| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff member #1 and #2 stated on their job application that they had resided outside of the state of Pennsylvania in the last 2 years, therefore they would have need an FBI criminal background check instead of the state background check provided.
*The provider provided documentation that the staff had amended their attestation of residency on 1/6/26, however with the information provided at time of hire, an FBI check would have needed to be conducted | 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.
| The violation occurred because the staff member mistakenly indicated on the employment application that they had not lived in Pennsylvania within the previous two years, and Human Resources staff relied on the photo identification residency information instead of the residency history question on the employment application when determining the required background checks. Upon review, the Human Resources Manager and the Program Director verified the staff member's residency history and confirmed that they had, in fact, resided in Pennsylvania for the prior two years. The personnel record was corrected to accurately reflect the verified residency history, and all active employee files were audited to ensure that background check requirements were applied correctly based on verified residency information. |
02/02/2026
| Implemented |
| 6400.110(e) | The home has 3 floors with functional smoke detectors; however, they are not interconnected and work independently of each other. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The violation occurred because staff failed to verify that the smoke detectors were in proper working order and interconnected during routine safety checks. On 1/7/2026, The Maintenance Department, in coordination with the Program Manager, has replaced the existing stand-alone smoke detectors with interconnected smoke detectors on each floor of the home so that activation of one alarm activates all alarms and is audible throughout the home. The installation included all three floors of the residence. The system has been tested and verified for proper interconnection and audibility throughout the home. See the attached#4 video for verification. |
01/07/2026
| Implemented |
| 6400.162(a) | The following medications were available in the home but was not labeled.
Estrovera, Flo PMS, Melatonin 5mg, Calcium/Mag/D3 500 mg, Vitamin B12/Folic Acid, Calodial Silver liquid 5ml | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | On 02/02/2026, the Program Specialist confirmed that a written prescriber order was received from the individual's primary care provider for the following OTC - see attached#5- and supplement items: Estrovera, Flo PMS, Calcium/Mag/D3 500 mg, Vitamin B12/Folic Acid, and Colloidal Silver liquid 5 ml. All previously identified issues were corrected. All items are now listed on the Medication Record and are stored appropriately.
Melatonin 5 mg was already properly labeled, and a valid prescription was already on file. see attached#6 |
02/02/2026
| Implemented |