Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256265 Renewal 11/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(d)(1)Up to date financial records for Individual #1 were requested. No records of funds received by or deposited with the family or agency were provided. An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency.On 1/3/24, LSS enrolled into online bank card statement associated with individual #1 to collect all financial records from each month. 01/03/2025 Implemented
6500.24(d)(2)Up to date financial records for Individual #1 were requested. No records of disbursements made to or for the individual were provided. An up-to-date financial and property record shall be kept for each indivudal that includes the disbursements made to or for the individual.On 1/3/24, LSS enrolled into online bank card statement associated with individual #1 to collect all financial records from each month. 01/03/2025 Implemented
6500.109(f)The fire drills conducted in January, April, July and October of 2024 all listed the front door as the exit used. Alternate exit routes shall be used during fire drills.Alternate exit routes shall be used during fire drills.On 12/23/2024, fire drill expectations were reviewed with this Life sharing provider. The LSS developed a tracking record for fire drills that includes alternative exit routes to be used in subsequent fire drills. 12/23/2024 Implemented
6500.121(c)(4)Documentation of a vision exam conducted in 2024 for Individual #1 was requested and not received. Documentation of the previous vision exam for Individual #1 was dated 10/30/23. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.On 12/23/2024, the LSS received the completed vision exam paperwork from Individuals #1¿s eye doctor that was completed 11/8/24. 12/23/2024 Implemented
6500.121(c)(7)Gynecological exams for Individual #1 were documented as being completed on 3/16/23 and 5/20/24. This exceeds the annual time frame requirement. 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.On 12/27/24, the LSS scheduled the next Gynecology appointment for individual #1 on 4/28/2025. 12/27/2024 Implemented
6500.124Acetaminophen prescribed for Individual #1 and documented on the November 2024 Medication Administration Record (MAR) was not in the home at the time of inspection. Vitamin D was not administered as prescribed on 11/3, 11/4, 11/5, and 11/6 as documented on the November 2024 MAR for Individual #1. EIM reports entered note that the error was due to the pharmacy not filing the prescription submitted. EIM reports noted the missed medication occurred on 11/3, 11/4, and 11/5. The November 2024 MAR notes that the medication was missed on 11/6/24 as well. On 1/11/24 the Neurologist for Individual #1 ordered labwork to determine Depakote levels to be completed "around 1/11/24." There was no documentation to support that the labwork had been completed as ordered. Health and pharmaceutical services were not provided as prescribed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.On 12/11/24, the Acetaminophen from the MAR was delivered to the home from the pharmacy. On 12/27/24, the LSS went to the home for verification. A call for a new script was also made for future administrations. On 11/27/24, the LSS put in a medication error for the the Vitamin D error on 11/6/24. The medicaton was delivered late on 11/6/24, but the provider gave the medication the next morning due to the time of delivery. On 12/23/2024, Life sharing specialist scheduled lab work for individual #1 to determine Depakote levels from Neurologist order. Lab work scheduled for 12/27/2024. 12/23/2024 Implemented
6500.20(b)(2)Vitamin D was missed on 11/3, 11/4, 11/ 5, and11/ 6 as documented on the November 2024 Medication Administration Record (MAR) for Individual #1. Enterprise Incident Management (EIM) reports entered note that the error was due to the pharmacy not filing the prescription submitted. EIM reports noted the missed medication occurred on 11/3, 11/4, and 11/5. The November 2024 MAR notes that the medication was missed on 11/6/24 as well. There was no report entered for the missed medication on 11/6/24.The agency and the home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the department within 72 hours of discovery by a staff person: A medication error as specified in § 6500.136 (relating to medication errors), if the medication was ordered by a health care practitioner.On 11/27/24, LSS put in a medication error for the incident of missed medication on 11/6/24. 11/27/2024 Implemented
6500.45(a)Verification of first aid and CPR training for Staff #1 was requested and not received.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.On 12/6/24, the Life Sharing provider completed the First Aid/CPR/AED training. 12/06/2024 Implemented
