Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00273202 Renewal 08/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(f)The side exit was the only emergency exit route used to evacuate for four consecutive fire drills ranging from 9/8/24 through 07/18/25.Alternate exit routes shall be used during fire drills.¿ Family Living Program Specialist was trained on regulation 6500.109f by program director on 9/11/2025. ¿ Family Living Program Specialist and Family Living Provider will review regulation 6500.109f Fire Drills by 10/15/2025. ¿ Family Living Program Specialist and Family Living Provider, during a home visit, shall identify 2 or more exits from the home in the event of a fire or emergency. This will be completed by 10/20/2025. ¿ Family Living Provider shall discuss, demonstrate and practice each fire drill exit with Client by 10/24/2025 to ensure the client knows all exits from the home in the event of a fire or emergency. ¿ Family Living Provider will document each fire drill from each exit. This will be completed by 10/24/2025 on the Home Safety Checklist. ¿ Family Living Provider will complete fire drills, at least quarterly, identifying to the client which exit is blocked, to encourage usage of alternative exits from the home. ¿ Family Living Provider will alternate which exit is expected to be used during each fire drill. ¿ Family Living Provider will document on the Home Safety Checklist which exit from the home was utilized during the drill. ¿ Family Living Program Specialist will develop and provide a tracking log to Family Living Providers to track and briefly document dates, times, locations of fire, sleep drill completion, and exits utilized to ensure various emergency evacuation situations are practiced. 09/11/2025 Implemented
6500.133(h)Individual #1 is prescribed Vitamin D3 1000 unit to be administered once daily by mouth. This medication bottle had an expiration date of 8/2022.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Provider Plan of Correction: · Family Living Program Specialist was trained by program director on reg 6500.152c on_9/11/2025 · Family Living Provider was trained by Family Living Program Specialist on reg 6500.152c on 9/11/2025. · Family Living Program Specialist will modify the medication log to include the expiration date for medications that are pro re nata (PRN) · Family Living Provider will document any PRN medications, including expirations dates on the monthly Medication Log. 09/11/2025 Implemented
6500.152(c)Individual #1's annual assessment, completed 4/21/25 states that she knows which items can be hot in the home and kitchen and knows to be careful around them to avoid getting burned. In the general health and safety risks section of Individual #1's individual plan, last updated 6/4/25 reads, "[Individual #1] needs physical assistance and verbal prompting to identify and move away from heat sources."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Provider Plan of Correction: · Family Living Program Specialist was trained by program director on reg 6500.152c on_9/11/2025 · Previous years assessments will be reviewed and compared with current ISP to ensure information is consistent. · Current needs and inconsistent information will be discussed with the team during the annual ISP meeting to ensure information is shared and information is correctly documented. · If, after the Annual ISP is completed and available for review, and changes/corrections to information is needed, an email request with the noted changes will be sent to the Service Coordinator within 14 days. · The email documenting the request for changes will be added to the client record in the Electronic Health Record. 09/11/2025 Implemented
SIN-00250829 Renewal 09/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.49(b)Family Living Provider #1 completed the modified medication training on 6/16/2023; however, documentation of the training was not kept by the agency.A training record for each person trained shall be kept.¿ Family Living Provider #1 completed modified medication administration training on 9/12/24 (copy of cert included) ¿ Family Living Program Specialist was trained on regulation 6500.49b by program director on 9/9/24 (training doc attached) ¿ Printed documentation of completion for training is filed in a binder created by Family Living Program Specialist, under the Modified Medication Training tab. ¿ An electronic copy is also retained in a Training folder, which is stored on the Pressley Ridge mainframe, and placed in the sub-folder labeled Modified Medication Administration Training. 09/24/2024 Implemented
6500.136(a)(2)Individual #1's September 2024 medication record did not include the name of the prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.¿ All Medication Administration Records (MARs) were reviewed and revised as of 9/10/24 to include prescriber (see revised MARS) ¿ Family Living Program Specialist was trained by program director on reg 6500 136a2 on 9/9/24 (see attached training doc) ¿ Family Living Providers will notify Family Living Program Specialist of any changes to medications or prescribers within 24 hours. ¿ Family Living Providers will document on MAR in Notes/Concerns box of any changes to medications or any changes in prescribers. ¿ Updated MARs will be completed and sent to family within 48 hours of notification of needed changes. 09/24/2024 Implemented
6500.136(a)(3)Individual #1's September 2024 medication record did not include drug allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.¿ All Medication Administration Records (MARs) were reviewed and revised as of 9/10/24 to include list of allergies (see revised MARS) ¿ Family Living Program Specialist was trained by program director on reg 6500 136a3 on 9/9/24 (see attached training doc) ¿ Family Living Providers will notify Family Living Program Specialist of any changes to allergies within 24 hours. ¿ Family Living Providers will document on MAR in Notes/Concerns box of any changes to allergies. ¿ Updated MARs will be completed and sent to family within 48 hours of notification of needed changes. 09/24/2024 Implemented
