Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238337 Renewal 02/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(c)The individual is incontinent and has purchased her own wet wipes every month during the 2023 year. This is a product that should be supplied to the individual.An individual's funds and property shall be used for the individual's benefit.Threshold will reimburse $196.22 back to Kathleen. Attachment # 1. 03/18/2024 Implemented
6500.66The side door exit did not have an exterior light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents.Exterior light was placed by the side door exit on 3/13/24. Attachment # 2. 03/13/2024 Implemented
6500.121(c)(6)Individual #1 had a TB test completed on 11.6.19 and not again until 2.3.23. This time frame exceeds the 2 year requirement.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.medical chart audits will be completed every quarter to ensure appointments are in compliance. Attachment # 4. 03/18/2024 Implemented
6500.121(c)(7)Individual #1 had a gynecological exam on 3/2/2020. This exam reflects she had a breast and pelvic examination. The pap smear was deferred due to her age. The comments reflect that a single digit vaginal exam was difficult to complete due to vaginal atrophy and they were unable to evaluate uterus and ovaries. States that a pelvic ultrasound can be completed to evaluate these areas. The form reflects there was a year follow up. However, there is no documentation to reflect that there has been any follow up gyn visit since 2020. Also there is no clear documentation that reflects due to her age that these appointments are no longer needed. 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.Kathleen has a GYN appointment scheduled for May 15, 2024. Attachment # 5. 05/15/2024 Implemented
6500.45(a)Staff #1 had her CPR certification on 1/7/21 and was not trained again until 2/14/23. This exceeds the time frame for the training. The initial CPR certification was valid for 2 years. Staff was due to be retrained in CPR by January 2023.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.Staff #1 has another CPR certification that was completed on 8/22/22. Attachment # 6. 03/18/2024 Implemented
SIN-00200599 Renewal 03/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(a)Individual #3 had a physical exam on 9/9/20 and their most recent physical exam was completed on 10/13/21. This exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator and lifesharing providers on 5/2/22 on physical date requirements reviewed  55 PA Code Chapter 6500.121(a) requirements. Individual #3 is scheduled for annual physical on 10/14/22. Attachment #1 06/01/2022 Implemented
6500.121(c)(1)Individual #3's physical exam dated 10/13/21 did not document a review of their previous medical history as this section of the form was left blank.The physical examination shall include: (1.) A review of previous medical history.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator and lifesharing providers on 5/2/22 on physical date requirements reviewed 55 PA Code Chapter 6500.121(c)(1) requirements. Attachment #1 06/01/2022 Implemented
6500.121(c)(4)Individual #3's physical exam dated 10/13/21 did not document Vision and hearing screening as both of these sections on the form were left blank. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/2. Training completed with lifesharing coordinator and lifesharing providers on 5/2/22 on physical 55 PA Code Chapter 6500.121(c)(4) requirements. Attachment #1 06/01/2022 Implemented
6500.121(c)(6)Individual #3's had a Tuberculin skin testing by Mantoux method with negative results on 3/23/22 and their previous Mantoux with negative results was on 12/5/19. This exceeds the requirement.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.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator and lifesharing providers on 5/2/22 on TB testing documentation 55 PA Code Chapter 6500.121(c)(6) requirements. Attachment #1 05/02/2022 Implemented
6500.121(c)(10)Individual #3's physical exam dated 10/13/21 did not document the specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals as this section of the form was left blank. The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator on 5/2/2022 on the physical documentation requirements and reviewed  55 PA Code Chapter 6500.121(c)(10) requirements. Attachment #1 06/01/2022 Implemented
6500.121(c)(11)Individual #3's physical exam dated 10/13/21 did not document their health maintenance needs, medication regimen and the need for blood work at recommended intervals as this section of the form 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.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator and lifesharing providers on 5/2/2022 on the physical documentation requirements and reviewed 55 PA Code Chapter 6500.121(c)(11) requirements. Attachment #1 06/01/2022 Implemented
6500.121(c)(12)Individual #3's physical exam dated 10/13/21 did not document the physical limitation of the individual as this section of the form was left blank. The physical examination shall include: Physical limitations of the individual.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator on 5/2/2022 on the physical documentation requirements and reviewed 55 PA Code Chapter 6500.121(c)(12) requirements. Attachment #1 06/01/2022 Implemented
6500.121(c)(14)Individual #3's physical exam dated 10/13/21 did not document their medical information pertinent to diagnosis and treatment in case of an emergency as this section of the form was left blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator and lifesharing providers on 5/2/2022 on the physical documentation requirements and reviewed 55 PA Code Chapter 6500.121(c)(14) requirements. Attachment #1 06/01/2022 Implemented
6500.121(c)(15)Individual #3's physical exam dated 10/13/21 did not document Special instructions for the individual's diet as this section of the form was left blank. The physical examination shall include: Special instructions for the individual's diet.Individual #3 is scheduled for a physical on 10/14/22; however staff is scheduling her for a physical to be done at Patient First by 6/1/22. Training completed with lifesharing coordinator and lifesharing providers on 5/2/2022 on the physical documentation requirements inlcuding individualized feeding plan and reviewed 55 PA Code Chapter 6500.121(c)(15) requirements. Attachment #1 06/01/2022 Implemented
6500.32(r)(1)Individual has the right to lock the individual's bedroom door. Individual #3 did not have a lock on their bedroom door.An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Individual #3 no longer resides in the home and transitioned to a CLA on 4/11/22. A bedroom door lock was installed on 4/12/2022. A key has been provided to the individual currently living in the home with the lifesharing provider who has a backup key. Attachment #4 04/12/2022 Implemented
