| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 07/9/26, at 11:00 AM, the basement had a fob key lock on the door leading to the basement. The basement has a manual door, leading to the outside of the home, which could be utilized for a fire exit. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Fob key lock to the door leading to the basement was disconnected 7.30.26 |
07/30/2026
| Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire 01/26/26, had a physical examination completed on 01/27/26. This exceeds the requirement of the employee having physical examination within 12 months prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Human Resources Director and Human Resources Specialist were trained on 7/30/2026 regarding the regulatory timelines of 55 Pa. Code § 6400.151(a), emphasizing that physicals must be completed prior to employment. The Human Resources Specialist completed an audit of all active residential staff's initial physical dates and compared them to their date of hire to check compliance throughout the department. Though the physical dates cannot be corrected, all non-compliances were recorded. |
10/31/2026
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1, date of hire 01/26/26, and had a Tuberculin skin test completed on 01/29/26. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The Human Resources Director and Human Resources Specialist were trained on 7/30/2026 regarding the regulatory timelines of 55 Pa. Code § 6400.151(c), emphasizing that physicals, which include a completed Tuberculin skin test by Mantoux method, must be completed prior to employment. The Human Resources Specialist completed an audit of all active residential staff's initial physical dates and compared them to their date of hire to check compliance throughout the department. Though the completed physical dates cannot be corrected, all non-compliances were recorded. |
10/31/2026
| Implemented |
| 6400.181(a) | Individual #1, date of admission 06/01/19, had an assessment completed on 08/6/24 and again on 10/3/25. This exceeds the annual requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individuals #1's assessment was completed on 10.3.25. A review was completed to ensure all initial assessment were completed within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. Any non-compliances were recorded. |
10/03/2025
| Implemented |