Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00276292 Renewal 10/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.18Individual #1's assessment completed 6/6/25 states the individual is unable to make change from a $1, $5, $10, or $20 bill. According to Program Specialist #1 Individual #1 received a "Large settlement," "More than Individual #1 could ever spend." The individual's, ISP, last updated on 9/15/25, indicates: "Individual #1 is dependent on others to manage [their] finances. Life Sharing Provider #2) is Individual #1's financial power of attorney, and the life sharing agency is their representative payee per individual's request. The money from the settlement is not recorded or being managed by the agency, who is the representative payee.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape, sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a family member or an agency staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Individual's functional assessment will be updated to show in greater detail individual's understanding of money management. ISP document will be updated to reflect these changes. Individual's settlement will continue to be managed as is with the contingency that a quarterly statement is provided to L'Arche (rep payee) as complies with the wishes of the individual and POA. This will be added to the ISP to ensure implementation and accountability. All funds distributed to individual c/o POA (Lifesharing provider) by Rep payee (L'Arche) will be tracked via a monthly ledger. Ledger and receipts over $15.00 will be retained and returned to rep payee. Individual's checking account where paychecks from employer are direct deposited will be retained. Individual will manage this account and access debit card as defined by updated functional assessment. Monthly statements and paystubs will be recorded by LS provider and reported to overseeing entities as required by Chapter 6500.18 and any other applicable jurisdictions. 11/15/2025 Implemented
6500.24(d)(1)Individual #1's assessment completed 6/6/25 states the individual is unable to make change from a $1, $5, $10, or $20 bill. Individual #1's attends employment four days a week for four hours each day. Individual #1 earns wages for employment and deposits into a personal checking account that is not managed by the agency, who is representative payee. An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency.Individual's functional assessment will be updated to show in greater detail individual's understanding of money management. ISP document will be updated to reflect these changes. Individual's settlement will continue to be managed as is with the contingency that a quarterly statement is provided to L'Arche (rep payee) as complies with the wishes of the individual and POA. This will be added to the ISP to ensure implementation and accountability. All funds distributed to individual c/o POA (Lifesharing provider) by Rep payee (L'Arche) will be tracked via a monthly ledger. Ledger and receipts over $15.00 will be retained and returned to rep payee. Individual's checking account where paychecks from employer are direct deposited will be retained. Individual will manage this account and access debit card as defined by updated functional assessment. Monthly statements and paystubs will be recorded by LS provider and reported to overseeing entities as required by Chapter 6500.18 and any other applicable jurisdictions. 11/15/2025 Implemented
6500.24(e)(1)Individual #1's assessment completed 6/6/25 states the individual is unable to make change from a $1, $5, $10, or $20 bill. On 10/16/2025 the agency did not have a separate record of financial resources including the dates and amounts of deposits and withdrawals for Individual #1's spending money.If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals.Individual's functional assessment will be updated to show in greater detail individual's understanding of money management. ISP document will be updated to reflect these changes. Individual's settlement will continue to be managed as is with the contingency that a quarterly statement is provided to L'Arche (rep payee) as complies with the wishes of the individual and POA. This will be added to the ISP to ensure implementation and accountability. All funds distributed to individual c/o POA (Lifesharing provider) by Rep payee (L'Arche) will be tracked via a monthly ledger. Ledger and receipts over $15.00 will be retained and returned to rep payee. Individual's checking account where paychecks from employer are direct deposited will be retained. Individual will manage this account and access debit card as defined by updated functional assessment. Monthly statements and paystubs will be recorded by LS provider and reported to overseeing entities as required by Chapter 6500.18 and any other applicable jurisdictions. 11/15/2025 Implemented
6500.24(e)(3)Individual #1's assessment completed 6/6/25 states the individual is unable to make change from a $1, $5, $10, or $20 bill. On 10/16/2025 the agency did not have documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual.If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by family members or agency staff.Newly imposed record keeping regimen from violation 6500.24(e)(1). All receipts in excess of $15.00 will be retained and recorded. Receipts to be collected by PS at monthly visits and turned in to rep payee. 11/15/2025 Implemented
6500.73On 10/16/25 at 11:56AM, there were three steps, coming from the lower-level family room into the garage. There was no handrail adjacent to the steps.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.Lifesharing Provider will gather quotes for a handrail to be installed. 11/15/2025 Implemented
6500.121(c)(9)Individual #1 had an annual physical on 3/18/25 but prostate examination was blank, there was no other recent prostate test or examination located in the individual's file. Individual #1 is 40 years of age or older. The physical examination shall include: A prostate examination for men 40 years of age or older.Lifesharing provider will obtain a copy of the lab work from physician. PS will attach to existing physical. 11/12/2025 Implemented
