| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(8) | Individual #1, date of birth 12/27/1955, had an annual mammogram on 2/12/2021 and then again on 4/22/2022. | 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 # 1 mammogram was completed but was late. The late mammogram was because there was a staffing shortage at the facility completing the mammogram.
In the future Life Sharing Program Director Ryan Stumph will locate other facilities if necessary to complete medical procedures in order to stay in regulatory compliance.
The life Sharing Program Director Ryan Stumph and Life Sharing Specialist Renee Kutchman are completing a master check list of medical appointments for all individuals.
The check list will be shared with all Life Sharing families and individuals.
the Executive Director will also be keeping track of the checklist to ensure compliance with dates and regulations. |
08/26/2022
| Implemented |
| 6500.182(c)(1)(vi) | The photograph in Individual 1's record was not dated. | Each individual's record must include the following information: Personal information, including: A current, dated photograph. | The Life Sharing Program Director Ryan Stumph got new pictures for all individuals in the Life Sharing program and then dated the pictures.
Individual Information Summary forms will be updated yearly by the Life Sharing Program Director Ryan Stumph including a review of the individual's picture and ensuring the picture is dated.
The Executive Director Nathaniel Haggerty will also review each individual's Information Summary Form yearly for accuracy and to make sure all photos are dated as required. |
09/02/2022
| Implemented |
| 6500.17(a) | The completed self-assessment was not dated so compliance was unable to be measured. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | The date the self-assessment was completed has now been put in the correct location.
The Life Sharing Program Director Ryan Stumph has marked on his yearly calendars the timeframe for completing future self-assessments within the regulatory requirement.
The Life Sharing Program Director Ryan Stumph will complete a self-assessment for each licensed facility. Ryan will then present the completed self-assessment to the Executive Director Nathaniel Haggerty for review and accuracy.
A checklist form has been developed to use when reviewing self-assessments for accuracy. The Program Director and Executive Director will use and complete the form when reviewing and completing the self-assessments. |
09/02/2022
| Implemented |