| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | No criminal history background check was done for staff member 1. | 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.
| Criminal check for Staff member 1 has been done. See documentation attached. |
08/21/2025
| Implemented |
| 6400.67(a) | The cabinet in the kitchen under the sink was loose.
The dryer vent was not hooked up to the dryer. | Floors, walls, ceilings and other surfaces shall be in good repair. | The kitchen cabinet with loose hinges have been fixed.
The dryer has been hooked up to the vent and has been used by staff. See documentation attached. |
08/25/2025
| Implemented |
| 6400.67(b) | There was paint peeling from the ceiling over the stove.
The bathroom in the basement has a broken sink and seems to be under construction. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 1. Ceiling over kitchen stove in 321 has been replastered and re-painted
2. Basement toilet construction has been completed and the area deemed safe for use. See documentation attached. |
08/26/2025
| Implemented |
| 6400.106 | No furnace inspection available at time of inspection. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace has been inspected, cleaned and certified in good working condition for use by Shillady plumbing LLC on 08/26/2025. See documentation attached. |
08/26/2025
| Implemented |
| 6400.18(i) | Incident ID # 9643168 has a discovery date of 06/21/25 and the incident was open past 30 days with no extension requested.
Incident ID # 9632323 has a discovery date of 06/02/25 and an extension was not requested until 08/01/25.
Incident ID #9639171 has a discovery date of 06/14/25 and an extension was not requested until 08/13/25. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Incident report has been completed and submitted in the EIM at on our end awaiting initiation review. |
10/09/2025
| Implemented |
| 6400.51(a)(3) | The 0rientation Training for staff member 1 was not completed within 30 days after hire. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Staff 1 was given 30days to complete all orientation training in line with 6100.143 but has still not complete the training. staff is currently off schedule from 0ctober 2nd 2025 and give till October 24, 2025, to complete all mandatory trainings. |
10/24/2025
| Implemented |