| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.72(b) | At 2:38 PM on 8/14/25, the exterior swing door of the attached garage could only be opened from the outside, but not from the inside of the garage, because its doorknob was broken. At 2:43 PM, the door to Life Sharing Provider #1's office was missing a doorknob. At 2:45 PM, located underneath the doorknob assembly of Individual #1's bedroom door, there was a circular hole, measuring two inches in diameter, bored completely through the door's structure. | Screens, windows and doors shall be in good repair. | New doorknob was delivered from Amazon directly to 209 Crescent pines Dr Verona Pa 15147. Life share specialist visited the home on 9/11/25 and maintenance was completed including instillation of new doorknob as well as patch to 2-inch hole in bedroom door. Doorknob key was placed outside of door accessible in the event of an emergency. |
09/12/2025
| Implemented |
| 6500.151(e)(12) | Individual #1's current assessment, completed on 7/2/25, did not contain any recommendations addressing specific areas of training, programming, and services, as this assessment's only recommendation stated, "[Individual #1] is not usually able to recognize when [they] are having an asthma attack and requires prompting to use [their] inhaler." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 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 |
| 6500.32(r)(1) | At 2:45 PM on 8/14/25, Individual #1's bedroom door was equipped with a privacy lock having a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #1 with a unique mechanism in which to lock and unlock 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. | On Friday 9/5/25 Program supervisor ordered 2 new doorknobs for Crescent Pines. The package was sent directly to 209 Crescent Pines Dr Verona Pa 15147. Life sharing specialist visited the home on 9/11/25 and maintenance was completed. |
09/12/2025
| Implemented |
| 6500.32(r)(4) | At 2:45 PM on 8/14/25, Individual #1's bedroom door was equipped with a privacy lock having a turn latch on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons 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. | On Friday 9/5/25 Program supervisor ordered 2 new doorknobs for Crescent Pines. The package was sent directly to 209 Crescent pines Dr Verona Pa 15147. Life share Specialist visited the home on 9/11/25 and maintenance was completed. Key for the lock will be hung outside of the door for easy and immediate access by the individual and staff persons in the event of an emergency. |
09/12/2025
| Implemented |
| 6500.136(b) | At 3:00 PM on 8/14/25, the staff signature key on the back of Individual #1's August 2025 Medication Administration Record was blank; and therefore, did not identify the initials of Life Sharing Provider #1 who had administered the medications. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Life share specialist completed re-education with provider on 9/11/25 regarding the medication administration process. Completion documented by program supervisor and was placed in providers training file. |
09/12/2025
| Implemented |
| 6500.152(c) | Individual #1's Service Plan, last updated 7/28/25, contained the following discrepancies between their current assessment, completed on 7/2/25, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 7/28/25, explained that besides hot water temperatures, "[Individual #1] must be supervised with all other heat sources." In contrast, Individual #1's assessment, completed on 7/2/25, indicates that, "Yes", Individual #1 can both sense and quickly move away from dangerous heat sources; regarding supervision in the home, Individual #1's Service Plan, last updated 7/28/25, informed that Individual #1 requires 24-hour general supervision of a responsible adult due to a visual impairment, and that "[Individual #1] does not need to be within eyesight or earshot." However, Individual #1 assessment completed on 7/2/25, indicated that Individual #1 requires a 1:1 staffing ratio in the home 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 7/28/25, explained that Individual #1 requires 24-hour general supervision of a responsible adult due to a visual impairment and that "[Individual #1] cannot independently navigate traffic and needs supervision, as [their] eyesight is poor." In contrast, Individual #1's assessment, completed on 7/2/25, stated that they require a 1:1 staffing ratio in the community and "Yes, [they] [are] able to carefully able to walk in the community."; and that, "Yes, [Individual #1] requires an average amount of staff supervision,"; and that they are able to use the public restroom independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 9/8/25 Program Supervisor communicated with individual #1¿s supports coordinator the revisions needed to correct discrepancies between ISP and assessment. Moving forward, life share staff will review individual ISP¿s monthly, to ensure that all necessary changes have been made by the individuals service coordinator. |
09/12/2025
| Implemented |