| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | At the time of the inspection on 9/29/26, it was discovered that none of the three bedrooms in the home were fully furnished as stated in the agency's self-inspection tool. All the bedrooms had a closet but only one of the bedrooms contained a bed frame and a mattress. The agency's self-inspection tool was signed by the agency CEO on 7/17/26 indicating there were no violations for regulations 81k (1-6) related to bedroom contents. The self-assessment tool provides definitions of the correction action status on the first page. The agency failed to follow these instructions as they did not identify these regulations as partially corrected or include that the reason the bedrooms were unfurnished was in the event the prospective individuals wanted to bring their own furniture. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Agency CEO retrained on regulation 55 Pa. Code 6400.43 (b) to ensure accurate completion of future self-inspections. Bedroom furnishings have been placed within the home by agency maintenance team on 10/7/2026 and will be maintained in accordance with regulatory requirement 55 Pa. Code 6400.81k (1-6) unless documentation supports an approved exception based on individual choice. Training documents and Bedroom furniture pictures will be emailed to Licensing Representative upon submission of this Plan of Correction for verification purposes. |
10/12/2026
| Implemented |
| 6400.70 | At the time of the inspection on 9/29/26, there was not an operable telephone in the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| An operable telephone with an outside line was restored in the home on 10/8/2026. Agency CCO was retrained on 55 Pa. Code 6400.70 to maintain an operable telephone that is always easily accessible to individuals and staff ensuring emergency services can be contacted quickly when needed. |
10/12/2026
| Implemented |
| 6400.73(a) | At the time of the inspection on 9/29/26, there was not a handrail at the exterior staircase that leads to the walkway that goes to the back of the building. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | A well-secured handrail was installed by agency maintenance team on the exterior staircase leading to the rear walkway located on 10/72026. Agency CCO retrained on 55 Pa. Code 6400.73(a) the physical site requirement that each ramp, interior stairway and outside steps exceeding two steps shall have a well secured handrail to ensure safe evacuation during an emergency and fall prevention. Training document and picture of the handrail will be emailed to Licensing Representative upon submission of this Plan of Correction for verification purposes. |
10/12/2026
| Implemented |