hours of training as required. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | The agency did not maintain an annual training plan or a system for tracking training hours completed by each staff person during the training year, so the shortfall in Staff Member 3's training hours was not identified and addressed before the end of the training year.
Staff Member 3 has completed 24 hours of required job-related training, and these training hours are now being recorded in the training record. The agency will implement an annual training calendar and individual training-hours logs for each staff member to prevent future occurrences of this type of violation. Attachment#11 |
07/30/2026
| Implemented |
| 6400.52(a)(3) | The program specialist (Staff #1) did not complete the annual 24 hours of training as required. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | The Program Specialist (Staff Member 1) did not complete the required 24 hours of annual training related to job skills and knowledge. The agency did not maintain a system for tracking training hours, so the shortfall in the Program Specialist's own annual training hours was not identified and addressed before the end of the training year. Staff Member 1 completed the required 24 hours of job-related training and completed training hours are being documented in the training record. The Program Specialist's training hours have been added to the staff compliance tracker. |
07/30/2026
| Implemented |
| 6400.52(b)(1) | The CEO (Staff #2) did not complete the required annual 12 hours of training. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | The agency did not maintain an annual training plan or a system for tracking training hours for management and administrative staff, so the shortfall in the CEO's annual training hours was not identified and addressed before the end of the training year.
Provider's Plan of Correction: Staff Member 2 to complete the required 12 hours of annual training and completed training hours are being documented in the training record. Management and administrative training requirements have been added to the staff compliance tracker. Attachment#12 |
07/30/2026
| Implemented |