| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(c) | Documentation for Staff One does not reflect a documented case-by-case hiring review related to criminal charges or prior convictions in relation to the position for which staff was hired. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| The PA criminal background check for Staff one was completed on 9/16/25. An assessment was not required. Please see attached |
04/30/2026
| Implemented |
| 6400.82(f) | There was no toilet paper or paper towels in the home's main bathroom. This was corrected at the time of the visit. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | As stated in the Plan of Correction, staff supplied toilet paper and paper towels in the home's main bathroom during the audit. |
02/25/2026
| Implemented |
| 6400.46(b) | Generic Fire Safety training was completed for Staff Two; however, required site specific training related to evacuation procedures and designated meeting locations specific to the home's design and layout was not completed. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff one completed their annual required site-specific training related to evacuation procedures
and designated meeting locations specific to the home's design and layout on xx date. Attached is a copy of the training roster. |
04/30/2026
| Implemented |
| 6400.46(b) | The staff on-site at the time of the visit knew to contact the fire alarm company prior to conducting a fire system test; however, did not know how to stop the alarm once it was set off for testing. Staff set off the fire alarm at 9:19am and it was still going off at the conclusion of the visit at 9:27am.
Documentation on site-specific fire safety training for all staff working in the home was requested and not received. In response, the provider stated that "All the new hire staff were transferred over as part of the new acquisition from (the previous provider). They were already working at the sites prior to starting to work with Merakey. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff two completed their annual required site-specific training related to evacuation procedures
and designated meeting locations specific to the home's design and layout on xx date. Attached is a copy of the training roster. |
04/30/2026
| Implemented |