| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | There was a broken/inoperable closet door found in individual #1room. | Screens, windows and doors shall be in good repair. | A work order ticket was placed on 10/9/2025 for Individual #1 closet door and maintenance came out to repair door on 10/9/2025. |
10/09/2025
| Implemented |
| 6400.110(a) | All homes must have fire alarms operating on each floor. Two of the three floors did not have working fire alarms. Provided documentation verified that work orders were issued on 6/2/25 and 10/1/25. Matters regarding fire safety should be given the highest priority and should have been rectified within the reported timeframe. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Smoke detectors will be installed on all floors, including basement and attic. |
12/01/2025
| Implemented |
| 6400.141(c)(4) | The Vision/hearing screening was not checked for individual #2 | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 Vision and Hearing screening occurred on 11/10/2025. |
11/10/2025
| Implemented |
| 6400.142(a) | Dental appt. on 05/08/23 recommended a 6-month follow-up. It was recommended that 2 teeth be removed. This should have been completed by 11/23. As of this date individual #2 has not seen a dentist. individual #2 has a scheduled appointment for 10/10/25. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 2 has a dental exam follow completed on 10/10/2025. |
10/10/2025
| Implemented |
| 6400.151(a) | -Staff #1 (DOH: 6/7/99): 1333 Brighton St Phila PA 19111
--The last physical completed on 2/8/24; there was no previous physical available.
-Staff #2 (DOH: 9/6/22): 11609 Proctor Rd Phila PA 19111
--The last provided physical was completed on 8/2022; there was no physical completed in 2024
-Staff #3: (DOH: 8/30/21): 4985 Pennway Ave Phila PA
--The available physical was completed on 7/28/25; there was no previous physical available. | 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. | All onboarding staff will have their physicals completed on their first day of work at the assigned site. The Credentialing Department will send reminder notifications to staff prior to their physical expiration date. Staff who do not update their physical documentation by the expiration date will be removed from the schedule until the updated physical is received, in accordance with COMHAR's Credentialing Policy and Procedures. |
01/01/2026
| Implemented |