Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00287374 Renewal 06/15/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.103Per the site records, the furnace at this location was cleaned on 06/30/2024 and 08/02/2025---more than one year apart. The furnace at this location was not cleaned annually as required.Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept.We were already cited on 6500.103 during August 2025 annual inspection. Below is our plan of correction for 8/2026 On 8/2/25, Furnace inspection was completed. As of 9/3/2025, the annual service date is recorded on the agency calendar to ensure that the furnaces are serviced on time. 09/03/2025 Implemented
6500.110(c)Family members shall be trained annually in fire safety. The caregiver had fire safety training on 5.30.25 and not again until 6.10.26. This exceeds the time frame.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).On 06/15/2026, management held a meeting to discuss steps needed to ensure that life sharing providers are trained on fire safety within 31 calendar days of an individual living in their home and retrained annually, in accordance with ODP regulations. 06/18/2026 Implemented
6500.122(a)An individual shall have a dental exam annually. The dental exam shall include teeth cleaning or checking of the gums. There was a dental exam dated on 1.23.26 which included a cleaning/exam; no other seen. Other documents reflect restorations. (DOA was 2.23.24; first dental in the book was from 11/20/24 and it was recommended that tooth #31 was to be extracted; next apt was not until 7.7.25, which a referral was put in for an oral surgeon, on 9.6.25 they finally extracted tooth #31, then on 1.23.26 there was finally an exam and teeth cleaning. Then on 2.3.26; 2.10.26; and 2.19.26 there were restorations on other teeth.An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually.Dental bi-annual exam and cleaning appointment is scheduled for 7/24/2026. 07/24/2026 Implemented
6500.123(a)If an individual refuses routine medical treatment, the refusals and continued attempts to train the individual shall be documented in the individual record. The agency reports that the individual refuses the use his CPAP machine. It appears that the individual has had this machine since 2024 and has consistently not utilized this and has had no medical follow up to this recommendation.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.On 6/15/2026, Provider staff had a conversation with John about using his CPAP. On 6/19/2026, Program Specialist conducted a face-to-face meeting with the individual regarding sleep apnea management. The Program Specialist had the individual viewed educational materials, including a video on CPAP utilization, to support his nocturnal health and safety. The Program Specialist also provided a list of alternative interventions for the individual and staff to review with his respiratory specialist on August 26, 2026, during his follow-up appointment. The short and the long-term benefits of utilizing this machine as recommended were also discussed with the individual. 06/19/2026 Implemented
6500.141At the time of the inspection there was a freezer located in the basement area. The freezer was leaking causing a puddle of brown liquid. Upon opening the freezer there was a build up of ice throughout the freezer. There were freezer bags filled with mixed peppers located at the bottom of the freezer. It appears that the ice was melting and possibly causing the peppers to defrost and leak as well causing the brownish color liquid on the floor where the freezer stood.Food shall be protected from contamination while being stored and prepared.On 6/15/2026, life sharing provider cleaned the brown liquid. On 6/20/2026, life sharing provider unplugged, cleaned, and organized the freezer. 06/20/2026 Implemented
6500.124On 2.24.24 a sleep study was recommended, it was reported he went, currently has a CPAP. Agency provided an after-visit summary for an apt at the Reading Hospital Sleep Lab that occurred on 10.15.24, there was no information on this form other than the issue addressed at today's visit was sleep apnea. The ISP reflects that the individual has a CPAP machine but choses to not use it. There are no follow up's regarding the CPAP machine or even the recommendation to utilize this machine. There was a CPAP machine in the home at the time of the inspection, however it was in the hallway closet and when I opened the bag, the pieces of the machine were still wrapped in the sealed plastic, and it was clear that it has never been used.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.A follow up appointment is scheduled with a respiratory specialist for 8/26/2026Moving forward, Staff will ensure that discharge paperwork is properly filled out prior to leaving the medical facility. Program Specialist will ensure the paperwork is reviewed; follow ups are scheduled; and recommendations are implemented as required by a medical provider. In addition, information will be provided to the support coordinator to update the individual's ISP. 08/26/2026 Implemented
6500.45(b)The primary caregiver shall be trained in First Aid/CPR prior to the individual moving in and annually thereafter. The caregiver was trained on 4.27.23 and not again until 6.27.25. This exceeds the time frame.The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter.On 06/15/2026, management held a meeting to discuss steps needed to keep track of staff training record and ensuring that trainings are completed within a required timeframe, in accordance with ODP regulations. 06/15/2026 Implemented
SIN-00271115 Renewal 08/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.103The furnace in home was not inspected annually. The furnace was inspected on 6/30/24 and not again until 8/2/25.Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept.On 8/2/25, Furnace inspection was completed. As of 9/3/2025, the annual service date is recorded on the agency calendar to ensure that the furnaces are serviced on time. 09/03/2025 Implemented
SIN-00247929 Renewal 08/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.125(a)Individual #1 moved into the Lifesharing Provider's residence on 04/20/2024. The only physical on file for Staff #1, the Lifesharing Provider, was dated 06/05/2024. Staff #1's Physical Examination was not completed within 12 months prior to Individual #1 living in the home as required.Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home.On 8/12/2024, we created a checklist through which we will keep track of potential and current lifesharing providers records as required by the regulations. The documents to track are as follow: annual physical, training and others. 08/12/2024 Implemented
6500.139(a)Individual #1 is not self-medicating. Documentation in the staff record showed that Staff #1, who administers this individual's medications, completed the initial Department-approved Medication Administration Training course while working for another provider agency. There was no record of Staff #1 completing the required annual practicums with the previous provider or with this current provider. There was a certificate of completion for the Modified Medication Administration training dated 01/09/2019; however, this alone is not sufficient to satisfy the Medication Administration training requirements. The documentary evidence found in the staff record showed that this staff was not qualified to administer medications to the individual.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration).As of 8/6/2024, a trained medication administration staff has been assigned to administer medication at Lynn Avenue until lifesharing provider is trained on medication administration. Lifesharing provider has been set up to take the medication administration training. 08/06/2024 Implemented