| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.23(a) | Family Living Provider #1's adult son and his adult partner are residing in the home. Individual #1 was admitted on 5/11/2024. As of, 2/21/2025, no Pennsylvania criminal history record check was completed for the adults living in the home. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home. | Coordinator and provider were retrained on 6500.23(a). Additionally, Coordinators were retrained on need for separate mailing address to be considered a separate apartment. Provider was notified on 2/25/2025 of need for criminal history check. Pennsylvania criminal history record check was submitted on for adult son and partner on 2/27/2025. Record checks were received and no record found for either adult. Both PA criminal history records were placed in provider book on 2/27/2025 and will be kept in the provider book at the office. |
03/19/2025
| Implemented |
| 6500.68(b) | On 2/21/2025 at 10:19AM, the hot water temperature measured 142.8F at the bathtub in the bathroom on the first floor of the home. Individual #1's assessment, completed on 6/1/2024, does not document the ability to independently temper water. Individual #1's service plan, last updated on 2/10/2025, reads, "[Individual #1] SHOWERS AND REGULATES WATER TEMPERATURE. HOWEVER, [Individual #1] NEEDS MONITORED DUE TO MAKING THE WATER TOO HOT AND THE TEMPERATURE WILL NEED ADJUSTED. [Individual #1] SEEMS TO LIKE HOT WATER." | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | Coordinator and provider were retrained on 6500.68(b). Provider was given a water check form and thermometer on 3/5/2025. Water was checked on 3/5/2025 and was 117 degrees Fahrenheit. Provider will check water temperature once a month and record water temperate on form. If water exceeds 120degrees Fahrenheit, provider will turn down hot water tank temperature and recheck water temperate one week after and re-record temperature on form. Coordinator will check water temperature form and water temperature when visiting the home once a month. |
03/05/2025
| Implemented |
| 6500.70 | On 2/21/2025 at 10:15AM, the home did not have an operable telephone that is easily accessible. | A home shall have an operable telephone that is easily accessible. | Provider and coordinator were retrained on 6500.70 and Telephone 6400.70 on 2/28/2025. Provider obtained phone and placed it in a stationary common space in the kitchen. Individual was notified and shown how to use phone on 2/28/2025. |
02/28/2025
| Implemented |
| 6500.73 | On 2/21/2025 at 10:27AM, there was no railing on the three exterior concrete stairs leading from the basement exit of the home. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | Life sharing coordinators and providers were retrained on regulation. Provider installed handrailing on steps of home on 3/4/2025. |
03/04/2025
| Implemented |
| 6500.125(a) | Family Living Provider #1, hired on 5/11/2024, had an initial physical examination on 7/10/24. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | Coordinator and provider retrained in 6500.125(a) on 2/27/2025. Provider was notified on physical date requirements. Provider was given form on 3/5/2025 with due date for next physical due on 7/10/2026. |
02/27/2025
| Implemented |
| 6500.125(a) | Individual #1 began living in the home on 5/11/2024. Family Living Provider #1's adult son, his adult partner and their minor children are residing in the home and do not have physical examinations. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | Coordinator notified provider on 2/22/2025 for need for physicals and Coordinators and provider were retrained on 2/22/2025. Provider made next available appointments for the four individuals on 3/11/2025. Physicals and TB tests were completed by 3/19/25. Coordinator provided form to include all four individuals with physical due dates and next due physicals. |
03/19/2025
| Implemented |
| 6500.151(e)(10) | Individual #1's assessment, completed on 6/1/2024, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Assessment updated to include lifetime medical history on 3/5/2025. Updated annual assessment was sent to team on 3/5/2025.
Annual assessment letters were updated on 3/5/2025 to include lifetime medical history in the contents. |
03/05/2025
| Implemented |
| 6500.151(e)(12) | Individual #1's assessment, completed on 6/1/2024, did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individuals' annual assessment was updated on 3/5/2025 with specific areas of training, programming and services. Annual assessment letter was updated and sent to team on 3/5/2025. |
03/05/2025
| Implemented |
| 6500.183 | On 2/21/2025 at 10:40AM, the most recent copies of Individual #1's Service Plan, assessment and dental examination were not present at the home. | Copies of the most current record information required in § 6500.182(c)(1)-(14) (relating to individual records) shall be kept in the family living home. | Coordinator and Provider were retrained on 6500.183 on 2/28/2025. Coordinator sent most recent copies of Individual #1's Service Plan, assessment and dental examination to Provider and placed them in the individual's book at the provider's house on 3/5/2025. |
03/05/2025
| Implemented |
| 6500.125(c)(2) | Individual #1 began living in the home on 5/11/2024. Family Living Provider #1's adult son, his adult partner and their minor children are residing in the home and do not have Tuberculin skin testing. | 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. | Coordinator notified provider of need for TB testing on 2/22/2025 and both were retrained on 2/22/2025. Provider made next available appointments for the four individuals on 3/11/2025. Provider gave TB test results to coordinator on 3/19/2025. Coordinator provided form to include all four individuals with physical due dates and next due physicals. |
03/17/2025
| Implemented |