Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266936 Renewal 05/20/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(f)Individual #1, date of admission 12/13/2024, had their initial assessment completed 1/23/2025. This assessment indicated that the individual required prompts to complete their oral hygiene. The agency did not develop a written plan for dental hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. During the intake process, an assessment of the individual¿s ability to perform dental hygiene tasks will be completed. Based on this assessment, a personalized dental hygiene plan will be developed. The plan will outline the individual's current level of independence in oral care, identify any needs or barriers, specify the type and level of assistance required, and detail the daily oral hygiene routine, including products and any adaptive equipment used. The plan will be reviewed and updated, at minimum annually, based on the recommendations of the individual¿s dentist and documented on the Lakeshore Community Services, Inc. Dental Report form. 06/18/2025 Implemented
6400.181(a)Individual #1, date of admission 12/13/2024, had their initial assessment completed 1/23/2025. This assessment indicated that the individual required prompts to complete their oral hygiene. According to ID Director #2, the assessment completed 1/23/2025 is incorrect and the individual has achieved dental hygiene independence. Individual #1's assessment was not updated to reflect this change in ability. [Repeat violation: 6/25/2024 et. al.] Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual's assessment has been updated to reflect changes in her dental hygiene needs. The updated assessment is provided to the treatment team. 06/18/2025 Implemented
6400.46(b)Program Specialist #1, date of hire 10/13/2014, participated in fire safety training on 10/10/2023 and again on 10/11/2024. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Human Resources and Training Specialists have changed the completion parameters in the Relia training system. The completion parameters now require completion within 330 days of the previous training 06/18/2025 Implemented
SIN-00209290 Renewal 07/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(c)Individual #1's fire safety training did not include the content of the training. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers 09/05/2022 Implemented
6400.141(a)Individual #1 had a physical examination completed 6/01/2021 and then again 6/17/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Annual physical exams will be scheduled no more than 15 days after the previous years physical was completed 09/01/2022 Implemented
6400.141(c)(11)Individual #1's physical examination completed 6/17/2022 did not include an assessment of the individual's health maintenance needs. It was left blank.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. Physical exam will be returned to the physician's office for correction 09/08/2022 Implemented
6400.166(a)(11)Individual #1's July 2022 medication administration record did not include a diagnosis or purpose for the following medications: Aspirin Low 81mg EC tablet, Certavite/anti oxide tablet, Cimetidine 800mg tablet, Clopidogrel 75mg tablet, Docusate Sod 100mg capsule, Fluticasone 50mcg spray, Folic acid 1mg tablet, Furosemide 20mg tablet, Lacosamide 150mg tablet, Lamotrigine 100mg tablet, Latanoprost .005% solution, Levetiracetam 1000mg tablet, Levothyroxine 125mcg tablet, Myrbetriq 25mg tablet, Olanzapine 5mg tablet, Omeprazole 20mg tablet, Peg 3350 Powder, Prednisolone 1% Op sus, Refresh PM OP ointment, Systane solution, Valacyclovir 500mg tablet, Venlafaxine 37.5mg ER Capsule, Vitamin B-12 1000mcg tablet, and Vitamin D-3 25mcg tablet.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.Program Specialists and Directors will review all Medication Administration Records to ensure that all medications prescribed have a diagnosis and reason for medication. Any found missing this information will be remediated by contacting the prescribing physician 10/01/2022 Implemented
SIN-00153770 Renewal 04/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)The ISP review completed for Individual #1 for review period 3/10/18 to 6/9/18 was signed on 6/4/18. The ISP review completed for Individual #1 for review period 6/10/18 to 12/9/18 was signed on 12/4/18. The ISP review completed for Individual #1 for review period 12/10/18 to 3/9/19 was signed on 6/5/19.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. VP of ID Services will provide to Program Director's written requirement for the proper completion and review process for Monthly and Quarterly Review of the ISP. Program Director's will retrain Program Specialists on ISP review date requirements. [Within 30 days of receipt of the plan of correction and upon hire, the Program director shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 10% sample of individuals' ISP reviews to ensure the program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. (DPOC by AES,HSLS on 5/3/19)] 05/17/2019 Implemented
SIN-00075552 Renewal 03/05/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
Article X.1007Lakeshore Community Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101-10225.5102) and its regulations (Pa. Code Ch. 15). Staff Person #1, hired on 9-12-2011, who had not resided in Pennsylvania for the 2 years prior to hire did not have the FBI clearance through the Pennsylvania Department of Aging. When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The Human Resources Specialist reviewed the requirements on the Office of Aging website and reviewed the requirements for Lakeshore Community Services. The employee (Staff #1) was notified. The employee was registered to have their fingerprints taken for the FBI clearance and the location of the facility to have the process completed. The agency has reviewed all current employees that would have been required to have the FBI clearance through the Office of Aging. The impacted employees have been contacted, provided appropriate documentation, and has a deadline of April 9th, 2015 to have the process completed. Going forward the Human Resources Specialist is requesting FBI clearances through the Office of Aging and following the appropriate procedure. 04/01/2015 Implemented
SIN-00091396 Renewal 03/02/2016 Compliant - Finalized