| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual #1's funds were used to purchase mouthwash on two occasions; 9/18/2020 at Walmart for $6.57 and again on 11/29/2020 at Walmart for $6.57. On 11/23/2020, Irish Spring bar soap was purchased for $4.21 at Walmart; and on 11/29/2020, Total Whitening toothpaste was purchased for $7.27 at Walmart. These toiletry items that were purchased by the individual with his own funds should have been included in the room and board payments made by the individual. | An individual's funds and property shall be used for the individual's benefit. | This regulation is important as the individual pays monthly R&B. As a result, the individual¿s basic hygiene products are provided for the individual. The Lifesharing provider was retrained on 3/11/2021 on what is covered under the R&B payment. Furthermore, her contract was reviewed with her, as it is expected that basic hygiene products are to be provided to the individual per her Lifesharing contract. The individual was reimbursed for the basic hygiene products in the amount of $28.38 on 3/5/2021. Moving forward, the coordinator will review COH receipts on a monthly basis to ensure no basic hygiene products were purchased with the individual¿s monies before submitting the ledger and receipts to the fiscal department. |
03/11/2021
| Implemented |
| 6500.110(b) | Individual #1's fire safety training plan dated 7/06/2020 did not include a designated meeting place. | 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. | This regulation is important to ensure the individual and Lifesharing family are well trained on all the necessary steps should a fire occur, including the designated meeting spot. This will ensure that all members of the home evacuate the home safely and to the same meeting place. The individual and the Lifesharing family completed an updated Fire Safety training on 3/17/2021 which included the residential emergency plan to review to ensure all members of the family were aware of the designated meeting place. The Lifesharing coordinator will ensure this document is included with the Fire Safety Training annually. |
03/17/2021
| Implemented |
| 6500.151(e)(1) | Individual #1's annual assessment dated 12/02/2020 did not document the individual's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | This regulation is important as it ensure all areas of the person¿s life are discussed and documented so that the most holistic form of care and support can be provided to the individual. While the needs and function strengths of the individual were included within the annual assessment, it was discovered there was no clear area within the assessment that included the individual¿s preferences. The Lifesharing coordinator was re-trained on this section of the regulations on 3/16/2021 and updated the annual assessment on 3/17/2021 to include these areas. |
03/17/2021
| Implemented |
| 6500.34(a) | The Individual Rights that were reviewed with and signed by Individual #1 on 2/03/2021 were not updated to reflect the individual rights contained in the current Chapter 6500 regulations. | 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 regulation is important as the individual is entitled to a thorough explanation of all of their individuals, as well as who to contact if they feel their rights are being violated. They are entitled to be informed of this rights in the mode of communication they best understand. Upon discovery of this violation, the new individual rights packet was located, reformatted to ensure all areas were covered, and the individual was informed of each right on 3/17/2021. This individual was also informed of who to contact if he feels his rights are being violated. The individual and the Lifesharing provider signed off on this rights packet on 3/17/2021. |
03/17/2021
| Implemented |
| 6500.136(a)(11) | Individual #1's Medication Administration Record (MAR) did not list a diagnosis or purpose for the following medications: Flonase, Equate, Docusate and Quetiapine Fumarate. | 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. | This regulation is important to ensure the person administering the individual¿s medication is aware of what each medication¿s purpose is for and what diagnosis the medication is associated with. The medication administration log was updated on 3/17/21 to include the diagnosis for each medication to ensure it is administered correctly. The Lifesharing coordinator will ensure, on a monthly basis, that the correct medication administration record is being utilized and that the medication administration record is updated immediately should there be a new medication added to the individual¿s regimen. |
03/17/2021
| Implemented |