| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.72(b) | At 1:30 PM on 8/14/25, there were eleven small circular and irregular-shaped tears in the lower center of the screen door outside of the sliding glass door leading from the dining room to the rear deck. | Screens, windows and doors shall be in good repair. | Screen was replaced on 9/9/25. Tears are no longer evident, and the screen door was re-installed. |
09/12/2025
| Implemented |
| 6500.101 | At 1:30 PM on 8/14/25, in addition to a standard locking system, the sliding glass door leading from the dining room to the rear deck was equipped with a foot pedal track brake lock on its bottom left corner, requiring a precise kicking motion to disengage it. At 1:32 PM, the exterior kitchen door leading to the side porch was blocked on the kitchen's interior side by the following objects: a large dustpan, two large shopping bags filled with contents; a Swiffer mop; a broom; a canister of cooking oil inside of a cardboard box; and a metal tin bin filled with bags of potatoes and onions. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | Brake lock was removed by provider on 9/9/25. |
09/12/2025
| Implemented |
| 6500.151(e)(12) | Individual #1's current assessment, completed on 11/25/24, did not contain any recommendations addressing specific areas of training, programming, and services, as this assessment's only recommendation stated, "Please follow all doctor's recommendations for continued good health." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | On 9/9/25 program supervisor revised individuals' assessment and sent to individuals' team via email, to include recommendations regarding training, programming and services. Documentation of email has been saved and filed in individual's record. |
09/12/2025
| Implemented |
| 6500.32(e) | At 1:45 PM on 8/14/25, Individual #1's bedroom door was equipped with a privacy lock having a pop mechanism on the interior and a pinhole access point on the exterior. Interviews with the agency revealed that Individual #1 had signed a form, indicating their choice not to have a bedroom door lock. | An individual has the right to make choices and accept risks. | On Friday 9/5/25, the program supervisor ordered 1 new doorknob for Mercer. Package was sent directly to 816 Mercer St. Turtle Creek Pa 15145. Life share specialist visited the home on 9/9/25 and installation was completed. |
09/12/2025
| Implemented |
| 6500.48(b)(2) | Life Sharing Provider #1 completed annual training in the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse on 8/7/24 for the 7/1/24 to 6/30/25 fiscal year by self-reading the material, as the there was no documented trainer. | 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. | Moving forward, staff will complete Relias training annually which will be documented in their file. Also, all training forms in relation to policy and procedures will be updated with the trainer¿s name and signature. |
09/12/2025
| Implemented |
| 6500.48(b)(3) | Life Sharing Provider #1 completed annual training in individual rights on 8/7/24 for the 7/1/24 to 6/30/25 fiscal year by self-reading the material, as the there was no documented trainer. | The annual training hours specified in subsection (a) must encompass the following areas: Individual rights. | Moving forward, staff will complete Relias training annually, which will be documented in their file. The trainer will be Relias and be noted on the certificate of completion for individual rights training. |
09/12/2025
| Implemented |
| 6500.152(c) | Individual #1's Service Plan, last updated 5/30/25, contained the following discrepancies between their current assessment, completed on 11/25/24, in the following health and safety skill domains: regarding supervision in the home, Individual #1's Service Plan, last updated 5/30/25, informed that Individual #1 can be left at home safely without supervision for 24 hours but would need to be checked on for any longer periods of time. Additionally, in this case, Individual #1 would have to have their meals prepared ahead of time. However, Individual #1's assessment completed on 11/25/24, indicates that Individual #1 is independent without supervision and that "Yes, "[Individual #1] requires an average amount of staff supervision; and regarding supervision in the community, Individual #1's Service Plan, last updated 5/30/25, explained that Individual #1 can be left alone without supervision and is "able to use public transportation for short trips and could travel." In contrast, Individual #1's assessment, completed on 11/25/24, indicates that they can independently cross streets that "Yes," Individual #1 is able to use the public restroom independently; and that, "Yes, [Individual #1] requires an average amount of staff supervision," and expounded upon the conditions that Individual #1 needs assistance in exploring and recognizing new community areas, businesses, or offices with which they are unfamiliar, as Individual #1 becomes anxious. After attending a new place with their Life Sharing Provider, Individual #1 is then able to go there independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 9/9/25 program supervisor communicated with service coordinator regarding community supervision section of the assessment. Confirmation of changes to the individuals ISP were completed by the SC on 9/9/25. |
09/12/2025
| Implemented |