| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(a) | No documentation was provided verifying that there is a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for advising the individual concerning the use of funds and property. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for advising the individual concerning the use of funds and property. | Staff 1 will fill out a Cash on Hand Ledger (Attachment 1) every month showing where the funds are going for Individual 1. |
02/10/2021
| Implemented |
| 6500.24(d)(1) | There is no current financial or property record for Individual #1. | 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. | Staff 1 and Individual 1 filled out an inventory of belongings sheet (Attachment 2) in addition to the Cash on Hand Ledger. (Attachment 1) |
02/10/2021
| Implemented |
| 6500.109(a) | There were no fire drills held from 11/20/20 to 1/27/21. | A fire drill shall be held at least every 3 months, until all individuals demonstrate the ability to evacuate within 2 1/2 minutes, or within the period of time specified in writing within the past year by a fire safety expert, without family assistance, or with family assistance if the individual is never alone in the home. The fire safety expert may not be a family member or employee of the agency. | A fire drill was conducted on 1/28/2021 (Attachment 3). Fire drills will be held monthly in the home, with a fire drill during sleep hours once quarterly. |
02/10/2021
| Implemented |
| 6500.110(b) | There is no training plan/evacuation plan in place for this home. | The training plan shall include training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the home, smoking safety procedures if any individuals or family members smoke in the home, the use of fire extinguishers and smoke detectors and notification of the local fire department as soon as possible after a fire is discovered. | An evacuation plan was put in place and followed during the 1/28/2021 fire drill. The designated meeting place is the mailbox. (Attachment 3) |
02/10/2021
| Implemented |
| 6500.110(c) | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually. There was no fire safety training held for Individual #1 or Staff #1 and Staff #2 in the home from 11/20/20- 1/27/2021. | 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). | Staff 1 and 2, and Individual 1 participated in fire safety training on 1/27/2021. (Attachment 4) Fire Safety training will be held for all residents of the home annually. |
02/10/2021
| Implemented |
| 6500.121(c)(4) | Individual #1 last had a vision screening on 8/26/19 and a hearing screening on 2/22/19 and not again since. Vision and hearing are to be screened annually. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual 1 had a vision appointment on 8/20/2020 and the next scheduled vision appointment is on 8/9/2021. The appointment on 8/20/2020 was prior to her moving into a CARES of Central PA Lifesharing home. No documentation was provided to CARES of Central PA from the previous residential setting. Individual 1 does not currently have a hearing screening scheduled due to wax build up in her ears. Her PCP attempted to remove it but was unsuccessful and rereferred her to the ENT specialist. The ENT Specialist attempted to remove the wax build up 2x (1/15/2021, 1/22/2021) but was unsuccessful, so they are scheduling surgery to have it removed. Surgery date is TBD at this time. Individual 1 will be offered annual screenings for vision and hearing. |
02/10/2021
| Implemented |
| 6500.121(c)(7) | Individual #1 had a gynecological exam on 5/29/19 and not again since. Gynecology exams are to occur annually. | 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. | Individual 1 has a gynecological exam scheduled for 3/1/2021. Individual 1 will be offered annual appointments. |
02/10/2021
| Implemented |
| 6500.121(c)(8) | Individual #1 last had a mammogram on 3/12/19 and not again since. Mammograms are to occur annually. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual 1 has a mammogram scheduled for 3/18/2021. Individual 1 will be offered annual appointments. |
02/10/2021
| Implemented |
| 6500.121(c)(11) | Individual #1 had an annual physical examination on 2/26/20. The physical exam completed on that date did not address health maintenance. That section of the form was left blank. | 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. | CARES of Central PAs RN spoke with Individual 1 doctor on 1/28/2021 regarding the Health Maintenance section of her 2/26/2020 physical, and was advised to complete this section and submit it to the doctors office. The fax was sent at 4:18pm on 1/28/2021. (Attachment 11) |
02/10/2021
| Implemented |
| 6500.182(a) | Individual #1 does not have an individual record. | A separate record shall be kept for each individual. | A record was created on 1/27/2021. Please see Attachment 5 for Individual 1 Fact Sheet. |
02/10/2021
| Implemented |
| 6500.186 | As of 1/27/21, Individual # 1 did not sign release of information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | Please see Attachment 6 Medical Information Release Form signed by Individual 1 on 1/27/2021. |
02/10/2021
| Implemented |
| 6500.124 | Individual # 1 is to be on an 1800 calorie diet. There is no documentation that the caloric intake is monitored to assure the Individual follows the recommended diet. As per doctor's recommendations, Individual #1 is to participate in 30 minutes of moderate activity a day. There is no documentation that this is being monitored to assure the Individual is receiving the recommended amount of exercise. Individual is to chew Ice Breaker gum four times a day at 30 minute intervals. There is no documentation that this is occurring. According to Individual #1's current med list she is to have the following PRN medications available at the home: Amoxicillin (500 mg-4 caps 1 hour prior to dentist appointment), Midol, Acetaminophen 325 mg (2 tabs), Mucinex (600mg), Simethicone (80 mg), and Hydrocortisone. None of these PRN medications were available at the time of the inspection. In addition, Individual #1 takes Trifemynor daily and Carbamide Peroxide daily. Neither of these medications are listed as current on the medication list. No current order was provided as documentation for the medications. | 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. | A chart was created to track Individual 1 daily exercise, gum chewing, and caloric intake. This chart is to be filled out daily by Staff 1, stating whether Individual 1 has stayed within the caloric intake, chewed gum, and has done physical activity. Please see Attachment 7 for January 2021 chart and Attachment 7a for Staff 1 training on this documentation. |
02/10/2021
| Implemented |
| 6500.32(r)(1) | Individual #1's bedroom door does not have the ability to be locked. Individual #1 was not offered the option to lock the bedroom door when she is not at home. | 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. | Individual 1 was offered a lock for her bedroom door on 1/27/2021 and she has declined at this time. (Attachment 8) |
02/10/2021
| Implemented |
| 6500.34(a) | No documentation was provided verifying that the individual rights and the process to report a rights violation were explained to the individual, and persons designated by the individual, prior to moving into the home and annually thereafter. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | This was reviewed with and signed by Individual 1 and Staff 1 on 1/27/2021. (Attachment 9) Individual Rights will be reviewed with Individual 1 annually. |
02/10/2021
| Implemented |
| 6500.34(b) | There was not a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights shall be kept. | A copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights shall be kept. | This was reviewed with and signed by Individual 1 and Staff 1 on 1/27/2021. (Attachment 9) Individual Rights will be reviewed with Individual 1 annually. |
02/10/2021
| Implemented |
| 6500.135(c) | According to Individual #1's current med list she is to take Minastrin 24 FE 1 tablet daily, Omeprazole 20 mg I capsule daily, and Breo Ellipta 100mcg-25-mcg-1 puff daily. These medications were not available at the home and are therefore not being administered as prescribed. No discontinued orders were provided. | A prescription medication shall be administered as prescribed. | A Medical Information sheet including an up to date Med List was completed by CARES of Central PA Lifesharing Coordinator and CARES of Central PA RN on 1/27/2021 to accurately reflect Individual 1 current medications. (Attachment 12) These updates were also sent to Individual 1 Supports Coordinator on 1/27/2021. |
02/10/2021
| Implemented |
| 6500.136(a)(1) | Individual #1 does not have medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | Individual 1 has a medication administration record, implemented on 1/27/2021. (Attachment 10) MARs will be completed daily and collected for review monthly by the Lifesharing Coordinator. |
02/10/2021
| Implemented |