| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff Member #1 was hired 10/4/24 but a criminal history record check was not completed until 9/5/25.
Staff Member #2 was hired 4/13/25 but a criminal history record check was not completed until 9/25/25. | 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.
| Director to provide FBI form for background clearance.
Director to schedule all new staff that live in PA less then 10 years with IdentoGo for FBI clearance and staff that has lived in PA over 10 years with the Pennsylvania State Police for clearance and wait for result before offering employment. |
01/27/2026
| Implemented |
| 6400.67(a) | The drain in the bathroom sink releases extremely slowly; can potentially overflow. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 09/29/2025, Director contacted Nelco construction and Maintenance LIC and repaired completed.
Please find attached invoice |
01/27/2026
| Implemented |
| 6400.68(b) | The running water of the kitchen sink returned with a temperature of 151.4F; bathroom sink returned with a temperature of 152.1F; and the shower returned with a temperature of 148.7F. All temperatures exceed the allowable threshold of 120F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On 09/29/2025, Directo contacted Nelco construction and Maintenance LIC to adjust the temperature on the hot water heater to 120 F degree |
01/27/2026
| Implemented |
| 6400.151(c)(3) | The physical of staff #2 does not include a signed statement that the staff member is free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | On 09/29/2025, Director provided staff #2 with physical form to have doctor sign/check the communicable diseases box. It was completed and returned by staff#2.
Please find attached form. |
01/27/2026
| Implemented |