| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | The documentation provided was inadequate to determine if 24 of the new hire staff were residents of Pennsylvania for 2 years prior to the criminal background checks. | 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.
| 1. It is the responsibility of the Program Director and Area Director to ensure that all newly hired staff meet this requirement. The system used to hire these employees did not include an attestation that a new employee lived in the state of PA for at least two years prior to date of hire. |
11/02/2023
| Implemented |
| 6400.64(a) | The floors in kitchen were visibly dirty near the sink area. Kitchen cabinets were dirty with what looked to be dirt accumulated over several months' time. The rangehood above the stove was sticky and dirty. Some of the dishes in cabinet had a caked white substance on them. The toilet bowl was dirty in the first bathroom. Inside of the bathroom vanity drawer was layers of dust bunnies and hairs. Overall, many of the surfaces noticeable could use a good dusting including corners and grooves. | Clean and sanitary conditions shall be maintained in the home. | 1. Staff working in the home completed a thorough cleaning of the home. Attachment 3A-3D |
11/02/2023
| Implemented |
| 6400.67(a) | The cabinet in the individual's private bathroom was broken. The entire right door came off when opened and could not be put back onto the hinge. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The agency employed maintenance and the cabinet door is in working order. Attachment 2 |
11/02/2023
| Implemented |
| 6400.72(a) | The air conditioning unit in the living room was not fully secured. Both sides of the air conditioner had 3-to-4-inch gaps between the window and the adjustable sliders. In addition, the main door to the apartment was open and there was no screen. As a result, there were flies throughout kitchen and dining room area creating unsanitary conditions. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 1. Due to the change in weather, the AC unit has been removed for the season. Maintenance will be employed when the weather changes again in the spring to install the AC unit with a piece of painted white wood to account for the gap when the AC unit is installed. Attachment 4 |
11/02/2023
| Implemented |
| 6400.82(f) | There was no soap available on the sink in the individual's private bathroom. Only paper towels were found on the sink in this 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. | 1. This has been corrected. Soap has been placed in the bathroom at Individual #1¿s home. Attachment 3A |
11/02/2023
| Implemented |
| 6400.151(a) | A physical exam for staff #1 is now due as the last exam was on 9/20/21. | 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. | 1. Staff #1 was diagnosed with COVID 19 and was unable to seen for the physical exam at the time of inspection. She did have a Negative TB test on 9/28/23. Her general physical exam was also completed on 9/28/23. Attachment 16 |
11/02/2023
| Implemented |
| 6400.52(a)(1) | Staff #1 did not complete 24 hours of training in the most recent training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | 1. Staff #1 completed 25 hours of training during the training year. This information was not properly tracked and filed as per agency protocol. |
11/02/2023
| Implemented |