| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(c) | It was believed that staff #1 left the home for an undetermined amount of time leaving the individual #1, #2, and #3 home alone and out of supervision compliance. This was neglectful. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Staff #1 had employment terminated as a result of Threshold's Certfified Investigation. All staff will be trained on supervision requirements as outlined in training Using Service Plans by 12/16/2022. |
12/16/2022
| Implemented |
| 6400.52(c)(6) | Staff #1, #2, #3, and #4 did not have the annual training of the individual's ISP for the training year 2021/2022. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff #2, #3, #4 will have ISP Training updated for each of the men residing at 5064A Pottsville Pike. |
12/31/2022
| Implemented |
| 6400.186 | Individual #1, #2, and #3 individual service plans were not being followed. The individuals all require 24 hour supervision with staff on the premises. This did not occur at the time staff #1 left the residence leaving all 3 individuals unsupervised for an undisclosed amount of time. | The home shall implement the individual plan, including revisions. | Staff #1 had employment terminated as a result of Threshold's Certfified Investigation. All staff will be trained on supervision requirements as outlined in training Using Service Plans by 12/16/2022. |
12/31/2022
| Implemented |