| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Support Professional #1, date-of-hire 6/20/23, did not have a Pennsylvania criminal history record check.. | 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 Supervisor did the background check for Direct Support professional #1 on 10/13/2023. The initial background check on file for staff #2 was done on 7/9/2020 because Direct Support professional #1 used to work for the Homecare business. |
09/23/2023
| Implemented |
| 6400.66 | On 9/21/2023, the exterior door located in the kitchen and leading to the side of the home was observed at 12:25 PM without an outside light or any other sufficient lighting source nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Outside lighting was installed on 10/11/2023. Receipt attached. |
10/11/2023
| Implemented |
| 6400.110(e) | On 9/21/23, the smoke detectors in this 3-floor home were found not to be interconnected at 12:13 PM. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Interconnected smoke detectors were ordered from amazon.com on 10/11/2023. Receipt attached. |
10/11/2023
| Not Implemented |
| 6400.18(a)(9) | EIM Incident #: 9231637 involving serious injury was discovered on 6/12/23 at 12:00 PM and reported on 6/13/23 at 7:43 PM. EIM Incident #: 9251083 involving serious injury was discovered on 7/19/23 at 6:00 PM and reported on 7/21/23 at 10:13 AM. EIM Incident #: 9274487 involving serious injury was discovered on 8/31/23 at 12:00 AM and reported on 9/2/23 at 6:27 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| The Certified Investigator organized a training on 10/9/2023 to discuss ODP Incident Management Bulletin # 00-21-02 that defines reporting timelines for various categories of incidents. |
10/09/2023
| Implemented |
| 6400.51(b)(5) | Direct Support Professional #2, date-of-hire 8/28/23, did not have orientation training on the restrictive procedure plan of Individual #1, for whom they provide direct care. | The orientation must encompass the following areas: Job-related knowledge and skills. | The Home Supervisor organized a training on Individual #1¿s ISP on 9/22/2023. |
10/11/2023
| Implemented |