| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.62(a) | Potentially poisonous cleaners were located unlocked under the sink in the kitchen. Various oils and hygiene products were located on the upstairs bathroom. Medication prescribed to individual #1 was unlocked on the sink in the bathroom. Program assessment notated potentially poisonous substances needed to be locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | This individual is aware of the dangers of poisonous materials. Individual 1's ISP was to be updated when they left their last placement, and it was not. An addendum request was sent to the SC on 5/11/23. The addendum was completed, and the ISP has been updated as of 5/17/23. (Attachment #1 sent to inspector) |
05/17/2023
| Implemented |
| 6500.64(a) | The upper-level bathroom shower had mildew build up around the corners of the shower. The sink was dirty with grime around the handles and in the sink bowl. Various open oils, soaps and hygiene items were stored on an open shelf above the sink. | Clean conditions shall be maintained in all areas of the home. | On 5/3/23, the Life Share Provider was counseled and retrained on the importance of keeping the bathroom clean, and was asked to clean his bathroom. Cleaning was confirmed by photo on 5/20/23.
(Attachment #2 sent to inspector)
This individual is aware of the dangers of poisonous materials. His ISP was to be updated when he left his last placement and it was not. An addendum was completed and his ISP has been updated as of 5/17/23.
(Attachment #1 sent to inspector) |
05/03/2023
| Implemented |
| 6500.101 | The Rear exit in the converted back porch was partially obstructed and a first level bedroom door locked from the inside of the bedroom which would prevent immediate escape in the event of an emergency. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | On 5/3/23, the Lifeshare Provider was counseled and retrained on the importance of keeping exits clear from clutter. The Lifeshare Provider cleared the area around the back porch exit and replaced the first floor bedroom doorknob. Compliance confirmed by photos on 5/20/23.
(Attachments #3, #8 and #9 sent to inspector) |
05/03/2023
| Implemented |
| 6500.121(c)(13) | Annual Physical Exam dated 8/24/22 for individual #1 does not include allergies. | The physical examination shall include: Allergies or contraindicated medications. | The PCP was requested to complete the missing sections on the individual's physical. The completed physical was received from the PCP on 5/22/23.
(Attachment #4 sent to inspector) |
05/22/2023
| Implemented |
| 6500.121(c)(15) | Annual Physical Exam dated 8/24/22 for individual #1 does not include special instructions for diet. | The physical examination shall include: Special instructions for the individual's diet. | The PCP was requested to complete the missing sections on the individual's physical. The completed physical was received from the PCP on 5/22/23.
(Attachment #4 sent to inspector) |
05/22/2023
| Implemented |
| 6500.32(r)(1) | The door knob on individual #1s bedroom door did not have the ability to be locked. Privacy preferences were not discussed in the individual plan. | 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. | A locking doorknob was purchased on 5/1/23. It is scheduled to be installed on 5/23/23.
(Attachment #7 sent to inspector) |
05/01/2023
| Implemented |
| 6500.133(d) | Cloradanide mouthwash was located in the upper-level bathroom in an unlocked area above the sink. Individual #1's plan does not notate that they can self-administer that particular medication. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The Lifeshare Provider removed the mouthwash from the bathroom. The provider was re-trained on 5/3/2023 that all medications must be kept in the medication box. |
05/03/2023
| Implemented |
| 6500.133(h) | Some medications prescribed to individual #1 including odansetron, expired as of 12/2/21 and Magic Wash, expired as of 4/28/21 were expired and not currently ordered but was still stored in the medication box with active medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired medications were discontinued by the PCP on 5/1/2023 and medications that did not have current prescriptions were removed.
(Attachment #5 sent to inspector) |
05/01/2023
| Implemented |
| 6500.139(a) | Lifesharer #1 last completed modified medication training course in 2020. This course should be repeated every 2 years. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration). | The Lifeshare Provider's training was completed/updated on 4/15/2023.
(Attachment #6 sent to inspector). |
04/15/2023
| Implemented |