| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(7) | Individual #1 has not had a gynecology exam since 2008. There is no deferment letter that documents how long the exam is deferred, a medical reason why it is deferred, or at what point a gynecology exam would need to be scheduled. | 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 physician to obtain a deferment letter that meets the requirements. The deferment letter for Individual #1 will document the length of time the exam is deferred, the medical reason why the exam is deferred, and the symptoms Individual #1 could have that would warrant a gynecology exam to be scheduled. |
10/05/2025
| Implemented |
| 6500.121(c)(14) | (Repeat from September 2024 Inspection) Individual #1's most recent physical completed 8/13/24 does not document the information pertinent to treat/diagnose in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 08/29/2025, CARES Compliance Officer faxed the PCP office to obtain the needed information (Attachment 32). On 09/02/2025, CARES Compliance Officer called PCP office to follow up on this request. The nurse confirmed fax was received and that Individual #1's doctor will review and respond with requested information. |
09/30/2025
| Implemented |
| 6500.48(b)(5) | There is no record that Staff #4 completed "the safe and appropriate use of behavior supports" training in training year 2024. | The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports. | This training will occur at the September 2025 monthly meeting with Staff #4. |
09/30/2025
| Implemented |
| 6500.135(c) | Individual #1 is prescribed ear drops to be administered weekly. They were administered ear drops 6/13/25, 6/14/25, 6/28/25, 6/29/25, and 6/30/25. | A prescription medication shall be administered as prescribed. | An EIM was filed on 08/15/2025 to document the medication error. In conversation with the Lifesharing Provider, it was determined that these errors occurred while the individual was with "Alternative Care". On 08/20/2025, the medication trainers at CARES of Central PA reached out to the Lifesharing Specialist regarding retraining for the target. The target of this incident, the Lifesharing Provider, will be retrained on documenting on the MARs at the September 2025 monthly meeting. |
09/30/2025
| Implemented |
| 6500.135(g) | (Repeat from September 2024 Inspection) Individual #1 was due for a Quarterly Psych Med Review on 7/16/25. This appointment did not occur. | 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. | The Lifesharing provider was educated on maintaining all scheduled appointments and was asked to ensure the next appointment is scheduled asap. The Lifesharing Specialist will obtain the date of the rescheduled appointment at the September 2025 monthly meeting. |
09/30/2025
| Implemented |
| 6500.136(a)(7) | Individual #1 is prescribed ear drops to be administered weekly. The MAR has contradictory information regarding the dose to be given. It documents both 5 drops and 6 drops to be given in the left ear weekly. | 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 reflect the correct number of drops to be given. (Attachment 34) |
09/30/2025
| Implemented |
| 6500.136(a)(13) | In June 2025, "MC and VS" administered medications to Individual #1. There is no documentation as to the names of "MC and VS". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | MC and VS are respite providers/natural supports for Individual #1. This will be documented on the MAR by a med admin trainer (Attachment 35). |
09/30/2025
| Implemented |