| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #2 had a PA criminal history check completed on 11/3/21 however his date of hire was 10/1/21.
Staff # 3 had a PA criminal history check completed on 11/3/21 however his date of hire was 10/1/21. | 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 Agency has developed a policy in place to ensure that all company new employees will not start work until after a favorable criminal history check is completed. |
12/10/2021
| Implemented |
| 6400.21(b) | Staff member #1 had a PA state Criminal Check but no declaration of PA residency. Without the residence declaration it cannot be determined if a FBI check would be needed. | 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.
| A criminal check was completed for staff #1 and it came out good. |
12/10/2021
| Implemented |
| 6400.21(c) | Staff#4 had their most recent background check was on 4/17/19 however the date of hire is 10/1/21. Greater than 1 year elapsed. | 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.
| The Agency has developed a policy in place to ensure that all company new employees will not start work until after a favorable background check is completed. |
12/10/2021
| Implemented |
| 6400.68(c) | The most recent documented coliform water test was completed on 9/24/18. The Test needs to be performed every 3 months to ensure safety of drinking water. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | A water test was completed on November 23, 2021 with Suburban Testing Labs (See attached for a copy of receipt) |
12/10/2021
| Implemented |
| 6400.82(e) | There were no bathmats or non-slip surfaces present on site. | Bathtubs and showers shall have a nonslip surface or mat. | A nonslip bathmat has been purchased and placed in the bathroom bathtub. See attached receipt) |
12/10/2021
| Implemented |
| 6400.141(a) | Individual #1 did not have a current or previous Physical Exam on file. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | An annual physical has been completed for Individual #1 on 11/18/2021. (See attach completed physical form) |
12/10/2021
| Implemented |
| 6400.142(a) | No current or previous dental exam on record for Individual #1. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 has a current dental appointment that was completed June 7, 2021. A copy of that dental appointment paperwork is attached. |
12/10/2021
| Implemented |
| 6400.151(a) | Staff #5 had a TB test on 11/3/21 however the physical did not have a statement stating that she is free of communicable disease.
Staff #6, Staff #7 and Staff #8 Had no physical or current TB test on file | 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. | A new Physical Form has been created with the statement ¿Is the person free of communicable diseases? Yes ( ) No ( ) ¿ (See attached) |
12/10/2021
| Implemented |
| 6400.46(b) | Staff fire safety training was completed by Program Specialist on 10/1/21 however the program specialist was not certified as a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Agency has completed a fire safety training for all employees on 11/15/2021 with National Safety Compliance Fire Safety Training Program ( Please see attached complete training forms) |
12/10/2021
| Implemented |
| 6400.46(c) | Staff #3 and Staff #8 had their First Aid training on 11/3/21 however they were working with the individual prior to this date. First Aid training is need that prior to the first time working with the individual. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Agency Compliance and Quality Director will ensure that all employees First Aid Training will be completed before they start work as per PA 6400 regulations requirement during first week of orientation. |
12/10/2021
| Implemented |
| 6400.163(f) | A medication for Individual #1 in need of refrigeration was located in small refrigerator, inside a closet, in the office area that did not have a lock on it. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | A lock was bought for the medication box and placed in the home refrigerator for safe keeping. A receipt of the lock is attached. |
12/10/2021
| Implemented |