6500.152(c)Individual #1's assessment, completed 6/12/24 indicated that Individual #1 is safe around poisons. Individual #1's ISP, updated 6/13/24 reads, "POISONOUS MATERIALS ARE NOT KEPT IN [Individual #1's] REACH AND [Individual #1] WOULD PROBABLY NOT INGEST A POISONOUS SUBSTANCE."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Assessment was reviewed and revised to match the ISP wording on 9/15/24. Family Living Program Specialist will review assessment and ISP at next quarterly meeting with supports coordinator in November 2024.¿ Family Living Program Specialist was trained by program director on reg 6500 152 c on 9/9/24 (see attached training doc) ¿ Each quarter, assessment packet dues dates will be determined and discussed during supervision with Clinical Coordinator/Program Director and Family Living Program Specialist. (see supervision form) 09/24/2024 Implemented
SIN-00233474 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.135(g)Individual #1 is prescribed psychotropic medication. Individual #1 had 3-month medication reviews on 10/19/22 and then again on 2/1/23.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.Psychotropic med reviews will be completed every 3 months. FLP and individual will be encouraged to schedule at time of current appointments to ensure they are within the required timeline. Families and individual will be reminded that if they need to change or reschedule due to illness that they should get documentation for this. 11/02/2023 Implemented
SIN-00211826 Renewal 09/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(6)Individual #1's most recent Tuberculin skin testing was completed on 8/22/2020.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.TB was completed on 9/14/22. Individual #1 had her physical scheduled for September 2022 and FLP had not recalled that previous TB had been in August. Physical and TB are now occurring on same day so the lapse should not occur again. 10/05/2022 Implemented
SIN-00137353 Renewal 06/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self assessment completed on 12/15/17 did not measure compliance regulations 6500.162 through 6500.176.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.the self assessment will be completed 3-6 months prior to expiration of certificate of compliance. director and coordinator will review each assessment once completed by the FLS to ensure each assessment is accurately completed in its entirety. training docs for all staff included for reg 6500.17 [Documentation of aforementioned audits of each assessment by the Director and the Coordinator shall be kept. (DPOC by AES,HSLS on 8/14/18)] 07/27/2018 Implemented
6500.23(a)Family Member #1, date of birth 5/14/98, had a Pennsylvania criminal history record check most recently completed on 11/12/14, prior to being 18 years of age.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.a criminal check will be completed for individuals living in the home when they are 18 individual had one at 16 new one was completed and mailed on 7/12/18. see attached form. fls and flp trained on reg 6500.23a included. [Immediately, the CEO or designee shall develop and implement a tracking system for all family living homes to be audited at least quarterly by a management staff person to ensure timely completion of criminal history record checks. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] 07/12/2018 Implemented
6500.43(d)(1)The following discrepancies were noted in Individual #1's assessment completed 6/16/17. In the Poison Evaluation for Personal Hygiene Products and for Cleaning Products, Individual #1 is assessed as not aware of purpose and use or avoiding various personal hygiene products and cleaning products; however, later in the assessment, in Emergency Situations, it states that Individual #1 safely uses or avoids poisonous materials. In the Mobility section, sub-section Self-Mobility, it is indicated that Individual #1 is both independent in skill area and also requires total assistance in skill area. In the Telephone Usage section, it indicates that Individual #1 cannot dial or answer the phone appropriately; in the Emergencies section it indicates that Individual #1 knows how to call emergency numbers effectively. In the Immediate Action Evaluation section is indicates that Individual #1 does not require supervision at medication administration; in the Self-Administration of Medication Addendum, it indicates that Individual #1 can participate in his/her medication routine but requires visual supervision for safety.The family living specialist shall be responsible for the following: Coordinating and completing assessments.The assessment will be completed accurately to reflect current functioning and capabilities of individual annually by fls and revised as needed. Coordinator will review accuracy prior to mailing out assessment. Coordinator and director will ensure that assessment and ISP are congruent with assessment. if discrepancies are found, written communication will be sent to SC for revisions. Training for FLS is included. Revised assessment is included. [Discrepancies in the ISP were sent to on 7/23/18. At least quarterly, the family living program specialist shall review all individuals' assessments and current ISPs to ensure individuals are accurately assessed.(DPOC by AES,HSLS on 8/23/18)] 07/12/2018 Implemented
