| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | There is no documented criminal history for Staff Members 7, 8, or 9. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The HR department will ensure that criminal history clearances are obtained and maintained for all staff members prior to providing services as required. The 3 staff members identified in the finding will have the required criminal history obtained and placed in their file. |
08/10/2026
| Implemented |
| 6400.21(b) | Staff Member 3 reported that the PA residency prior to employment had not exceeded two years; however, no FBI clearance was provided.
Staff Member 4 was hired on April 13, 2026, but the FBI clearance was completed on April 22, 2026.
Staff Member 5 commenced employment on May 26, 2026, yet the FBI clearance was finalized on June 5, 2026.
Staff Member 6's date of hire was October 27, 2025. Additionally, Staff Member 6 noted that PA residency had not exceeded two years prior to employment, but there was no FBI clearance available. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| The HR department will ensure that staff members obtain the required FBI background clearance and that documentation of the clearance and that documentation of the clearances is maintained in the personnel file. HR management will review the file to ensure all required criminal history and background clearances are completed and properly documented. |
07/13/2026
| Implemented |
| 6400.151(a) | Staff Member 1 was hired on April 27, 2026, but the physical examination was not completed until May 4, 2026.
Staff Member 2 was hired on November 24, 2025, but the physical examination was not completed until December 1, 2025. | 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 Department will ensure that the identified staff member has a completed physical examination documented in their personnel file. The Human Resources Department will review the staff member's employment and physical examination dates monthly to ensure compliance with all requirements. |
07/15/2026
| Implemented |