Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281892 Renewal 01/06/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.66The light on the front porch of the home was not functional at the time of the inspection.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.Life Sharing provider repaired the porch light. See attachment #7 01/09/2026 Implemented
6500.70The telephone in the home was not operable at the time of inspection.A home shall have an operable telephone that is easily accessible.Life Sharing provider was able to repair home phone. Life Sharing Program Specialist called the number and phone was working. See attachment #8 01/08/2026 Implemented
SIN-00259826 Renewal 02/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.136(a)(11)Two prescription medication entries found on Individual #2's February 2025 Medication Administration Record (MAR) lacked a diagnosis or purpose for the medication: QC Fiber Therapy ("TAKE 2 TABLESPOONS BY MOUTH EVERY DAY AT 8PM") and Nystatin Powder 100,000 Unit/Gm ("APPLY 1 APPLICATION TOPICALLY 2 TIMES DAILY").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.Medication logs were corrected on 2/17/2025 with the diagnoses/purpose that were missing. By April 2025 and ongoing, Threshold will receive the updated medication logs with updated diagnoses from the pharmacy. See attachment #2 and #3. 02/17/2025 Implemented
6500.151(a)Individual #3's two most recent Individual Assessments were completed on 03/07/2023 and 04/19/2024, more than one year apart. This individual's Individual Assessment was not updated annually as required.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 annual assessment was completed and sent on 3/12/2025 for an ISP meeting that is scheduled on 4/15/2025. See attachment #5 03/12/2025 Implemented
6500.151(f)Per an Individual Support Plan (ISP) meeting sign-in sheet found within the Individual Record, Individual #3's Individual Plan Team met on 04/04/2024 for the Individual Plan Meeting. As the Individual Assessment was completed 04/19/2024, it could not have been provided to the members of the individual's Individual Plan Team at least 30 calendars prior to the Individual Plan Team Meeting as required. There was no evidence within the Individual Record to show that an older copy of the assessment was sent to team members prior to the meeting.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.A letter was sent to individual #3's team on 3/12/2025 for an ISP date on 4/15/2025. This is at least 30 days prior to the ISP meeting. See attachment #7 03/12/2025 Implemented
SIN-00238343 Renewal 02/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.66The garage area had a side door which exited to the side of the home. This exit did not have an exterior light. There was a motion light that was on the front of the garage door which would illuminate the driveway area, however the side of the home did not have a light at the exit door.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 3/16/24. Attachment # 19. 03/16/2024 Implemented
6500.101The side door exit off of the garage leads to the side of the home. The walkway which leads to the driveway was blocked with folded up picnic tables. These tables were folded and placed against the side of the home. In the event that door was used for an emergency or fire escape there would not be readily accessible paths to evacuate that area.Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed.Tables were removed from blocking the walkway on 3/15/24. Attachment # 20. 03/15/2024 Implemented
6500.32(r)(4)Both individual bedrooms in this home utilize a pin hole locking mechanism. This form of lock does not allow for easy and immediate access in the event of an emergency.An individual has the right to lock the individual's bedroom door. The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Both of the individual's bedroom locks were changed on 3/16/24. Both individuals have keys to their bedrooms. Attachment # 21, 22. 03/16/2024 Implemented
SIN-00200608 Renewal 03/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(e)A sleep drill was documented as being conducted on 8/12/20. The next documented sleep drill was held on 11/27/21. Sleep drills shall be held during sleep hours at least every 12 months.A fire drill shall be held during sleeping hours at least every 12 months.Training completed with lifesharing coordinator and lifesharing providers on 5/2/22 on fire drills 55 PA Code Chapter 6500.109 (3) requirement. Attachment #1 05/02/2022 Implemented
6500.121(c)(4)Individual #2's vision was not assessed at annual physical on 6/28/21. Prior annual vision exam was conducted on 9/27/18 with instructions to return in two years. Subsequent exam was due by 9/27/20. The next documented vision exam was conducted on 4/7/21. This exceeds the recommendation of the doctor and regulation. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.On 3/24/22, Individual #1's eye doctor faxed a memo stating that patient was not seen in the office in 2020 due to pandemic and office not running at full capacity. Attachment #18. 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 05/02/2022 Implemented
6500.48(b)(2)Sufficient documentation to support that annual training on abuse occurred during the 7/1/20 -06/30/21training year was not in the record of Staff #1. Documentation of training on the Threshold Abuse Policy was documented as occurring on 2/19/21. Policy and content of training was requested and not provided. Training on all components of the regulation could not be verified.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 #1 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 3/9/22. Attachment #19 05/30/2022 Implemented
6500.48(b)(5)Individual #2 has a behavior support plan in place. There is no documentation to support that Staff #1 received training on the behavior support plan and 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 Targeting Behavioral Needs training on 5/11/21. Attachment #20 Staff #1 reviewed behavior support plan, and received training on behavior support plan by behavioral specialist on 5/5/2022. Attachment #21 05/05/2022 Implemented
6500.48(b)(6)There is no documentation to support that Staff #1 received training on the Individual Support Plan (ISP) for Individual #2 updated on 8/25/21. Annual training on the implementation of the ISP is required.The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan.Staff #1 has since completed the Implementation of ISP training on 4/30/22. Attachment #22 04/30/2022 Implemented
6500.139(a)Certificate dated 5/22/19 for "Giving Medications at Home" was presented as the current medication training for Staff #1. 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).Individual #1 is self-medicating and staff #1 is not administering medication. Attachment #24. Staff #1 is working on completing Modified Medication Administration Training by 5/15/22 as a precautionary measure in the event staff #1 would need to administer medications. 05/09/2022 Implemented
6500.151(a)Two assessments were submitted for review for Individual #2. Annual assessment dated 3/2/21 and assessment update dated 7/21/21. The documents were identical with no updated information. When requested an additional assessment dated 3/2/22 but printed on 3/21/22 at 5:34pm was presented as the most recent assessment. Assessment reviewed in the home was the 3/2/21 document originally submitted for review. Assessments are to be updated on an annual basis.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 #1's assessment was updated on 3/17/2022. Attachment #23 Lifesharing coordinator received training on 4/11/22 on completion of residential indiviudal annual assessments. Attachment #9a 04/11/2022 Implemented
6500.166(a)Individual #2 has a restrictive plan in place with an implementation date of 10/23/21. There was no evidence to support that staff received training in the use of the specific techniques or procedures that are used to implement the plan.A person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.Staff #1 reviewed behavior support plan, and received training on behavior support plan by behavioral specialist on 5/5/2022. Attachment #21 05/05/2022 Implemented