| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | In February and March Individual #1's flex card was used to purchase items that are to be covered by room and board. | Individual funds and property shall be used for the individual's benefit. | Upon finding the misuse of an individual's flex card an incident was entered into EIM and an investigation was open. This was completed on 4.21.25. Investigation is still ongoing. Upon completion of the investigation, Individual #1 will be reimbursed for any items that should have been covered by room and board.
Director of Programs will review the Room & Board guidelines with the Residential Managers specifically what we as a provider are responsible to purchase, not using individual flex cards, EBT cards and/or funds. This was completed on 4.29.25. |
05/09/2025
| Accepted |
| 6400.22(d)(1) | Individual #1's flex card account is not current and up to date. The log for April 2025 was completely blank. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Director of Programs will review with the Residential Managers the JFC protocol for proper and accurate documentation of individuals finances. This was completed on 4.29.25.
Director of Programs will meet with the Residential Manager to retrain on the proper steps required to take with accurate and proper documentation of individuals finances including timeframes to meet. This was completed on 4.24.25. |
05/09/2025
| Accepted |
| 6400.46(b) | Staff #3 had FS safety training on 3/19/24 and not again since, outside of the annual timeframe. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including annual fire safety training. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.52(a)(1) | Staff #3 did not have 24 hours of training. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including all mandatory annual trainings. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.52(c)(1) | Staff #3 did not have annual training in Person Centered Practices, Community Integration, etc. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including person centered practices. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.52(c)(2) | Staff #3 did not have annual training in Prevention, Detection, Reporting of Abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including prevention, detection & reporting of abuse. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.52(c)(3) | Staff #3 did not have annual training in Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including individual rights. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.52(c)(4) | Staff #3 did not have annual training in Recognizing or Reporting Incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including recognizing or reporting incidents. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.52(c)(5) | Staff #3 did not have annual training in Use of Behavior Supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until all required trainings are completed, including use of behavior supports. Residential Manager will work with the employee to ensure all training is completed.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |
| 6400.169(a) | Staff #3 did not complete the 2024 recertification process correctly and is not med trained. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Director of Programs notified the Director of Human Resources that the identified staff member was to be removed from the house schedule immediately. This was completed on 4.21.25.
Staff member will not be placed back on the house schedule until the medication administration course is completed in full. JFC Certified trainer will work with the employee to ensure the course is completed in its entirety and employee passes all the course requirements.
Upon proof of training, the staff member will be given credit for the training. |
05/16/2025
| Accepted |