6500.34(a)Individual #1 was informed of individual rights 6/5/24 and again on 8/7/25. This exceeds the annual requirement. Additionally, the following rights were not included on the 8/7/25 right documentation: 6500.32(a) An individual may not be discriminated against because of race, color, creed, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age., 6500.32(b) An individual has the right to speak freely, 6500.32(c) An individual may not be exploited, abandoned, 6500.32(d) An individual shall be treated with dignity and respect, 6500.32(e) An individual has the right to make choices and accept risks, 6500.32(f) An individual has the right to refuse to participate in activities and services, 6500.32(g) An individual has the right to control the individual's own schedule and activities, 6500.32(h) An individual has the right to privacy of person and possessions, 6500.32(j) An individual has the right to voice concerns about the services the individual receives, 6500.32(p) An individual has the right to choose persons with whom to share a bedroom, 6500.32(q) An individual has the right to furnish and decorate the individual's bedroom in accordance with § 6500.33 (relating to negotiation of choices), 6500.32(r) An individual has the right to lock the individual's bedroom door, 6500.32 (r)(1) Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door, 6500.32(r)(2) Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, 6500.32(r)(3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance, 6500.32(r)(4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, 6500.32(r)(5) The primary caregiver shall have the key or entry device to lock and unlock the door, 6500.32(s) 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 6500.32(t) An individual has the right to access food at any time, 6500.32(u) An individual has the right to make health care decisions, and 6500.32(v) An individual's rights may only be modified in accordance with §6500.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.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.Individual rights document used by provider agency updated to accurately reflect those rights defined by 6500.34(a) 11/12/2025 Implemented
6500.135(g)Individual #1 had a psychotropic medication review conducted 9/6/24 and then again 12/19/2024 and not again until 7/1/25. The time between appointment exceeds the every 3-month requirement. The following psychotropic medication reviews conducted did not include the reason for prescribing the medication: 10/2/25, 7/10/25, 12/19/24, 9/6/24.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage.Life sharing provider and PS have spoken to physician illustrating the importance of keeping these appointments and making sure not more than 90 days pass between appointments. Reason for prescribing medications will be included on med review paperwork. 11/15/2025 Implemented
6500.152(c)Individual #1 had an annual Individual Service Plan, (ISP) developed on 6/4/25. The assessment used to revise and update the individual plan was sent to plan team members on 6/6/24 and was not current.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Assessment will be updated annually as required and delivered to team members a minimum of 30 days prior to the ISP meeting. 11/12/2025 Implemented
6500.162On 10/17/25 the agency's restrictive procedures policy was requested but the agency was unable to produce the policy.A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures, and a process for the individual and family to review the use of restrictive procedures shall be kept.Agency has restrictive procedures policy. This policy will be uploaded and/or sent to audit supervisor. 11/18/2025 Implemented
SIN-00216159 Renewal 11/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.135(g)Individual #1, date of admission 1/01/2022, is prescribed a medication to treat symptoms of a diagnosed psychiatric illness. A medication review was completed by a licensed physician on 3/01/2022 and then again on 8/16/2022. This exceeds the 3-month requirement.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Psychiatric medication management will be completed at least every 3 months to document the reason for prescribing the medication, the need for continuing the medication and the necessary dosage. The treating doctor will be responsible for this change. The change has been made immediately. The Health Care Provider has also been provided a copy of our regulations. Regularly scheduled appointments have been setup on a recurring basis, and the Assigned Program Specialist will monitor the appointment dates for timeliness. We have ensured the Prescribing Doctor has a copy of the regulations, and the Program Specialist will review continuity of care appointment forms. The Assigned Program Specialist will maintain a spreadsheet of appointment dates coinciding with the appropriate regulations. Training / Retraining will be provided to the Program Specialist and Provider on 6500.135(g), which is If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. [Documentation of completed psychiatric medication review for individual, dated 12/8/22, was received on 2/15/23 and reviewed 2/27/23. Documentation of training related to regulation 6500.135g, dated 1/13/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 12/27/2022 Implemented