6500.48(a)There was no documentation to support that Staff #1 received the required 24 hours of training. Verification of training hours for Staff #1 was requested and not received.The primary caregiver and the life sharing specialist shall complete 24 hours of training related to job skills and knowledge each year.This cannot be corrected for the past fiscal year, however, it had already begun to be addressed before the licensing date for next year. It is now corrected globally. 11/27/2024 Implemented
6500.48(b)(1)Verification of training on the application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships for Staff #1 was requested and not received.The 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.On 7/10/24, Provider completed the Person-Centered practices training on ODP. ODP training certificate verified by LSS for staff #1. 11/27/2024 Implemented
6500.48(b)(2)Verification of training on 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 for Staff #1 was requested and not received.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.On 6/25/2024, Staff #1 completed training on Abuse: Detection, Reporting and Prevention of Abuse, Suspected Abuse and Alleged Abuse on ODP. Training was completed but access to ODP account was unobtainable due to forgotten email/password. ODP training certificate verified by LSS for staff #1. 11/27/2024 Implemented
6500.48(b)(3)Verification of training on Individual rights for Staff #1 was requested and not received.The annual training hours specified in subsection (a) must encompass the following areas: Individual rights.On 6/28/2024, Staff #1 completed the Individual Rights training on ODP. Access to the ODP account was gained and documentation of completed training was provided on 12/6/24. ODP training certificate was verified by LSS for staff #1. 11/27/2024 Implemented
6500.48(b)(4)Verification of training on recognizing and reporting incidents for Staff #1 was requested and not received.The annual training hours specified in subsection (a) must encompass the following areas: Recognizing and reporting incidents.On 12/5/2024, provider #1 completed the Incident Managment Bulletin: Preventing Incidents on ODP. This training is in place of the Recognizing and Reporting Incidents section of ODP. Training certificate verified by LSS. 12/05/2024 Implemented
6500.48(b)(5)Verification of training on the safe and appropriate use of behavior supports for Staff #1 was requested and not received.The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports.On 6/26/2024, Staff #1 completed the Behavior Support and Crisis Intervention Plans: Development & Entry into HCSIS on ODP. Access to the ODP account was gained and documentation of completed training was provided on 12/6/24. On 11/27/24, the ODP training certificate was verified by LSS for staff #1. 11/27/2024 Implemented
6500.151(f)There was no documentation to support that the assessment for Individual #1 had been sent to the team members prior to the individual plan meeting as required.The life sharing specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.On 12/6/2024, the completed annual assessment was sent to the SC for their file. 12/06/2024 Implemented
SIN-00195951 Renewal 11/03/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(g)Times of day and night were not varied for the fire drills that were reviewed. Fire drills were held every three months during calendar year 2021. Two drill were held during sleeping hours (4/12/2021 and 10/29/2021) and were both held at 11:30PM. The two drills held during waking hours (1/20/2021 and 7/12/2021) were both held at 5:00PM.Fire drills shall be held on different days of the week and at different times of the day and night.A tracking form has been put in place so lifesharing providers can ensure that they are conducting the drills on different days of the week and at different times of the day. 01/01/2022 Implemented
6500.17(a)The Self-Assessment completed for the home was not dated, making it impossible to determine if it was completed within 3 to 6 months prior to the expiration date of the agency's certificate of compliance.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.In the future all self-assessments will be dated so it can be determined that they were completed within 3-6 months prior to the expiration of the agency's certificate of compliance. 05/01/2022 Implemented
6500.48(b)(1)The annual training hours for life sharing specialist Staff #1 for training year 7/01/2020 to 6/30/2021 did not include: facilitating community integration, individual choice and supporting individuals to develop and maintain relationships.The 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.The life sharing specialist Staff #1 for training has now completed additional training hours that include facilitating community integration, individual choice and supporting individuals to develop and maintain relationships. 11/24/2021 Implemented
6500.48(b)(6)The annual training hours for life sharing specialist Staff #1 for training year 7/01/2020 to 6/30/2021 did not include: Implementation of the individual plan.The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan.Lfiesharing speciliast #1 has received training on the implementation of the individual plan. 12/01/2021 Implemented
