| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff #1 did not complete an FBI clearance within 5 days of date of hire. These staff indicated residing outside of Pennsylvania within the last two years. | 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.
| On July 30, 2025, Lifetime Management conducted an in-service training session for the Office Manager/Administrator, who is responsible for overseeing our hiring procedures. During this training, we updated our hiring policy to ensure that Lifetime Skills complies with the requirement to conduct FBI background checks within five days of the hire date. The background check must be completed within five working days following the date of hire. |
08/06/2025
| Implemented |
| 6400.64(e) | The trash receptacle in the kitchen measures over 18 inches tall and did not have a lid upon it nor available. | Trash receptacles over 18 inches high shall have lids. | On July 30, 2025, the Executive Director of Lifetime Skills, in collaboration with the maintenance department, purchased new trash receptacles for the kitchen and ensured that each trash can is equipped with a lid. Additionally, the Director, site manager, and maintenance personnel will conduct thorough inspections of the trash cans at all residential sites to ensure full compliance with ODP regulations. |
07/30/2025
| Implemented |
| 6400.67(a) | The cabinets on the kitchen sink are dry-rotted and beginning to separate. | Floors, walls, ceilings and other surfaces shall be in good repair. | On July 19, 2025, our maintenance staff, under the supervision of the executive director, completed repairs in all areas identified as needing attention. The repairs included fixing the broken towel holder in the bathroom. |
07/19/2025
| Implemented |
| 6400.110(g) | The fire alarms did not sound when attempting to test them during inspection; batteries were checked but none were available. | If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. | On July 30, 2025, the Executive Director of Lifetime Skills, alongside the dedicated maintenance department, undertook the important task of replacing the batteries in the smoke detector and fire alarm systems. These essential safety devices are now fully operational, ensuring a reliable line of defense against potential fire hazards. |
07/30/2025
| Implemented |
| 6400.112(d) | 914 South Avenue, Secane Apt. H38 --
· The evacuation time for an awake fire drill, 1/13/25 was 2:35 seconds which is over the allotted 2:30 seconds w/o a signed letter indicating an extended evacuation for the individual via a fire safety expert ***Mathew Black
· The evacuation time for an awake fire drill, 3/5/25 was 2:50 seconds which is over the allotted 2:30 seconds w/o a signed letter indicating an extended evacuation for the individual via a fire safety expert*** | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | On August 4, 2025, Lifetime Skills, under the guidance of its CEO, has updated the fire drill record form. This revised form is now designed to ensure that all conducted home fire drills are documented, with an emphasis on recording both the starting and ending times, reflecting a precise duration of 2.3 seconds for each drill. |
08/04/2025
| Implemented |
| 6400.141(a) | Physical exam for Individual #1 is dated 11/22/2024, which is after their date of admission 10/28/2024. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The individual's file contains only the recent physical examination, completed after their admission. This person was admitted to Lifetime Skills CLA from a non-ODP setting in an urgent placement situation. In response to this oversight, the Program Specialist at Lifetime Skills has taken steps to address the violation of 55 PA Code Chapter 6400.141(a), which requires physical exams to be conducted within 12 months before admission and annually thereafter. |
08/06/2025
| Implemented |
| 6400.166(a)(13) | Individual #1's MAR was not initialed upon the delivery of the morning dosage for the medication Metropolol 25MG on 7/17/25. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Individual #1's Medication Administration Record (MAR) was incomplete during the administration of medications. Lifetime Skills conducted retraining for the staff in question on proper documentation procedures through its MAR training program and this error has since been corrected by the staff. |
08/06/2025
| Implemented |