| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The 07/18/2025 criminal background check for Staff #1 noted a "Record." A case-by-case review to determine whether to hire the person was not completed. | 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.
| A review was noted for the employee; however, the details of the review were not included. The committee completed the review again and documented details for Staff#1. |
10/08/2025
| Implemented |
| 6400.64(a) | The bathroom tub was visibly dirty.
The carpet throughout the living room and dining room was dirty and had several stains throughout. | Clean and sanitary conditions shall be maintained in the home. | Tub was cleaned 9/18/25
Carpets were cleaned 9/18/25 |
10/08/2025
| Implemented |
| 6400.112(c) | The 11/15/24, 12/26/24, and 01/23/25 Fire Drills did not indicate if smoke detectors were operable | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Records for drills were reviewed, and it was noted that the drills included an indication of operable smoke detectors on these drill forms, as shown by a "yes" check next to the question about smoke detector operability. |
10/08/2025
| Implemented |
| 6400.32(h) | The blinds in Individual #3 's bedroom were not long enough to fully cover the window and provide adequate privacy from the outside. | An individual has the right to privacy of person and possessions. | Individual #3's blinds were repaired. |
10/08/2025
| Implemented |