6500.136(a)(11)Individual #1's November 2022 Medication Administration Record did not include the diagnosis or purpose for the following medications: Aspirin 325 MG - Take one tablet by mouth daily; Vitamin D3 25 MCG - Take one softgel by mouth once daily; Citalopram Hydrobromide 40 MG Tab Auro - Take one tablet by mouth every day; Bupropion Hydrochloride Er (Sr) 12 hr 100 MG Tab - Take one tablet by mouth everyday; and Quetiapine Fumarate 50 MG Asce - Take one tablet by mouth every day.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The individual will utilize the L'Arche Erie Pharmacy of choice who will make the change in provider. Once the individual has been setup with our pharmacy, the medication administration record will be created to include diagnosis and purpose for medications. The Physician / Nursing Department will be responsible for this change. Individual and Provider have been notified the change in pharmacy must be completed within 30 calendar days. Nursing Department will work with contracted pharmacy to get individual #1 enrolled. Once enrolled, Nursing Department will provide correct MAR forms to Provider, which will include individual #1's diagnosis and purpose for medications. Individual #1 will be enrolled in contracted pharmacy, MARs will be checked by Nursing Department before sent to Provider to ensure they include diagnosis and purpose for each medication, and training will be provided to the Provider. Provider will be retrained by January 10, 2023, on 6500.136(a), which is that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for medication, include pro re nata. [Documentation of a blank individual Medication Administration Record (MAR), that does not indicate the month or year, but contains a diagnosis or purpose for each prescribed medication was received on 2/15/23 and reviewed 2/27/23. Documentation of training for Life Sharing provider related to regulation 6500.136, dated 2/9/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 01/10/2023 Implemented
6500.136(b)On 11/23/22, the following medications for Individual #1 were recorded as administered through and including 11/30/2022: Aspirin 325 MG - Take one tablet by mouth daily; Vitamin D3 25 MCG - Take one softgel by mouth once daily; Citalopram Hydrobromide 40 MG Tab Auro - Take one tablet by mouth every day; Bupropion Hydrochloride Er (Sr) 12 hr 100 MG Tab - Take one tablet by mouth everyday; and Quetiapine Fumarate 50 MG Asce - Take one tablet by mouth every day.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Provider will not sign medication records in advance, but instead, sign the record at the time the medication is administered. The LS provider will be responsible for this change. The change will happen Immediately; Provider was informed on 11/23/2022 that all medication recordings on and after that date should be at the time the medication is administered. Provider has stopped pre-dating medication records. The Program Specialist and / or Medication Administration Certified Trainer will complete random checks in the home to verify medication records are not being signed off prior to the medication being administered. The Provider will be retrained on 6500.136(a-d) by January 10, 2023, and the Provider will be required to sign and date the retraining form. The form will be maintained by HR. [Documentation of a blank individual Medication Administration Record (MAR), that does not indicate the month or year, but contains a diagnosis or purpose for each prescribed medication was received on 2/15/23 and reviewed 2/27/23. Documentation of training for Life Sharing provider related to regulation 6500.136, dated 2/9/23, was received on 2/15/23 and reviewed 2/27/23. Documentation of "random check" of medication administration documentation, dated 2/9/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 01/10/2023 Implemented
6500.139(a)Life Sharing Caregiver #1, date of hire 1/01/2022, completed the modified medication administration course on 2/28/2020. On 11/23/22, the recertification course has not yet been completed by Life Sharing Caregiver #1. This exceeds the 2-year requirement.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).Provider will be enrolled in Medication Administration Training course by December 31, 2022. Certified Medication Administration Trainer and LS Provider will be responsible for the change. Provider will be enrolled in Medication Administration Training course by December 31, 2022. Course will be completed no later than January 31, 2023. Certified Medication Administration Trainer is required to enroll provider in the Medication Adminstration Training Course by December 31, 2022. Once the Provider has been enrolled, the Provider is required to fulfill online and face-to-face training requirements. Certified Medication Administration Trainer will track training completion date once the Provider is considered re-certified to ensure re-training is completed within 730 days (2 years) from the last course completion date. Certified Medication Administration Trainer will track training completion date once the Provider is considered re-certified to ensure re-training is completed within 730 days (2 years) from the last course completion date. All Medication Administration Training records are record due dates are maintained within BambooHR for Providers and employees. This system provides reminders of upcoming due dates to Providers and the Certified Medication Administration Trainer. The Certified Medication Administration Trainer has been provided training / retraining on 6500.139. The retraining record will be kept in the employee's file. Also, the Provider will review 6500.139, and complete an in-service training by December 31, 2022. [Documentation of training in relation to regulation 6500.139 for the Medication Administration Trainer, dated 12/27/22, was received on 2/15/23 and reviewed 2/27/23. Documentation of training in relation to "Medication Administration in Lifesharing Homes," dated 1/13/22, was received on 2/15/23 and reviewed 2/27/23. Documentation of training for Life Sharing Provider related to regulations 6500.136 and 6500.139, dated 2/9/23, was received on 2/15/23 and reviewed on 2/27/23. Documentation that Life Sharing Provider completed the Modified Medication Administration Course Renewal, dated 2/14/23, was received on 2/15/23 and reviewed 2/17/23. DPOC by HDKP, HSLS, on 2/27/23.] 01/31/2023 Implemented
SIN-00197732 Renewal 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.108(a)The fire extinguishers in the basement, first floor, and second floor of the home had a 1-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.L'Arche purchased three new fire extinguishers for the home with a 5#ABC rating. 12/15/2021 Implemented
SIN-00254986 Renewal 10/17/2024 Compliant - Finalized
SIN-00233113 Renewal 10/17/2023 Compliant - Finalized