| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | On 8/7/2024 at 11:57am, the mechanical vent in the main floor full bathroom was plugged with dirt and debris and was not providing sufficient air flow. This vent is the only form of ventilation in the bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Maintenance cleaned the vent on 08/12/2024 |
08/12/2024
| Not Implemented |
| 6400.66 | On 8/7/2024 at 11:59an, the walk-in pantry, located between the main floor bathroom and the kitchen was observed without a light fixture. On 8/7/2024 at 12:12pm, the only light fixture in the basement was located near the basement steps. There was not sufficient lighting on the far side of the basement. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance installed two lights in the basement on 8/14/2024 and one light in the walk-in pantry on 08/15/2024. |
08/15/2024
| Implemented |
| 6400.67(b) | On 8/7/2024 at 12:10pm, the floor in the basement was observed with significant pools of water and wet mud throughout the entire basement, creating potential slipping hazards. On 8/7/2024 at 12:12pm, two cords and one wire were observed hanging from the basement ceiling. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance dry locked the walls and secured the cords that was hanging down on 08/14/2024 |
08/14/2024
| Not Implemented |
| 6400.73(a) | On 8/7/2024 at 12:22pm, the steps leading from the upper-level hallway to the attic were observed without a secure handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Maintenance installed a handrail in the attic on 08/20/2024. |
08/20/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 2/28/2024, did not include an assessment of the individual's health maintenance needs. This section on the physical examination form was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The program specialist contacted the Physician, and the physical form was updated on 08/30/2024 |
08/30/2024
| Not Implemented |
| 6400.141(c)(13) | Individual #1's physical examination, completed 2/28/2024, did not include the individual's allergies or contraindicated medications. This section on the physical examination form was left blank. | The physical examination shall include: Allergies or contraindicated medications. | The program specialist contacted the Physician, and the physical form was updated on 08/30/2024 |
08/30/2024
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 2/28/2024, did not include the individual's medical information pertinent to diagnosis and treatment in case of an emergency. This section on the physical examination form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The program specialist contacted the Physician, and the physical form was updated on 08/30/2024 |
08/30/2024
| Not Implemented |
| 6400.181(e)(12) | Individual #1's initial assessment, completed 6/9/2024, did not include recommendations for specific areas of training, programming and services. This section was marked "N/A". | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist updated the assessment on 08/19/202. |
08/19/2024
| Implemented |
| 6400.212(b) | Program Specialist #3, date of hire 5/28/2024, signed and dated Individual #1's lifetime medical history form with a date of 2/28/2024; three months prior to her date of hire. On page #2 of the lifetime medical history form, Program Specialist #1 scribbled out a portion of the entry in the date section, making the entry illegible. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| The form was updated on 08/19/2024, and the correct program specialist signature and date is now on the form. |
08/19/2024
| Implemented |
| 6400.46(a) | Program Specialist #2, date of hire 6/17/2024, completed initial fire safety training on 6/24/2024. This training did not include site specific information such as evacuation procedures and meeting places for the homes they are assigned to work. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The program specialist was retrained on 08/09/2024 and a form was created with site specific information of all homes, and fire drill form was also updated on 08/09/2024. |
08/09/2024
| Implemented |
| 6400.46(b) | Chief Executive Officer #1 provides direct services to the individuals residing at the agency. Chief Executive Officer #1 completed annual fire safety trainings on 8/6/2023 and 8/3/2024. These trainings did not include site specific information such as evacuation procedure and meeting places for the homes they are assigned to work. Direct Service Worker #4 completed annual fire safety trainings on 8/5/2023 and 8/4/2024. These trainings did not include site specific information such as evacuation procedure and meeting places for the homes they are assigned to work. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The DSP was retrained on site specific information for all the homes on 08/09/2024 and the CEO was retrained on 08/09/2024, and a form was created with site specific information of all homes, and fire drill form was also updated on 08/09/2024. |
08/09/2024
| Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1 was not trained on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 7/1/2023 - 6/30/2024 training year. Direct Service Worker #4 was not trained on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 7/1/2023 - 6/30/2024 training year. | 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. | CEO completed the training on abuse prevent and detection on 08/19/2024 through myODP. |
08/19/2024
| Implemented |
| 6400.52(c)(4) | Chief Executive Officer #1 was not trained on recognizing and reporting incidents during the 7/1/2023 - 6/30/2024 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | CEO completed the training through myODP on 08/26/2024 |
08/26/2024
| Implemented |
| 6400.52(c)(6) | Chief Executive Officer #1 was not trained on the implementation of the individual plans for the individual's they provide services to during the 7/1/2023 - 6/30/2024 training year. Direct Service Worker #4 was not trained on the implementation of the individual plans for the individual's they provide services to during the 7/1/2023 - 6/30/2024 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | CEO was trained on 08/12/2024 on ISP's and the DSP was trained on 8/30/2024 on ISP's. |
08/30/2024
| Implemented |