| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 6/3/25, Individual #1's funds were used to purchase sunscreen, which is an item that is to be covered by room and board. | Individual funds and property shall be used for the individual's benefit. | Individual #1 was reimbursed the amount of the sunscreen ($8.97) on 10/24/25. See the receipts showing purchase and receipt showing reimbursement in supporting documentation titled "Sunscreen." |
11/28/2025
| Implemented |
| 6400.22(d)(1) | On 6/4/25, Individual #1 purchased a $20 gift card for the Lancaster Stormers. No tracking was available for this gift card. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The gift card was purchased on 6/4/25 and used to purchase items while at the ball game. Please see the attached receipt showing the balance of gift card as of 6/4/25. The gift card is with the funds at the home. Please see attached receipt titled "Stormer Gift Card Balance." A ledger was created documenting all transactions of the gift card and documented the current balance. |
11/28/2025
| Not Implemented |
| 6400.46(b) | Staff #1 had fire safety training on 9/3/24 and not again since, outside of the annual timeframe. Staff #2 had fire safety training on 10/4/24 and not again since, outside of the annual timeframe. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff #2 completed their fire safety training in Relias on 10/22/25. |
11/28/2025
| Implemented |
| 6400.169(a) | Staff #3 is not med trained. Their total score on their med-training was only 89.13. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff was immediately removed from administering medication. They will be attending the medication administration course on 11/6/25. |
11/28/2025
| Not Implemented |