SIN-00194004 Unannounced Monitoring 10/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.64(a)The water control knob for the tub/shower in the 2nd floor hall bathroom had a substantial amount of a black substance resembling mold or mildew between clear plastic outer part of the knob and the inner metal part of the knob.Clean conditions shall be maintained in all areas of the home.The water control knob for the tub/shower in the 2nd floor hall bathroom has been replaced.. The importance of maintaining clean conditions in all areas of the home has been reviewed with the lifesharing provider at Oswego Lane. 11/10/2021 Implemented
6500.73The two exits at the rear of the home on the first floor, one in the kitchen and one in the laundry area, each had three steps and no handrail.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.Handrails will be installed on the two exits at the rear of the home on the first floor, in both the kitchen and the laundry area where there are three steps. The LSP will be trained/retrained on the need for a handrail when there are more than two steps. 12/10/2021 Implemented
6500.101In the basement area of the home, there was a storage closet and a closet housing a sump pump. Both of the closets had a door with a pin-style locking device. The door knobs were reversed with the pinhole locking mechanism on the inside of the closet, which could result in possible entrapment and obstructed egress if an individual was in the closet and the door was closed and locked from the outside.Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed.In the basement of the home the locks have been reversed on door to the storage closet and the door to the closet housing the sump pump so that the pinhole portion of the lock is on the inside of the closet thus making it not possible for someone to become entrapped in either closet. The egress is no longer able to be obstructed if an individual was in the closet and the door was closed. It is now possible exit the closets by turning the door knobs. 11/20/2021 Implemented
6500.136(a)(11)The October 2021 medication administration record (MAR) for Individual #1 did not include a diagnosis or purpose for the following medications: Levocetirizine 5mg tabs, Metamucil, and Thiothixene 5mg tabs.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.The diagnosis or purpose for the medications (Levocetiriizine, Metamucil and Thiothixene) for Individual #1 has been added to the October 2021 MAR. 11/10/2021 Implemented
SIN-00180310 Renewal 12/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.73There were approximately 6 steps going up through the Bilco doors in the basement. There was no handrail at this exit.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.A handrail will be installed on the interior stairway (6 steps) going up through the Bilco doors in the basement. The lifesharing provider will be responsible for installing or having this railing installed. The lifesharing specialist shall confirm that the handrail has been installed either virtually or by visiting the site. 02/19/2021 Implemented
6500.109(f)Exits were not alternated for fire drills. The front door was the only exit utilized this year.Alternate exit routes shall be used during fire drills.All lifesharing providers will receive additional fire drill training by 1/25/21. In the future the lifesharing specialists will track the fire drills and ensure that alternate exits are used. If the same exit is used more than two times in a row, the lifesharing specialist will have the lifesharing provider repeat the drill and use a different exit 01/25/2021 Implemented
6500.110(c)Staff #2 had fire safety training on 1/30/2019 and not again until 7/29/2020, which exceeds the annual requirement.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).In the future the lifesharing specialist will ensure that all family members and individuals, including children, are trained within 31 calendar days of an individual living in the home and retrained annually thereafter in accordance with the training plan specified in subsection (a). The Fire safety requirement will be included on the annual training syllabus. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/25/2021 Implemented
6500.48(b)(1)Staff #2 and Staff #3's annual trainings did not include person-centered practices, rights, individual choice and supporting individuals to develop and maintain relationships.The 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 #2 and Staff #3 will be trained on the application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships by 1/25/21. An annual syllabus has been developed to ensure that the new annual training requirements are met and include the application person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships. Lifesharing providers will be encouraged to use the training materials on the myodp website. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/25/2021 Implemented
