Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(a) | Staff #1 had a date of hire that was 8/1/22, however the PA criminal Background was completed on 8/23/22 | 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.
| CFO retrained HR staff on 09/12/2022 on Chapter 6400 background compliance verification requirements |
09/12/2022
| Implemented |
6400.21(b) | Staff #2 had an FBI Check completed through OCYF which is not accepted under the 6400 regulations. | 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.
| CFO retrained HR staff on 09/12/2022 on Chapter 6400 background compliance verification requirements. Staff #2 PA Background check was done on 09/09/2022 (see attachment 7) |
09/09/2022
| Implemented |
6400.64(a) | The laundry room contained substantial lint around the dryer and vents in laundry area.
In the bathroom there was a buildup of debris in the skylight/vent area including a dead bird. | Clean and sanitary conditions shall be maintained in the home. | Bathroom and Laundry rooms were cleaned by staff on 09/08/2022 (see attachment #3) to remedy the violation. |
09/08/2022
| Implemented |
6400.67(a) | The flooring in the laundry room is peeling up just at the edge of where one would step up to get in. | Floors, walls, ceilings and other surfaces shall be in good repair. | Floor Repairs were made on 9/20/2022 (see attachment #2) by the Assistant Residential Director to remedy the violation. |
09/20/2022
| Implemented |
6400.72(a) | The screen was missing in font window/kitchen area. It had the frame of where a screen once was but was ripped out. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screen Repairs were made on 9/20/2022 (see attachment #1) by the Assistant Residential Director to remedy the violation. |
09/20/2022
| Implemented |
6400.82(f) | No Trashcan present in bathroom | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | New trashcan was added to a bathroom 9/20/22 (see attachment #4) by the Assistant Residential Director to remedy the violation. |
09/20/2022
| Implemented |
6400.151(a) | Last physical provided for staff #3 was August 8, 2019. Staff physicals need to be completed every two years. | 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. | Staff #3 physical was completed on 8/15/2022 (see attachment #10) |
08/15/2022
| Implemented |
6400.24 | Controlled substance in the home was not being counted/double locked as required under the Controlled Substance Act of 1970 | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Second lockable container and count sheet were added to a med box on 09/08/2022 by the Assistant Residential Director to remedy the violation. |
09/08/2022
| Implemented |
6400.207(4)(I) | Individual #1 is prescribed Prescribed PRN Lorazepam 0.5 for behavioral purposes which is outlined in the prohibited procedures section of the RCG | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Program specialist reached out to the individual #1 Psych Doctor prior to inspection and prescribed medication was changed from PRN to BID on 9/7/2022 |
09/07/2022
| Implemented |