6500.48(b)(2)Staff #3 and Staff #4 did not receive annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 7/1/20-6/30/21 training year.The annual training hours specified in subsection (a) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the Child Protective Services Law (23 Pa.C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff #3 has since completed the following training in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the Child Protective Services Law (23 Pa.C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations: Abuse: Detection, Reporting, and Prevention of Abuse, Suspected Abuse and Alleged Abuse training on 5/2/2022. Attachment #5. p Staff #4 has since completed the following training in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the Child Protective Services Law (23 Pa.C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations: Abuse: Detection, Reporting, and Prevention of Abuse, Suspected Abuse and Alleged Abuse on 8/27/21. Attachment #6 05/31/2022 Implemented
6500.139(a)Certificate dated 8/14/15 for "Giving Medications at Home" was presented as the current medication training for Staff #3. The "Giving Medications at Home" training does not satisfy current regulations.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration).Staff #3 has since completed Modified Medication Administration Training Course on 3/24/22. Attachment #8 Training 05/16/2022 Implemented
6500.151(a)Individual #3's assessment that was dated as 5/25/21 and updated 7/24/21 included all identical information in the sections from their 7/22/20 assessment. This included recommendations for services where it stated "assist Kathy" which is not Individual #3's name that was an error in the assessment dated 7/22/20 and the assessment dated as 5/25/21 and updated 7/24/21.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the 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 home.Individual #3's assessment was updated on 3/23/22. Individual #3 transitioned to a CLA on 4/11/22 and another assessment will be completed within 60 days by CLA program specialist. Attachment #9. Lifesharing coordinator received training on 4/11/22 on completion of residential individual annual assessment. Attachment #9a 06/11/2022 Implemented
SIN-00183514 Renewal 03/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.48(b)(1)Staff # 1 did not receive annual training encompassing the application of person centered practices, facilitating community integration, individual choice, and supporting individuals to develop and maintain relationshipsThe annual training hours specified in subsection (a) must encompass the following areas: The application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships.Staff has completed this training on 1/30/21, it was not presented at the time of inspection. See attached certificate. 05/31/2021 Implemented
6500.48(b)(5)Staff # 1 did not complete annual training on the safe and appropriate use of behavior supports.The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports.Staff #1 completed training on the safe and appropriate use of behavior supports by 4/23/2021. See attached training documentation. 05/31/2021 Implemented
SIN-00169126 Renewal 12/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self-assessment was not dated and therefore it could not be determined if it was completed within 3 to 6 months prior to the license expiration date of 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-00129117 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.137(a)Individual #1's medication box contained Tylenol 500mg tablets. They had been opened and the provider stated she gives it to the individual for something like a headache. That was not on the MAR. Written on the MAR was MAPAP 325mg with the directions to take two tabs (650mg) by mouth 4x a day as needed. That was not available for the individual. Therefore, the medication was not properly administered as directed.Prescription medications and insulin injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The medication was removed from the individual¿s #1 medication box at the time of the inspection after discovered that it was not the same medication prescribed by her doctor. A note was received from indivduals#1 doctor to discontinue KM's MAPAP (Tylenol). The medication will be removed from individual¿s #1 MAR by 4/1/2018 Program specialist will continue to complete a medication audit on a monthly basis to ensure all individual¿s prescribed medication is available and MAR¿s are accurate. 04/01/2018 Implemented
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 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
6500.151(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 attachment #12) 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 #13). 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 #14). 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 # 15). ¿ 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 #16). 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 #17) 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. (Please see attached #18). 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 #19) 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
SIN-00109721 Renewal 02/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(e)This residence held 2 fire drills (3/23/2016; 9/22/2016). Both drills were held at 6AM & both were marked as Awake drills. Due to this, no sleep drills were held during the year.A fire drill shall be held during sleeping hours at least every 12 months.A sleep drill was conducted and documented 3/15/2017, 11:45PM at 201 N. Dwight Street. SEE ATTACHED #1. A Fire Drill record review will be added to LifeSharing House Audit Checklist by LifeSharing Specialist. SEE ATTACHED #2. Training will be provided to Providers & Lifesharing Specialists regarding requirement for at least annual night time fire drills which occur different days of the week and different times of the day and night with accurate documentation. Training will be conducted by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
6500.109(g)This residence held 2 fire drills (3/23/2016; 9/22/2016). Both drills were held at 6AM. Fire drills shall be held on different days of the week and at different times of the day and night.A sleep drill was conducted and documented Wednesday, 3/15/2017, 11:45PM at 201 N. Dwight Street. SEE ATTACHED #1. A Fire Drill record review will be added to LifeSharing House Audit Checklist by LifeSharing Specialist. SEE ATTACHED #2. Training will be provided to Providers & Lifesharing Specialists regarding requirement for at least annual night time fire drills which occur different days of the week and different times of the day and night with accurate documentation. Training will be conducted by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
SIN-00259820 Renewal 02/13/2025 Compliant - Finalized
SIN-00219619 Renewal 02/21/2023 Compliant - Finalized
SIN-00071372 Renewal 11/05/2014 Compliant - Finalized