| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual #1's funds were used to purchase items that are to be covered by room and board on 5/25/25. | An individual's funds and property shall be used for the individual's benefit. | DPOC-9/5/25-JC
EIM 9675804 was filed on 08/14/2025 to address individual 1 spending their personal money on personal care items (Attachment 7). Individual 1 and their mother (the rep payee) have been educated that these are the responsibility of the Lifesharing Provider to provide. The rep payee is insistent that they do not want the Lifesharing Provider to have to pay for these items, so moving forward, CARES will pay for individual 1's Depends via an Amazon subscription. CARES of Central PA will reimburse individual 1's rep payee for all Depends on the COH ledger on 05/25/2025. Cares of Central PA will reimburse Individual #1 for the money they spent on personal care items that are included in room and board. |
10/05/2025
| Implemented |
| 6500.24(d)(1) | Individual #1's ending balance in June 2025 should have been 2.42 based on the documented transactions. It was reported as $14.61. | 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. | The July 2025 Cash on Hand Ledger has been updated to accurately reflect the cash carry over from the June 2025 Cash on Hand Ledger in the amount of $2.42 (Attachment 10). This will be signed at the monthly meeting in September. |
09/30/2025
| Implemented |
| 6500.24(e)(3) | Individual #1 spent $27.19 on 6/21/25. There was no receipt. | 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. | On 06/21/2025 individual 1 "took out cash" in the amount of $15.00 and spent $12.19 at a restaurant. Both receipts were present during the inspection (Attachment 8). The Lifesharing provider documented both receipts on 1 line of the cash on hand ledger, totaling $27.19 spent on 06/21/25. This has been corrected on the June 2025 cash on hand ledger (Attachment 9). This will be signed at the monthly meeting in September. |
09/30/2025
| Implemented |
| 6500.64(a) | At the time of the inspection, the bathroom in the basement had animal excrement on the bathroom floor. Additionally, there was a lot of hair in the bathroom sink. | Clean conditions shall be maintained in all areas of the home. | The bathroom sink and floor have been cleaned (Attachment 11). |
09/30/2025
| Implemented |
| 6500.121(c)(7) | Individual #1 had a gynecology exam on 2/27/24 and not again since, outside of the annual timeframe. There is no deferment letter. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | DPOC-JC-9/5/25 An appointment will be scheduled with Individual #1's physician to obtain a deferment letter that documents how long the appointment is deferred, the medical reason the appointment is deferred, and what symptoms Individual #1 would have that would warrant a gynecology exam to be scheduled. |
10/05/2025
| Implemented |
| 6500.135(g) | (Repeat from September 2024 Inspection) Individual #1 attended a quarterly psych med review on 4/15/25 and not again since, outside of the quarterly time frame. | 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. | Individual 1 had a psych med review on 04/15/2025. The next appointment was scheduled for 05/30/2025 but was cancelled by the doctor's office for an unknown reason. This appointment was rescheduled by the doctor for 08/20/2025. This appointment occurred as scheduled (Attachment 14) and the next appointment is scheduled for 09/19/2025. |
09/30/2025
| Implemented |
| 6500.136(a)(7) | Individual #1's MAR documents that the dose of the Acetaminophen is 500mg. However, it is 1000mg, because the individual is to take two tablets. The Ibuprofen is documented on the MAR as 400mg, take one tablet as needed. The dose available in the home was only for 200mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The MAR has been updated to state 1000mg instead of 500mg for Acetaminophen (Attachment 16). The Lifesharing provider provided further information that the Ibuprofen prescription was temporary for post-surgical pain only. This medication expired in July 2025 and was discarded per doctor's instructions (Attachment 17). This medication has also been removed from the MAR (Attachment 16). |
09/30/2025
| Implemented |