| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.71 | On 7/02/2025 at 12:17pm the only landline phone was in Individual #1's bedroom, and did not include emergency numbers for nearest hospital, police, fire department, ambulance, and poison control. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home. | This was self-corrected on site by the Life Sharer Partner on 7/2/25 while the ODP Inspector was present. In the future, the Life Sharer Partner will ensure that the list of emergency numbers will be present at all times. |
07/02/2025
| Implemented |
| 6500.121(c)(4) | Individual #1's physical examination completed 3/19/2025 did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | A revised form was not utilized for this person's physical exam on 3/19/25, nor were they associated with Emmaus Community of Pittsburgh yet at the time of the exam. Emmaus Community of Pittsburgh has an updated compliant Physical exam form as of 12/2024 that will be used for all individuals. Included in this physical form is a section for HEENT; head, ears/ hearing, eyes, nose and throat. This form will meet the requirement for the regulation, 6500.121(c)(4). At this individual's annual exam in March of 2026 the updated Emmaus Physical form will be presented to the MD and completed. |
07/15/2025
| Implemented |
| 6500.121(c)(14) | Individual #1's physical examination completed 3/19/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Emmaus Community of Pittsburgh has an updated compliant Physical exam form as of 12/2024 that will be used for all individuals. This form will meet the requirement for the regulation, 6500.121(c)(14). At this individual's annual exam in March of 2026 the updated Emmaus Physical form will be presented to the MD and completed. The Life Sharing Partner will ensure that all necessary parts/sections are completed thoroughly. The Life Sharing Specialist will review the physical upon completion to make sure the form has been completed in entirety. |
07/15/2025
| Implemented |
| 6500.125(c)(2) | Life Sharing Provider #1, date of hire 11/01/2024, had a Tuberculin skin test by Mantoux method with negative results completed 11/02/2024. Individual #1's admission date was 11/01/2024. | The physical examination shall include: (2) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. | The Emmaus team met to discuss the findings of the inspection on 7/2/25 and the Human Relations department and the Life Sharing Specialist is aware of this regulation, 6500.125(c)(2). |
07/02/2025
| Implemented |
| 6500.152(c) | Individual #1's individual support plan, last updated 6/20/2025, states the individual needs eyesight supervision around heat sources, needs verbal prompting to evacuate, and is never unsupervised in the home. Individual #1's assessment completed 12/23/2024 documents the individual is independently safe with heat sources, can independently evacuate the home, and can be alone in the home for up to 2 hours. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | A conversion followed the 7/2/25 Inspection with the Life Sharing Partner and Life Sharing Specialist. The corrected information were communicated with the SC to make the necessary changes, so that the current ISP will match the Annual Assessment. |
07/15/2025
| Implemented |