6500.43(d)(6)The following discrepancies were noted between Individual #1's ISP, updated 5/9/18, and Individual #1 assessment, dated 6/16/17. The Know and Do section of the ISP indicates that Individual #1 uses a wheelchair, a stander and can crawl on the floor while in his/her bedroom; the Physical Development section indicates that Individual #1 has limited motor skills due to cerebral palsy, uses a wheelchair daily to ambulate, wears bilateral AFOs, can roll to his/her stomach and push him/herself up to all fours, and can walk 400-500 feet at a time. The assessment indicates that Individual #1 is independent in the Motor Skills section which includes but is not limited to standing, walking, running, and jumping. The Know and Do and General Health and Safety Risks sections, it is indicated that Individual #1 has medications administered to him/her. Per the assessment, only verbal prompts and supervision are necessary when medicating to ensure safety. The Know and Do section also indicates that Individual #1 requires total assistance while in the shower, has a shower chair and needs someone to help with transferring into the bath, which Individual #1 prefers. The Water Safety section indicates that Individual #1 needs assistance with bathing and is not able to regulate water temperature due to difficulty with Cerebral Palsy and turning knobs. Per the assessment, Individual #1 can regulate water temperature, uses no adaptive equipment, and does not require supervision while in the shower/bath. The Know and Do section also indicates that Individual #1 needs someone to put on shoes and socks for due to physical limitation. The assessment indicates in the Dressing section that Individual #1 can put on and take off socks, put on and take off shoes, and tie shoes with verbal prompts. The General Health and Safety Risks and Fire Safety sections of the ISP indicate that Individual #1 requires physical assistance to evacuate in case of a fire as Individual #1 uses a wheelchair. Per the assessment, Individual #1 is independent in all areas of mobility and is able to go to the designated meeting area, and "knows how" to exit the home. The ISP indicates in the Cooking/Appliance Use section and in the Meals/Eating section that Individual #1 does not use any sharp knives; the assessment indicates in the Meal Preparation/Dining section, sub-section Dining Skills, that Individual #1 uses knives appropriately.The family living specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions for content accuracy.FLS will complete assessments for individuals . Clinical coordinator for review assessment prior to being mailed out. The team will review assessment at ISP meetings to ensure they are consistent and congruent. If they are not SC will be requested to update ISP so that it matches what the assessment has determined as an accurate reflection of the individuals capabilities . communication will be documented and filed . [Discrepancies in the ISP were sent on 7/23/18. At least quarterly, the family living program specialist shall review all individuals' assessments and current ISPs to ensure individuals are accurately assessed.(DPOC by AES,HSLS on 8/23/18)] 07/10/2018 Implemented
6500.121(c)(6)Individual #1, admission date 7/6/16, had a Tuberculin skin test completed 8/20/16.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.youth was with family in foster care prior to converting to lifesharing. physical had been completed as required for regulations this would have been cited in prior audit. all TB are completed prior to individual starting and done every other year. [Immediately, the CEO or designee shall develop a tracking system of individuals' physical examinations and Tuberculin skin testing to ensure timely completion. At least quarterly, the tracking system shall be audited by designated management staff person to ensure notification and competition of individuals' physical examinations and Tuberculin skin testing. (DPOC by AES,HSLS on 8/23/18)] 07/10/2018 Implemented
SIN-00117831 Renewal 07/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(11)Individual #1's physical examination completed on 12/10/16 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section 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 was reviewed on 7/26/17 by PA and health maintenance needs, med regimen, and need for blood work was added. Family living provider and specialist trained on 6500.121 c11. wrong form had been used on intake physical. Family living provider now has new form. FLspecialist will review files quarterly to ensure all documentation is filled out completely and on right forms. [Within 30 days of receipt of the plan of correction and upon completion, the family living specialist shall review all individuals' completed physical examinations to ensure all required information as per 6500.121(c)91)-(15) is included and there are not any required areas left blank; missing information shall immediately be obtained. Documentation of reviews shall be kept. (AS 8/11/17)] 08/03/2017 Implemented
6500.121(c)(14)Individual #1's physical examination completed on 12/10/16 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.physical was reviewed on 7/26/17 by PA and medical info pertinent to diagnosis and treatment in case of emergency were added. Family living provider and specialist were trained on 6500.121 c14. wrong form had been used on intake physical. Family living provider now has new form. FLspecialist will review files quarterly to ensure all documentation is filled out completely and on right forms.[Within 30 days of receipt of the plan of correction and upon completion, the family living specialist shall review all individuals' completed physical examinations to ensure all required information as per 6500.121(c)91)-(15) is included and there are not any required areas left blank; missing information shall immediately be obtained. Documentation of reviews shall be kept. (AS 8/11/17)] 08/03/2017 Implemented
SIN-00195483 Renewal 10/21/2021 Compliant - Finalized
SIN-00157708 Renewal 06/20/2019 Compliant - Finalized
SIN-00096242 Renewal 06/09/2016 Compliant - Finalized