6500.48(b)(2)Staff #2 and Staff #3's annual trainings did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse.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 #2 and Staff #3 will be trained in the prevention, detection and reporting of abuse by 1//25/21. An annual training syllabus has been developed to ensure that the new annual training requirements are met and include the prevention, detection and reporting of abuse, suspected abused and alleged abuse Lifesharing providers will be encouraged to use the training materials on the myodp website. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/25/2021 Implemented
6500.48(b)(3)Staff #2 and Staff #3's annual trainings did not include Individual Rights.The annual training hours specified in subsection (a) must encompass the following areas: Individual rights.Staff #2 and Staff #3 will be trained in individual rights by 1/31/21. An annual syllabus has been developed to ensure that the new annual training requirements are met and include individual rights.. Lifesharing providers will be encouraged to use the training materials on the myodp website. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/31/2021 Implemented
6500.48(b)(4)Staff #2 and Staff #3's annual trainings did not include recognizing and reporting incidents.The annual training hours specified in subsection (a) must encompass the following areas: Recognizing and reporting incidents.Staff #2 and #3 will be trained on recognizing and reporting incidents by 1/25/21.. An annual syllabus has been developed to ensure that the new annual training requirements are met and include recognizing and reporting incidents. Lifesharing providers will be encouraged to use the training materials on the myodp website. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/25/2021 Implemented
6500.48(b)(5)Staff #2 and Staff #3's annual trainings did not include 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 #2 and staff #3 will be trained on the safe and appropriate use of behavior supports by 1/25/21. An annual training syllabus has been developed to ensure that the new annual training requirements are met and include the safe and appropriate use of behavior supports. . Lifesharing providers will be encouraged to use the training materials on the myodp website. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/25/2021 Implemented
6500.48(b)(6)Staff #2 and Staff #3's annual trainings did not include implementation of the individual plan.The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan.Staff #2 and Staff #3 will be trained in the implementation of the individual plan by 1/31/21 . An annual syllabus has been developed to ensure that the new annual training requirements are met and include the implementation of individual plan.. Lifesharing providers will be encouraged to use the training materials on the myodp website. The lifesharing specialists will track the training of the LSP's and ensure that all the required annual training requirements are met. 01/31/2021 Implemented
SIN-00122744 Renewal 10/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.31(b)Individual #1's rights were signed late. They were signed on 01-13-16 then not again until 02-14-17.A statement signed and dated by the individual, or the individual's parent, guardian or advocate if appropriate, acknowledging receipt of the information on individual rights upon admission and annually thereafter, shall be kept.In the future the Program Specialist will ensure that each individual signs the rights statement up on admission and annually thereafter. Rights due dates will be electronically tracked and reminders sent to both the LSP and the Program Specialist 45 days prior to the annual due date. 12/01/2017 Implemented
6500.66The interior stairs that lead to a basement area commonly used by the individual had no lighting. It was pitch black and the steps were not visible.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.At the time of the inspection the stairway leading from the main floor of the home to the basement was dimly lit. There was not a light shining directly over the stairs. A light has been installed in the stairway itself to provide more light over the steps. 11/17/2017 Implemented
6500.110(c)Individual #1's annual safety training was almost a month late. She had it on 01-13-16, then not again until 02-14-17.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). All training is being tracked by Extended Reach and reminders of training that is due will be sent to the Program Specialist and LS provider 45 prior to the training being due. 12/01/2017 Implemented
6500.121(a)Individual #1's physical was late. She had one 05-26-16 and not again until 07-31-17.An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter.In the future all individuals will have physicals completed within an annual time frame. Annual physical dates will be tracked on Extended Reach and reminders will be sent to both the LSP and Program Specialists 45 days prior to annual physical date to ensure compliance. 12/01/2017 Implemented
