| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.110(c) | The most recent fire training for Individual #1, Life Sharing Provider #1, Family Member #2, and Family Member #3 was completed on 8/06/19. | 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). | The Life Sharing Specialist re-trained Life Sharing Provider #1, Family Member #2 and both life sharing participants who live in the home in Fire Safety on 3/18/2021 (see attached documentation). The training coordinator will track the due dates of annual training requirements to ensure compliance with all regulations and will keep copies of completed trainings on file in office. *Family member #3 has moved from the residence prior to plan of correction implementation and therefore was unavailable to be trained, however, Family member #3 has no current plans to move back in. |
03/25/2021
| Implemented |
| 6500.125(c)(2) | Life Sharing Provider #1 had a Tuberculin skin test completed 6/20/15 and not since. | The physical examination shall include: (2) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. | The Life Sharing provider #1 is scheduled for the soonest available physical examination on May 17, 2021 to include the administration and subsequent reading of a Tuberculin skin test by Mantoux method. All life sharing providers and affiliated family members/others living in the home will be required to complete bi-annual physical examinations to include Tuberculin skin testing by Mantoux method effective immediately (soonest available appointment with medical professional as needed based on bi-annual requirement and date of last physical/TB testing) and will submit their documentation for verification to the Human Resources Director. |
05/19/2021
| Implemented |
| 6500.135(a) | D3 25mcg(1000) iu Bone Health Dietary Supplement was administered to Individual #1 from 3/01/21 to 3/04/21 at 8:00AM without a prescription by an authorized prescriber. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The Life Sharing Specialist retrained the Life Sharing Provider on the requirement of needing a prescription from an authorized prescriber for all medications administered as well as administering the prescription as written by the physician on 3/24/2021 (see attached documentation). The Life Sharing Specialist obtained a new, current prescription on 3/8/2021: Vitamin D3 125mcg (5,000 unit) capsule 125mcg PO 1 PO Wednesday and 1 PO Saturday, however, the provider continued to administer the mediation daily ¿ a medication error was reported through the EIM system; the provider was retrained and the medication will be administered properly starting 3/27/2021. The Life Sharing Specialist will review all medications monthly to ensure that there is a current prescription that matches the medication on the MAR, that the medications are documented and administered as prescribed and to ensure complete and thorough MAR documentation is demonstrated consistently. |
03/27/2021
| Implemented |