| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | No ventilation (mechanical or window) in Individual #1 bathroom, or the 2nd bathroom | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The mechanical ventilation system has been serviced and cleaned out. It is now operating properly. Please refer to attachments 8, and 9 |
04/11/2022
| Implemented |
| 6400.81(k)(6) | No mirror in 2nd bedroom-unoccupied | In bedrooms, each individual shall have the following: A mirror. | A Mirror has been placed in the room |
04/11/2022
| Implemented |
| 6400.82(f) | There was bar soap at tub, but no hand soap at sink. No soap, no paper or cloth towels, in 2nd 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. | Soap and Paper towels have been placed in each bathroom at the sink. |
04/11/2022
| Implemented |
| 6400.111(c) | There was no fire extinguisher located in the kitchen. There was an extinguisher elsewhere in the home. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | A Fire extinguisher was placed under the sink in the kitchen at the location. Please refer to attachments 16 |
04/11/2022
| Implemented |
| 6400.24 | The regulations regarding PA residence are not being followed. Residence verification/declaration were not completed for Staff Member 1, 2, 3, and 4. It could not be determined if these staff resided in PA for 2 consecutive years. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The staff has completed the residency affidavit. Please refer to attachment 6 |
04/11/2022
| Implemented |
| 6400.52(b)(1) | CEO trainings were not documented, therefore, it was unable to determine if the trainings were completed. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | CEO will sign a training sign-in sheet to show proof of Training Record. Please refer to attachment 7. |
04/11/2022
| Implemented |