Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.17(a) | The last self-assessment for this residence was completed in 2015. | If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home 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. | Self assessments for all lifesharing homes will be completed 3-6 months prior to the expiration of the license. In the coming year the self inspections will be completed between 2/1/19 and 5/1/19. The lifesharing specialist assigned to each site shall submit the required self assessments to the program director. |
09/21/2018
| Implemented |
6500.67 | In the finished basement, there were several ceiling tiles with water damage. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The ceiling tiles with the water damage have been replaced. |
09/21/2018
| Implemented |
6500.68(b) | Individual #1 is unable to regulate his own water temperature for showering. The water temperature in this residence read 129.3, which exceeds the requirement by 9 degrees. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The hot water temperature has been reset at 120. The program specialist will monitor the water temperature at this site during home visits. The water temperature in all sites that have individuals who are not able to regulate their own water temperature will be monitored during home visits conducted by the lifesharing specialist. |
08/08/2018
| Implemented |
6500.70 | There was no landline phone at this residence. | A home shall have an operable telephone that is easily accessible. | A landline phone has been installed. In the future the program specialist will verify the presence of land line phones during site visits. All LSP's will be reminded of the requirement to have a land line phone. |
09/21/2018
| Implemented |
6500.103 | The last record of the furnace being cleaned in this residence was 6/17/2015. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | The gas furnace at this site was cleaned on 8/8/18. In the future the dates of furnace cleanings are being tracked electronically to ensure compliance with the annual requirement. |
08/08/2018
| Implemented |
6500.109(f) | Since 4/2017, only the back door was used as an exit during fire drills. | Alternate exit routes shall be used during fire drills. | A fire drill was conducted at this site on 7/26/18 and the exit used was the front door. In the future the program specialist shall ensure that alternate exits are used on future fire drills at all lifesharing sites. |
07/26/2018
| Implemented |
6500.121(c)(1) | The section was blank on Individual #1's physical exam dated 2/21/2018. | The physical examination shall include: (1.) A review of previous medical history. | The physical examinations for individual #1 dated 2/21/18 has been amended to include a review of previous medical history. In the future the program specialist shall ensure that the physical exams are entirely completed prior to placing in the individual's chart. |
08/01/2018
| Implemented |
6500.121(c)(14) | This section was blank on Individual #1's physical exam dated 2/21/2018. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical has been amended and medical information pertinent to diagnosis and treatment in case of an emergency has been added to the physical exam dated 2/21/18 for individual #1 |
09/21/2018
| Implemented |
6500.151(a) | Individual #1 was admitted on 4/4/2018. He didn't have an initial assessment until 6/19/208, which exceeds the 60 day requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the family living 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 family living home. | Going forward the program specialist will ensure that the initial assessments for new admissions to family living homes are completed within the 60 days required timeframe. There have not been any new admissions since the licensing inspection |
08/01/2018
| Implemented |