| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.107(d) | The home opened in June 2020. At the time of the 12/8/2020 inspection, there is no evidence that the 4 smoke detectors in the home were checked for operability monthly, from July through December 2020. | A smoke detector shall be tested each month to determine if the detector is operative. | CCO has created a monthly checklist for smoke detector checks. Life sharing provider will be responsible for completing the monthly checks and will submit to the life sharing specialist for review. The life sharing provider will ensure that monthly checks are completed. The CCO will check sporadically and ensure that this regulation is met. |
12/18/2020
| Implemented |
| 6500.151(e)(4) | Individual #1's 7/14/2020 assessment does not include his level of supervision needed in his current, family living home placement. His assessment states he can have up to two hours of unsupervised time at home. He recently moved into his current home in January of 2020, after living at another residence for the better part of his 40 years of life. However, he has a 9/21/2020 supervision plan stating that his two hours of unsupervised time has not been trialed yet and he would need to utilize up to 30 minutes of unsupervised time at home at a time to determine how much unsupervised time at home is applicable for Individual #1.
Additionally, the individual's assessment states that he would need assistance to respond appropriately to a dangerous situation at home, has limited skills that would hinder his ability to prevent a crisis from happening, he would need assistance to state his name, address, phone number and in case of an emergency if faced with a crisis or emergency, and needs assistance in complete basic first aid. | The assessment must include the following information: The individual's need for supervision. | Lifesharing specialist has fixed all documentation errors to reflect the individual's current need in both the assessment and plan for supervision to ensure that it matches the ISP. The life sharing specialist will ensure that all documents reflect accurate information in all documents. Sporadic checks to be completed and documented by CEO. |
12/28/2020
| Implemented |
| 6500.151(e)(5) | Individual #1's 7/14/2020 assessment does not include his current level of ability to self-administer medications. His assessment states he can self-administer his medications but also that his family living provider assists with proper administration of a foot lotion to ensure it is applied correctly. Defined under 6500.131(e)(4), an individual must be able to take or apply the individual's own medication with or without the use of assistive technology to be considered capable of self-administering their medications. Due to this definition, the individual is not able to self-administer his foot lotion, and this was not stated within his assessment. | The assessment must include the following information: The individual's ability to self-administer medications. | Assessment has been updated to reflect individual's need for assistance in applying lotion to feet by life sharing specialist to match the information contained in the plan for self administration of medication. Life sharing specialist will monitor medication and self administration skills monthly during monitorings. CCO and CEO will monitor all assessments and plans sporadically throughout the year to ensure all documents have the same information. |
12/21/2020
| Implemented |
| 6500.181(b)(1) | Individual #1's record did not include the name, address, telephone number and relationship of the person to be contacted in case of an emergency. | Emergency information for an individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of emergency. | All demographic information documents has been updated to include the verbiage "person to be contacted in case of an emergency". All individuals demographics have been updated and will be maintained by the life sharing specialist and on going checks to be completed by CCO or CEO when doing self audits. |
12/28/2020
| Implemented |
| 6500.32(s) | Individual's #1 and #2 were not offered a key or entry mechanism to the front door of the home. Neither individuals' assessments or individual plans state their wishes on obtaining a key or entry mechanism to the front door. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | Keys have been made and distributed to the individuals. Life sharing provider will ask individuals if they have a key at monthly monitorings. If individual no longer has a key, a plan to get a new key will be implemented. During self inspections, CCO and CEO will also ensure that keys are present during self audits and moving forward. |
12/28/2020
| Implemented |
| 6500.34(a) | Individual #1 moved into the licensed family living setting on 6/5/2020. The Department issued updated, regulatory individual's rights to inform individuals of and the process to report those rights, effective 2/3/2020. At the time of the 12/8/2020 inspection, individual rights defined in Pa. Code 55 chapter 6500.(32)(a), (d), (e), (f), (g), (j), (p), (q), (r), (s), (t), (u), and (v) were not reviewed with Individual #1 upon his admission to the facility or after. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | The old consent packet was accidently used to complete annual rights review. CCO has removed all old documents from the drive as well as the office to ensure that the correct form will be used moving forward. CCO reviewed individual rights documents with all persons and each individual has signed off on the new document, CCO will ensure that this regulation is met. |
12/21/2020
| Implemented |
| 6500.43(e)(2) | The agency does not have evidence that Staff person #3, who is performing program specialist duties, has earned a bachelor's degree (or qualifications defined under 6400.43(e)(3) by way of official transcript). The agency had evidence of an unofficial transcript (official transcript or copy of degree is required to meet regulation), stating that her suspected graduation will occur in December 2020. Staff person #3 has been working with the company in the capacity of program specialist since 8/18/2020. | A life sharing specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with persons with an intellectual disability or autism. | Official transcripts have been ordered to replace current unofficial transcripts but have not yet been received due to holiday break and pandemic. Staff person #3 has since graduated from college and that document was added to the file as well. In the future CCO will ensure that, if applicable, all PS's that have not obtained a diploma, have official transcripts prior to hiring. |
01/29/2021
| Implemented |
| 6500.136(a)(1) | Individual #1 is prescribed foot creams, Ammonium Lactate and Ketoconazole, and requires his family living provider to assist him daily with the application of the creams to ensure they are applied and rubbed in correctly. As defined in the Pa Code 55 chapter 6500 regulations, an individual who cannot apply or administer medications independently, must have a record kept of the contents defined in 6500.136(a)(1)(16) for the medication administration. The individual's application of his foot creams and it's requirements, was never documented. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | A medication administration record was started immediately and continues to be completed. In the future, the life sharing specialist will monitor monthly all medication administration needs or new medication to ensure that the individual is truly self medicating. This will be documented on the life sharing specialist's monthly monitoring form and checked during self audits by CCO and CEO to ensure compliance moving forward. |
12/21/2020
| Implemented |