| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(c) | Documentation for Staff One did not reflect a documented case-by-case hiring review related to criminal charges or prior convictions in relation to the position for which the 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.
| Staff member 1 had up-to-date clearances upon hire and at the time of licensing review within 1 year of hire. The PA criminal background check for Staff 1 was completed on 12/4/25 and the assessment was completed on 12/17/25. Pease see attached background check and assessment. |
04/30/2026
| Implemented |
| 6400.62(a) | Poisons were found unlocked throughout the house. The ISP for Individual One states they "do not have access to any cleaning products or hazardous materials," and "Merakey does ensure that all cleaning products are safely locked." The ISP for Individual Two states, "(They) need an environment where poisonous substances are appropriately secured." | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials were locked and/or removed from areas with food upon discovery during the audit. |
04/30/2026
| Implemented |
| 6400.62(d) | Boost drinks were found stored alongside liquid laundry detergent, zep cleaner, and hand soaps in the freestanding closet in the basement living area. This was corrected at the time of the visit. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | All poisonous materials were locked and/or removed from areas with food upon discovery during the audit. |
04/30/2026
| Implemented |
| 6400.67(a) | The office ceiling was damaged from what appeared to be a water leak. Staff reported the leak occurred the previous week, and a maintenance request was submitted; however, the request was not provided for review. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to fix the office ceiling. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.68(b) | Water temperatures in the home consistently measured over 120 degrees Fahrenheit notably in the kitchen (133 °), main hallway bathroom (132.4°), Individual Two's bathroom (129.4°), and basement bathroom (129.7°). | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Program leadership submitted a maintenance request immediately to Merakey's facilities Department the day of the licensing audit to fix the water temperature at Jody Ln. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.80(a) | The rear porch egress and stairs were not cleared of snow. This was in process of being corrected at the time of the visit. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Staff removed snow on the walkways at all the exits upon discovery during the audit. |
04/30/2026
| Implemented |
| 6400.82(f) | Individual Two's bathroom did not have toilet paper or individual paper towels or cloths. Staff stated that the individual will use them to clog the toilet, so they were locked in the hallway supply closet. When the individual needs toilet paper, they use the call button next to the toilet to notify staff; however, this is not stated in the individual's ISP. | 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. | Immediately after the licensing audit, the Program Specialist emailed the Support Coordinator to schedule a critical revision of individual #2 ISP. |
05/15/2026
| Implemented |
| 6400.111(e) | The home is three (3) stories including the basement and attic. There was one smoke detector on each floor; however, the detectors were not interconnected. | A fire extinguisher shall be accessible to staff persons and individuals. | Program leadership submitted a maintenance request to Merakey's facilities Department the day of the licensing audit to ensure that all detectors in the house are interconnected. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |