| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(e) | This home serves Individual #4, who is less than 17 years of age. Staff #3, Staff #4, and Staff #5 began working in the home with Individual #4 on 01/02/2026. There was no record of a Pennsylvania (PA) Child Abuse History Clearance (PA Child Abuse History Certification, CY113) for these three staff nor a record that these staff applied for such clearances as provisional hires. | If the home serves primarily individuals who are 17 years of age or younger, 23 Pa.C.S. § § 6301¿6384 (relating to the Child Protective Services Law) applies. | Corrections were made to the agency's provisional hiring form to ensure proper verification of Pennsylvania residency requirements and the need for FBI background checks in accordance with CPS regulations. Additionally, training was conducted for all personnel responsible for completing and reviewing background checks to ensure hiring documentation is completed accurately and in compliance with applicable regulations. |
05/04/2026
| Implemented |
| 6400.62(a) | At the time of inspection, a bottle of Lysol all purpose cleaner was found unlocked in the base cabinet next to the sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | At the time of inspection, a bottle of Lysol All Purpose Cleaner was found unlocked in the base cabinet next to the sink. The cleaning product was immediately removed and secured in a locked area to ensure compliance with 55 Pa. Code §6400.62(a). |
04/27/2026
| Implemented |
| 6400.70 | The phone for the home was found to be locked in the staff office. The phone was not easily accessible to Individual #5 as required. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| At the time of inspection, Individual #5 had a restriction in place that restriction in place for phones. Each agency home is equipped with both a landline telephone and a shared cellular device connected to the corporate network. The shared cellular phone remained available for use by all individuals and staff. The landline has since been addressed to ensure continued compliance with 55 Pa. Code §6400.70. Please see attachment 14 |
05/30/2026
| Implemented |
| 6400.104 | The notifications to the local fire department were not kept current. Fire drills indicate that Individual #5 and Individual #6 resided in the home from 5/12/25 until 9/25. The fire drill held on 9/21/25 noted that only Individual #6 was in the home and continued to be the only resident documented for the fire drills until the drill held on 1/2/26. The fire drill completed on 1/2/26 noted that Individual #4 was now the only Individual residing in the home. Notification of the changes in the home were not sent to the local fire department as required.
The fire drills completed in September and October of 2025 indicated that Individual #6 required verbal prompts. The exact location of the Individual's bedroom was not documented in the notification letter sent on 12/2/25 as required. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The agency's understanding of the notification requirements to the local fire department differed from the clarification provided during the annual inspection and exit interview. Upon clarification, an updated notification letter reflecting the current individuals residing in the home was submitted to the local fire department to ensure compliance with 55 Pa. Code §6400.104 on 05/08/2026. Please see attachment #15. |
05/08/2026
| Implemented |
| 6400.111(e) | The home had two fire extinguishers on the main floor where the kitchen was located. Both fire extinguishers were found locked and not accessible to Individual #5. | A fire extinguisher shall be accessible to staff persons and individuals. | All fire extinguishers have been made accessible. |
05/10/2026
| Implemented |
| 6400.194(d) | The record of human rights team meetings held was requested and not received, There was no documentation to illustrate that a record of the human rights team meetings were kept. | A record of the human rights team meetings shall be kept. | At the time of the annual inspection, the agency was unable to readily produce records of Human Rights Team meetings upon request. Documentation was maintained within the agency's digital archive system; however, inconsistencies in naming conventions made retrieval difficult. The agency has since aligned and standardized naming conventions within the digital archive to improve document organization, accessibility, and retrieval of Human Rights Team records to ensure compliance with 55 Pa. Code §6400.111(e). |
06/01/2026
| Implemented |