| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | On 5/5/21, Individual #1's money was used to purchase disposable briefs for incontinence products which are covered under room and board expenses. | An individual's funds and property shall be used for the individual's benefit. | Non-Residential Director, LifeSharing Specialist, and LifeSharing Providers will be trained on the regulatory requirements concerning what constitutes Room and Board, what is the responsibility of the individual, and what is the responsibility of the agency. This training will be completed on December 1, 2021, by the Director of Quality Assurance and Training.
The LifeSharing Provider is responsible to obtain receipts and document all purchases in the monthly ledger. If an expenditure is noted that may be part of the Room and Board contract, the LifeSharing Provider will speak with the LifeSharing Specialist for further information regarding reimbursement. To ensure no further infractions occur, the LifeSharing Specialist is responsible to review the individuals¿ ledgers to ensure no monies have been spent on items covered by Room and Board. If an expenditure is noted that may be part of the Room and Board contract, the LifeSharing Specialist will speak with the LifeSharing Provider and Individual for further information regarding the purchase. If the expenditure is covered under Room and Board, immediate remediation must occur. A requisition will be sent by the Non-Residential Director to the agency Fiscal department for reimbursement |
12/01/2021
| Implemented |
| 6500.73 | The steps leading to the outside entrance from the basement are not equipped with a handrail. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | Non-Residential Director, LifeSharing Specialist, and LifeSharing Providers will be trained on the regulatory requirements 6500.73 concerning the need for a handrail on accessible stairways exceeding two steps. This training will be completed on December 1, 2021, by the Director of Quality Assurance and Training.
The LifeSharing Provider is responsible to arrange a contractor to install a handrail on the interior stairway leading to the outside entrance from the basement by 12/15/2021.
If the LifeSharing Provider has difficulty in locating an appropriate contractor to install the railing, the LifeSharing Provider will contact the Non-Residential Director. The Non-Residential Director will work with the Facilities Director to help obtain alternative contractors.
To ensure no further infractions occur, the LifeSharing Provider will identify potential hazards that may need addressed within the home and work with LifeSharing Specialist to address any needed repairs/additions. |
12/01/2021
| Implemented |
| 6500.103 | The furnace was cleaned on 12/27/19 and not again until 11/11/21; outside of the annual time frame. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | trained on the regulatory requirements 6500.103, concerning the need for furnaces within the homes to be cleaned at least annually. Written documentation of the cleaning must be kept. This training will be completed on December 1, 2021, by the Director of Quality Assurance and Training.
The LifeSharing Provider is responsible to arrange a contractor to clean and inspect the furnace. The LifeSharing Provider must ensure that the furnace cleaning and inspection occurs annually, during the same month as the previous year's inspection, or earlier.
If the LifeSharing Provider has difficulty in locating an appropriate contractor to clean and inspect the furnace, the LifeSharing Provider will contact the Non-Residential Director. The Non-Residential Director will work with the Facilities Director to help obtain alternative contractors or agencies.
LifeSharing Provider will ensure that the furnace within the home is inspected and cleaned annually, during the same month as the previous year's inspection or earlier. LifeSharing Provider will attain documentation of furnace inspection. To ensure no further infractions occur, Life Sharing Provider will send copy of the documentation of the furnace cleaning/inspection to the LifeSharing Specialist. LifeSharing Specialist will review documentation and contact the LifeSharing Provider if missing any documentation |
12/01/2021
| Implemented |
| 6500.121(c)(8) | Individual #1 last had a mammogram completed on 6/15/20 and not again since; outside of the annual time frame. | 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 #1s physician was contacted and the office is procuring a scheduled mammogram. Non-Residential Director, LifeSharing Specialist, and LifeSharing Providers will be trained on the regulatory requirements, including 6500.121c8, concerning the annual mammogram and the procedure for the completion of the forms and appointments. All appointments must be completed annually, and there is only a 15-day allotted time from the date of the previous appointment. The training will be completed on December 1, 2021, by the Director of Quality Assurance and Training.
The LifeSharing Specialist is responsible to track all appointment dates, will have access to the permanent records, and keep a log of all annual dates to ensure compliance with the regulations.
The LifeSharing Provider is responsible to schedule the above appointments, send the appointment information to the LifeSharing Specialist, and submit all corresponding paperwork within one business day. LifeSharing Specialist is to review all appointments starting 12/01/2021 and ending 5/31/2022 utilizing the Excel Spreadsheet. |
12/01/2021
| Implemented |
| 6500.121(c)(14) | The most recent annual physical completed for Individual #1 on 11/10/21 had the section "medical information pertinent to diagnosis and treatment in case of an emergency" of the form blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Non-Residential Director, LifeSharing Specialist, and LifeSharing Providers will be trained on the regulatory requirements, including 6500.121c6, concerning the annual exams and the procedure for the completion of the forms and appointments. The training will be completed on December 1, 2021, by the Director of Quality Assurance and Training.
The LifeSharing Specialist is responsible to ensure that annual physical exams are completed in its entirety with no blank blocks in the specified areas.
Once the annual exam appointment is completed, the LifeSharing Provider will scan and email the form to the LifeSharing Specialist within one business day. The LifeSharing Specialist will file the copy of the annual exam paperwork in the individual's permanent chart. The LifeSharing Specialist will arrange/schedule a time to visit the physical site of the LifeSharing provider to collect the original annual exam paperwork.
The LifeSharing Specialist is responsible to ensure that all medical information pertinent to diagnosis and treatment in case of emergency are listed on the annual physical. |
12/01/2021
| Implemented |