| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(d)(1) | At the time of the inspection, there was no 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. | Life Sharing Specialist and Life Sharing Provider were trained on Regulation 6500.24(d)(1) on 4/24/2024 in regards Annual property inventory by Director of Quality Assurance (MP). See Attachment #9. A current copy of Individual #1's Property Inventory List was developed and sent as Attachment #10. |
04/24/2024
| Implemented |
| 6500.121(c)(11) | Individual #1's most recent physical completed on 11/14/23 does not address health maintenance needs, medication regiment, or bloodwork. This section 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. | Life Sharing Specialist and Life Sharing Provider were trained on Regulation 6500.121(c)(11) on 4/24/2024 in regard to all required information on the annual physical by Director of Quality Assurance. See Attachment #11. A copy of Individual #1's annual physical exam with updated information sent as Attachment #12. |
04/24/2024
| Implemented |
| 6500.133(h) | At the time of the inspection, the milk of magnesia available in the home was expired. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The provider properly discarded the expired milk of magnesia on 4/17/2024 and obtained a new bottle that is not expired. Picture sent as Attachment #13. The provider will talk to the prescribing doctor to see if the MOM can be discontinued, as it has not been needed in more than a year. Life Sharing Specialist and Life Sharing Provider were trained on Regulation 6500.133(h) on 4/23/2024 by Director of Quality Assurance. See Attachment #14. |
04/23/2024
| Implemented |
| 6500.136(a)(2) | At the time of the inspection, the following medications on the MAR did not document the correct prescribers: Tamsulosin, Paroxetine, Vitamin D 3, Risperidone, Valacyclovir, and Phenazopyridine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | April's MAR was updated to show the correct prescribing physicians, sent as Attachment #15. Life Sharing Specialist and Life Sharing Provider were trained on Regulation 6500.136 (a)(2) on 4/24/2024 in regards using the correct prescriber on the MAR by Director of Quality Assurance. See Attachment #16. |
04/24/2024
| Implemented |
| 6500.151(a) | Individual #1's date of admission was 10/3/23. The initial assessment was not completed until 12/29/23, past the 60-day requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home. | Life Sharing Specialist was trained on regulation 6500.101 on 4/24/2024 in regard to assessments and time-frame requirements by the Director of Quality Assurance (MP). See Attachment #17. |
04/24/2024
| Implemented |
| 6500.151(d) | The initial assessment was completed on 12/29/23, but the FLS did not sign and date it until 1/2/24. | The life sharing specialist shall sign and date the assessment. | Life Sharing Specialist was trained on regulation 6500.101 on 4/24/2024 in regard to signing assessments by Director of Quality Assurance. See Attachment #18. |
04/24/2024
| Implemented |