6500.121(c)(6)Individual #1's TB test was late. She had one on 02-11-14 then not again until 06-08-16.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.In the future (individual #1) will have Tuberculin skin testing done by Mantoux method every two years. The electronic record keeping system will send a reminder to both the LSP and the Program Specialist 45 days prior to the annual due date to help ensure future compliance for all individuals. 12/01/2017 Implemented
6500.121(c)(7)Individual #1 did not have a annual breast exam. 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.A separate gyn form has been developed with specific blanks for the doctor to indicate clearly whether or not a breast exam, pelvic exam and PAP test have been completed and at what intervals they are recommending the exams be completed for each individual. Individuals who refuse any part of the gyn exam will be counseled as to the importance of the exam by the Program Specialist and if they continue to refuse, the refusal will be documented. The breast exam was performed on 3/22/2017. Documentation of the exam was not present in the file during inspection. 11/17/2017 Implemented
6500.121(c)(10)There was no section pertaining to communicable diseases on Individual #1's physical form. 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.During the licensing inspection it became apparent that the annual physical for JS was missing the 2nd page and that page of the form contains the section pertaining to communicable diseases. In the future the Program Specialist will ensure that all the pages of the annual physical exam are present and completed prior to filing the form in the individual¿s record. Additionally, we are working with the physician''s office to get a statement that individual is free from communicable diseases. 12/29/2017 Implemented
6500.121(c)(11)Assessment of health maintenance needs was left blank on Individual #1's physical form. 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.The section pertaining to health maintenance needs on Individual #1 has now been completed as n/a. The Program Specialist will develop a letter to physicians to be presented to the physician along with the physical form at the time of the physical instructing them not to leave anything blank on the physical. The Program Specialist will review all incoming physical forms to ensure compliance. Any physicals found to have blanks will be returned to the physician for completion. Documentation will be kept for physicals that were returned 12/01/2017 Implemented
6500.121(c)(12)The section pertaining to physical limitations was left blank on Individual #1's physical form. The physical examination shall include: Physical limitations of the individual.The section pertaining to physical limitations on Individual #1 has now been completed as n/a. The Program Specialist will develop a letter to physicians to be presented to the physician along with the physical form at the time of the physical instructing them not to leave anything blank on the physical. The Program Specialist will review all incoming physical forms to ensure compliance. Any physicals found to have blanks will be returned to the physician for completion. Documentation will be kept for physicals that were returned 11/17/2017 Implemented
6500.121(c)(15)A section pertaining to diet was not on Individual #1's physical form. The physical examination shall include: Special instructions for the individual's diet.The section pertaining to dietary needs on Individual #1 has now been completed as n/a. The Program Specialist will develop a letter to physicians to be presented to the physician along with the physical form at the time of the physical instructing them not to leave anything blank on the physical. The Program Specialist will review all incoming physical forms to ensure compliance. Any physicals found to have blanks will be returned to the physician for completion. Documentation will be kept for physicals that were returned 11/17/2017 Implemented
SIN-00104046 Renewal 10/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(d)(1)The Licensing Represemtative was handed Individual #4's financial log and bank envelope and was told verbally by Staff #2 that Individual #4 doesn't have any money. However there were 2 $20 bills - $40 total. When shown to Staff #2, she said that this was actually the other individual's money. The financial log in the same red 3-ring binder which states that Individual #4 has a balance of $0.65 with a $75 monthly spending deposit from 10/03/2016 . However in another envelope there was a receipt dated 10/13/2016 from Burlington in the amount of $68.95 for 5 items purchased that staff #1 is stating that is Individual #1's. There was also a receipt for $11.42 from McDonalds dated 10/13/2016. This combined would equal $80.37 spent which would put Individual at a negative balance of -$4.72, however staff #2 stated that Individual #4 would owe her $2 after Staff #3 added up the receipts and stated out loud, "she actually would be in the hole." An accurate financial record was not being kept for Individual #4.  An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency.Since the time of inspection financial records are being kept up to date. The lifesharing provider has been retrained in consumer financial management and record keeping. Financial records are reviewed by the lifesharing specialists during home visits. 01/12/2017 Implemented
