| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment of the home dated 7/14/25 did not address 6400.181a through and including 6400.181f. This section of the self-assessment was left blank. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| In accordance with 55 PA Code 6400.15(a) the agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals within 3 to 6 months prior to the expiration of the agency's certificate of compliance, to measure and record compliance with this chapter. |
12/29/2025
| Implemented |
| 6400.112(c) | Fire drills were conducted on 10/27/24, 11/24/24, and 12/23/24 but the fire drill record did not indicate the time the fire drill was conducted | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | In accordance with 55 PA Code Chapter 6400.112(c) a written fire drill record shall be kept of the date, time, the amounts of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was active. |
12/19/2025
| Implemented |
| 6400.112(e) | The home most recently completed a fire drill during sleep hours on 3/10/25. This exceeds the at least every 6-months requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | In accordance with 55 PA Code Chapter 6400 a fire drill shall be held during sleeping hours at least every 6 months. |
12/19/2025
| Implemented |