| 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. The 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. |
07/30/2025
| Implemented |
| 6400.141(a) | Individual #1had a well visit care for diabetes & high blood pressure on 6/18/25; however, per the regulatory requirement an individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 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 Sertraline 50MG 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. The documentation error was corrected by the staff and supervised by the agency's nurse. |
07/18/2025
| Implemented |