| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(a) | The self assessment completed on 12/15/17 did not measure compliance regulations 6500.162 through 6500.176. | If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home 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. | the self assessment will be completed 3-6 months prior to expiration of certificate of compliance. director and coordinator will review each assessment once completed by the FLS to ensure each assessment is accurately completed in its entirety. training docs for all staff included for reg 6500.17 [Documentation of aforementioned audits of each assessment by the Director and the Coordinator shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 6500.23(a) | Family Member #1, date of birth 5/14/98, had a Pennsylvania criminal history record check most recently completed on 11/12/14, prior to being 18 years of age. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home. | a criminal check will be completed for individuals living in the home when they are 18 individual had one at 16 new one was completed and mailed on 7/12/18. see attached form. fls and flp trained on reg 6500.23a included. [Immediately, the CEO or designee shall develop and implement a tracking system for all family living homes to be audited at least quarterly by a management staff person to ensure timely completion of criminal history record checks. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
07/12/2018
| Implemented |
| 6500.43(d)(1) | The following discrepancies were noted in Individual #1's assessment completed 6/16/17. In the Poison Evaluation for Personal Hygiene Products and for Cleaning Products, Individual #1 is assessed as not aware of purpose and use or avoiding various personal hygiene products and cleaning products; however, later in the assessment, in Emergency Situations, it states that Individual #1 safely uses or avoids poisonous materials. In the Mobility section, sub-section Self-Mobility, it is indicated that Individual #1 is both independent in skill area and also requires total assistance in skill area. In the Telephone Usage section, it indicates that Individual #1 cannot dial or answer the phone appropriately; in the Emergencies section it indicates that Individual #1 knows how to call emergency numbers effectively. In the Immediate Action Evaluation section is indicates that Individual #1 does not require supervision at medication administration; in the Self-Administration of Medication Addendum, it indicates that Individual #1 can participate in his/her medication routine but requires visual supervision for safety. | The family living specialist shall be responsible for the following: Coordinating and completing assessments. | The assessment will be completed accurately to reflect current functioning and capabilities of individual annually by fls and revised as needed. Coordinator will review accuracy prior to mailing out assessment. Coordinator and director will ensure that assessment and ISP are congruent with assessment. if discrepancies are found, written communication will be sent to SC for revisions. Training for FLS is included. Revised assessment is included. [Discrepancies in the ISP were sent to on 7/23/18. At least quarterly, the family living program specialist shall review all individuals' assessments and current ISPs to ensure individuals are accurately assessed.(DPOC by AES,HSLS on 8/23/18)] |
07/12/2018
| Implemented |
| 6500.43(d)(6) | The following discrepancies were noted between Individual #1's ISP, updated 5/9/18, and Individual #1 assessment, dated 6/16/17. The Know and Do section of the ISP indicates that Individual #1 uses a wheelchair, a stander and can crawl on the floor while in his/her bedroom; the Physical Development section indicates that Individual #1 has limited motor skills due to cerebral palsy, uses a wheelchair daily to ambulate, wears bilateral AFOs, can roll to his/her stomach and push him/herself up to all fours, and can walk 400-500 feet at a time. The assessment indicates that Individual #1 is independent in the Motor Skills section which includes but is not limited to standing, walking, running, and jumping. The Know and Do and General Health and Safety Risks sections, it is indicated that Individual #1 has medications administered to him/her. Per the assessment, only verbal prompts and supervision are necessary when medicating to ensure safety. The Know and Do section also indicates that Individual #1 requires total assistance while in the shower, has a shower chair and needs someone to help with transferring into the bath, which Individual #1 prefers. The Water Safety section indicates that Individual #1 needs assistance with bathing and is not able to regulate water temperature due to difficulty with Cerebral Palsy and turning knobs. Per the assessment, Individual #1 can regulate water temperature, uses no adaptive equipment, and does not require supervision while in the shower/bath. The Know and Do section also indicates that Individual #1 needs someone to put on shoes and socks for due to physical limitation. The assessment indicates in the Dressing section that Individual #1 can put on and take off socks, put on and take off shoes, and tie shoes with verbal prompts. The General Health and Safety Risks and Fire Safety sections of the ISP indicate that Individual #1 requires physical assistance to evacuate in case of a fire as Individual #1 uses a wheelchair. Per the assessment, Individual #1 is independent in all areas of mobility and is able to go to the designated meeting area, and "knows how" to exit the home. The ISP indicates in the Cooking/Appliance Use section and in the Meals/Eating section that Individual #1 does not use any sharp knives; the assessment indicates in the Meal Preparation/Dining section, sub-section Dining Skills, that Individual #1 uses knives appropriately. | The family living specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions for content accuracy. | FLS will complete assessments for individuals . Clinical coordinator for review assessment prior to being mailed out. The team will review assessment at ISP meetings to ensure they are consistent and congruent. If they are not SC will be requested to update ISP so that it matches what the assessment has determined as an accurate reflection of the individuals capabilities . communication will be documented and filed . [Discrepancies in the ISP were sent on 7/23/18. At least quarterly, the family living program specialist shall review all individuals' assessments and current ISPs to ensure individuals are accurately assessed.(DPOC by AES,HSLS on 8/23/18)] |
07/10/2018
| Implemented |
| 6500.121(c)(6) | Individual #1, admission date 7/6/16, had a Tuberculin skin test completed 8/20/16. | 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. | youth was with family in foster care prior to converting to lifesharing. physical had been completed as required for regulations this would have been cited in prior audit. all TB are completed prior to individual starting and done every other year. [Immediately, the CEO or designee shall develop a tracking system of individuals' physical examinations and Tuberculin skin testing to ensure timely completion. At least quarterly, the tracking system shall be audited by designated management staff person to ensure notification and competition of individuals' physical examinations and Tuberculin skin testing. (DPOC by AES,HSLS on 8/23/18)] |
07/10/2018
| Implemented |