6500.43(b)At the time of inspection Staff #3 was the only Family Living Specialist employed. She was in charge of 17 homes, which exceeds the requirement.A family living specialist shall be assigned to no more than 8 homes.An additional family living specialist has been hired. Sixteen homes will be divided among the two family living specialists and the 17 home will be assigned to a different program specialist. 01/12/2017 Implemented
6500.43(c)At the time of inspection Staff #3 was the only Family Living Specialist employed. She was in charge of 22 individuals, which exceeds this requirement.A family living specialist shall be responsible for a maximum of 16 people, including people served in other types of services.An additional family living specialist has been hired. In the future case loads for family living specialists will not exceed the maximum number of 16. 01/13/2017 Implemented
6500.73The front stairway outside of the home has a step up to the long sidewalk-type step then a step up to a shorter landing, then 2 steps up to the left and a step into the doorway for a total of 5 steps. There is no handrail. There are 2 sets of stairs leading from the garage; one leading to the main house and another leading to a closet area. Both sets of stairs consist of 3 stairs and do not have a handrail.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.A railing will be installed by the front stairway of the home for the three steps from the shorter landing into the home. A railing will also be installed on the 2 sets of three steps from the garage into the house and in the closet area. 03/15/2017 Implemented
6500.121(c)(7)Individual #4 had a PAP completed on 4/9/2015. She didn't have another PAP completed until 8/16/2016, which exceeds the annual requirement. There was no record of her having a breast exam performed. 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.In the future appointments will be more closely tracked to ensure compliance with the regulations. A copy of the doctor's notes for the gyn exam on 8/16/16 was obtained and indicates that a breast exam was performed at this visit Additionally the gyn form has been revised so that it more clearly specifies what was done at the exam and the need for future examinations. 10/21/2016 Implemented
6500.137(a)Individual #4 is prescribed Carbamide 6.5% (ear wax removal Generic for Debrox 6.5% solution) Instill 2 drops into both ears once daily on every Monday and Thursday (8pm) This is blank on 10/17/2016 as if not administered by the provider. Staff #2 stated that she gave it but did not mark the sheet. Staff #2 took the form and put her initials onto the form at this time. However, then she said that Individual #4 was in respite at that time and she could not have given it. 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 lifesharing provider has been retrained in medication administration and the importance of accurate documentation. The med logs are reviewed by the lifesharing specialists during home visits. 01/12/2017 Implemented
6500.141In the garage there are 3 deep freezers, one of which had opened packages of meat (turkey necks) and a large cooking pot with a frozen liquid which is covered with a large opened black, plastic trash bag. A second freezer had a large number of whole frozen fish which were not wrapped. The kitchen freezer had spills on the bottom surface of the freezer (yellow, green, black) appearing to be frozen spilled foods/liquids which could cause contamination.Food shall be protected from contamination while being stored and prepared.The freezer in the kitchen has since been cleaned out. The large freezers in the garage have also been cleaned out and the food is all stored properly. The provider has been trained in food sanitation/safety. 01/12/2017 Implemented
6500.156(b)Individual #4 did not sign the ISP Reviews that were completed on 1/13/2016, 4/25/2016, and 7/25/2016.The family living specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #4 has signed ISP Reviews dated 1/13/16. 4/25/16 and 7/25/16. All future ISP Reviews will be signed by the individual. 01/12/2017 Implemented
6500.156(c)(2)Reviews of ISP areas such as health & safety are not being completed in the ISP Reviews for Individual #4.The ISP review must include the following: A review of each section of the ISP specific to the family living home licensed under this chapter.Quarterly Review of ISP form has been revised to include a review of each section of the ISP specific to the family living home licensed under this chapter. In the future this new form will be used and include areas such as health and safety. 02/09/2017 Implemented