Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00200594 Renewal 03/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(9)A physical for Individual #1 was completed on 6/2/21. There was no documentation that a PSA was completed as part of the physical as required. Documentation of a previous PSA completed on 5/29/20 was provided. This is outside of the annual requirement The physical examination shall include: A prostate examination for men 40 years of age or older.Training completed with lifesharing coordinator and lifesharing providers on 5/2/22 on 55 PA Code Chapter 6500.121(c)(9) physical date requirements along with proper documentation of PSA. Individual #1 (William) is scheduled for physical on 5/31/22 for annual physical examination and PSA will be completed. Attachment #1 06/03/2022 Implemented
SIN-00169121 Renewal 12/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.103The gas furnace in the home was last cleaned/filter changed on 10/24/18.Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept.Furnace was serviced and filter changed on 1/24/2020. See Attachment 3. LifeSharing Provider & LifeSharing Specialists will use a tracking tool to monitor furnace schedule. See attachment 4. All LifeSharing Providers will be trained on Chapter 6500.103 related to annual cleaning and filter change of furnaces by LifeSharing Specialists, Colleen Collins and/or Chidi Uduma by 2/3/2020. 02/03/2020 Implemented
6500.151(e)(13)(viii)The annual assessment completed on 2/27/19 for Individual #1 did not document the individual's progress over the last 365 calendar days and current level in the area of managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas : Managing personal property.LifeSharing Specialist completed individual's current progress and growth in managing personal property by 1/30/2019. See Attachment 1. Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 1/15/2020. All Assessments will be reviewed and updated for accuracy by Program Specialist by 2/28/2020. A new Annual Assessment form will begin implementation effective 3/1/2020. See Attachment 2. 03/01/2020 Implemented
6500.17(a)The self-assessment was completed on 9/27/19 which was not within 3 to 6 months prior to the expiration date of the agency's certificate of compliance which is 12/09/19.If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes 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.Self-Assessment tool will be scheduled to be completed in July or August in 2020 and each successive year, which is within 3-6 months prior to the expiration date of the agency's certificate of compliance. This will be monitored by Martha Gonzalez, Director of IDD Residential Services. 01/30/2020 Implemented
SIN-00129115 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.151(e)(13)(i)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of health.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: Health.Program Specialist completed individual¿s #1 assessment including information on progress in the area of health. (Please see attached #2). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(ii)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.Program Specialist completed individual¿s #1 assessment including information on progress in the area of motor and communication skills. (Please see attached #3). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(iii)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living.Program Specialist completed individual¿s #1 assessment including information on progress in the area of activities of residential living.(Please see attached #4). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(iv)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Program Specialist completed individual¿s #1 assessment including information on progress in the area of personal adjustment. (Please see attached #5) Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(v)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialist completed individual¿s #1 assessment including information on progress in the area of socialization. (Please see attached #6). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(vi)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of recreation. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.Program Specialist completed individual¿s #1 assessment including information on progress in the area of recreation. (Please see attached #7). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(vii)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of financial independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.Program Specialist completed individual¿s #1 assessment including information on progress in the area of financial independence. (Please see attached #8). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(viii)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas : Managing personal property.Program Specialist completed individual¿s #1 assessment including information on progress in the area of managing personal property Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.151(e)(13)(ix)Individual #1's assessment did not include any information on progress or lack thereof in the last 365 days in the area of community integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration.Program Specialist completed individual¿s #1 assessment including information on progress in the area of community integration. (Please see attached #10). Program Specialist will continue to complete Individual¿s assessments on a regular basis as required The program Specialist will be responsible to ensure individual assessments completely and up to date Ongoing basis as required. 03/29/2018 Implemented
6500.182(c)(10)The ISP dated 07-21-17 for Individual #1 contained errors that were identified but not brought to the attention of the Plan Lead for correction. Each individual's record must include the following information: Content discrepancy in the ISP, the annual updates or revisions under §  6500.156.The program Specialist sent an email to SC on 2/13/2018 asking to correct the identified errors contained on Individual #1 ISP. (See attached #1 copy of the email) Program Specialist will continue to complete reviews of the Individuals¿ ISP and will request SC¿s via email of any changes needed. The program Specialist will be responsible The process is effective immediately and will be ongoing. 02/13/2018 Implemented
SIN-00107190 Renewal 02/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(a)Individual #2 had a physical exam on 3/26/2015. He didn't have another physical exam until 4/21/2016, which exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter.All annual physicals have been reviewed to ensure that each was completed within 12 months prior to living in the home and annually thereafter by 4/13/2017 by Nancy Campling, Director of Medical Support. Review ensured completeness of documentation of the annual examination record. LifeSharing staff will utilize Individual Compliance Tracking Data Base to ensure timely compliance with upcoming medical appointments. SEE ATTACHED #7. Annual Physical WAS completed timely for Individual #4 on 3/29/2017. SEE ATTACHED 7A. Timeliness and thoroughness of annual physical exam training will be conducted with LifeSharing Providers and Lifesharing Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
6500.134(a)Individual #2's MAR sheet indicates he is prescribed Aspirin (81mg QD) and it is initialed as administered from 2/1-2/28/2017. However, this medication was not in his pre-filled pharmacy packets. The Family Living Provider stated that the individual's doctor discontinued this medication. It was noted during this inspection that it was discontinued on 2/2/2017. This medication should not be included on the MAR nor should it be signed out as administered.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.Medication Administration Record for Individual #2 was revised in February 2017 & preprinted in March 2017 to show administration needs per physician¿s order-Aspirin, 81mg, QD was discontinued. SEE ATTACHED 5. All Medication Administration Records will be reviewed by Medical Support Staff by 5/15/2017 to assure accuracy. Medication Administration Record audit by LifeSharing Specialist will now include review of updated physician¿s orders. SEE ATTACHED #6. LifeSharing Provider will complete medication administration re-training by 5/15/2017. Training regarding Medication Administration Records documentation will be conducted with Lifesharing Providers by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
6500.156(b)Individual #2's ISP Reviews are not signed & dated by the individual and the Family Living Specialist. The family living specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #2¿s ISP Reviews have been and will be signed and dated by the Individual and the Family Living Specialist. SEE ATTACHED #4. All ISP Review Signature Sheets will be reviewed/updated to assure signature by Individual & LifeSharing Specialist or Director by 4/21/2017. Training regarding Individual and Lifesharing Specialist ISP Review signature will be conducted with Lifesharing Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
6500.182(c)(1)(ii)There are no identifying marks listed in Individual #2's record. Each individual's record must include the following information: Personal information, including: The race, height, weight, color of hair, color of eyes and identifying marks.Individual #2¿s record is updated with the following information: Personal information, including: The race, height, weight, color of hair, color of eyes and identifying marks. SEE ATTACHED #3. All Individual¿s records have been reviewed/updated to assure compliance by 4/13/2017. Training regarding Individual¿s records will be conducted with Lifesharing Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
6500.182(c)(1)(vi)There is no date marked on Individual #2's photograph in his record.Each individual's record must include the following information: Personal information, including: A current, dated photograph.Individual #2¿s photo is updated to include a current date. SEE ATTACHED #3A. All individual¿s records will be updated to include a current, dated photograph by 4/21/2017. LifeSharing House Audit Checklist by LifeSharing Specialist will be updated to include audit of individual¿s record to include a current, dated photograph. SEE ATTACHED #2. Training regarding Individual¿s records will be conducted with Lifesharing Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
SIN-00183509 Renewal 03/23/2021 Compliant - Finalized
SIN-00071367 Renewal 11/05/2014 Compliant - Finalized