| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(d)(1) | Individual #1's Property Record does not include three electronic tablets, and a television located in Individual #1 bedroom. | 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. | An up-to-date financial and property record shall be kept for each individual that includes the personal possessions and funds received by or deposited with the family or agency.
Providers Plan of Correction: On 08/12/2025, Individual 1's Inventory of Belongings was updated to include the flat screen TV and their 3 tablets (Attachment 1). |
09/30/2025
| Implemented |
| 6500.121(a) | Individual #1's Initial Physical Examination was not completed at the initial 01/27/25 appointment. The Physical Examination form was updated on 05/15/2025, which is past the Date of Admission (DOA). | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | During the time of individual 1's admission, it was noted that the physical was not completed. Staff at CARES of Central PA as well as the SC Supervisor, had attempted to rectify this prior to admission. Staff at CARES of Central PA had even gone to the doctor's office to have it filled out. At those times it was reported they would fax it back to CARES completed. However, that did not happen prior to the move in date. Individual 1's start of services with CARES Of Central PA's 6500 was due to emergency situation of being evicted from his apartment, therefore pushing the start date back was not feasible. CARES of Central PA staff continued to pursue obtaining the completed physical, which was obtained on 05/15/2025 (Attachment 2), within 30 days of their move in. |
09/30/2025
| Implemented |
| 6500.121(c)(11) | There is no record that Individual #1's need for "blood work at recommended intervals" was reviewed at any Physical Examination form in the record. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The original physical obtained by CARES that contained blanks omitted the "yes/no" question regarding the need for bloodwork. This was rectified on the corrected physical obtained by CARES on 05/15/2025 (Attachment 2), which was present during the inspection. |
09/30/2025
| Implemented |
| 6500.121(c)(13) | There is no record that Individual #1's "Allergies or contraindicated medications" were reviewed at any Physical Examination form in the record. | The physical examination shall include: Allergies or contraindicated medications. | The original physical obtained by CARES that contained blanks omitted the special instructions for the individual's diet. On 09/04/2025, CARES of Central PA faxed individual 1's doctor's office requesting they readdress the indications of N/A (Attachment #43a). The doctor's office faxed back the physical with this information on 09/05/2025 (Attachment #43b). |
09/30/2025
| Implemented |
| 6500.121(c)(14) | There is no record that Individual #1's "Medical information pertinent to diagnosis and treatment in case of an emergency" were reviewed at any Physical Examination in the record. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The original physical obtained by CARES that contained blanks omitted the special instructions for the individual's diet. On 09/04/2025, CARES of Central PA faxed individual 1's doctor's office requesting they readdress the indications of N/A (Attachment #43a). The doctor's office faxed back the physical with this information on 09/05/2025 (Attachment #43b). |
09/30/2025
| Implemented |
| 6500.121(c)(15) | There is no record that Individual #1's "Special instructions for the Individual's diet" was reviewed at any Physical Examination in the record. | The physical examination shall include: Special instructions for the individual's diet. | The original physical obtained by CARES that contained blanks omitted the special instructions for the individual's diet. On 09/04/2025, CARES of Central PA faxed individual 1's doctor's office requesting they readdress the indications of N/A (Attachment #43a). The doctor's office faxed back the physical with this information on 09/05/2025 (Attachment #43b). |
09/30/2025
| Implemented |
| 6500.122(d) | Individual #1's 06/16/25 dental examination did not specify if Individual #1 gums and dentures were cleaned and/or checked. | The dental examination shall include teeth cleaning or checking gums and dentures. | On 08/21/2025, CARES Compliance Officer faxed the dental office to obtain the needed information on the appointment form from 06/16/2025. The dental office faxed the form back with the request information the same day (Attachment 3). |
09/30/2025
| Implemented |
| 6500.48(b)(5) | Staff person #4 did not complete Use of Behavioral Supports during their annual training. | The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports. | This provider completed 2024 trainings prior to this content being added to the CARES annual training document on 09/06/2024, and they have not yet completed their 2025 annual trainings. This provider is no longer going to provide LIFE sharing services moving forward with CARES of Central PA. |
09/30/2025
| Implemented |
| 6500.135(g) | Individual #1's 06/25/25 Psychotropic Medication Review Form does not include Individual #1's "need to continue the medication". | 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. | On 08/21/2025, CARES Compliance Officer faxed the psychiatrist's office to obtain the needed information from 06/25/2025 psychotropic medication injection appointment. The psychiatrist's office faxed back the visit note which indicates the continuation of the injection/medication to treat bipolar disorder (Attachment 5). |
09/30/2025
| Implemented |