| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.73 | The stairway leading from a second-floor family bedroom had seven steps and there was no 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. | A handrail was placed on 3/36/23 by the provider. |
03/27/2023
| Implemented |
| 6500.121(c)(4) | The annual physical examination for Individual #1 completed on 2/22/2023 did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Program Specialist and provider were both reminded that all areas of the annual physical form must be filled out, which includes hearing. |
03/28/2023
| Implemented |
| 6500.125(a) | Family member Staff #3 does not have a physical examination on file. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | Staff #3 was 6 weeks old when the individual moved in 2014. We were never instructed that they needed a physical prior because she was so young. The regulations now state that children one year of age and older will have a physical. |
04/06/2023
| Implemented |
| 6500.125(c)(2) | Family member Staff #2 does not have a Tuberculin skin test with negative results on file. Family member Staff #3 does not have a Tuberculin skin test with negative results on file. | 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. | Staff #3 was 6 weeks old when individual moved in 2014. We were never instructed that she required a mantoux at a certain age. Staff #2 was 2 years old at the time. Regulations did not state that she required a mantoux. Now they say for family member's 1 year of age or older. The regulation states that it should be done every 2 years. However, during exit we were told once and done. Staff #2 received a mantoux on 4/4/23 and it was read and negative on 4/6/23. Same for Staff #3. The regulation is not well written. It reads as if they should have one every 2 years. |
04/06/2023
| Implemented |
| 6500.34(a) | Individual rights were reviewed and signed on 1/03/2023 by Individual #1, but the rights statement was not complete. The individual was not informed that the primary caregiver is required to have a key or entry device to lock and unlock the door to the individual's bedroom. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | All individual rights were revised to include that the primary caregiver is required to have a key or entry device to lock and unlock the door to the individual's bedroom. |
03/24/2023
| Implemented |
| 6500.48(b)(5) | The 24 hours of annual training completed by Staff #1 during training year 2022 did not include training in the safe and appropriate use of behavior supports. | The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports. | Staff #1 did take the safe and appropriate use of behavior supports training on 4/10/23. A checklist for all mandatory trainings for lifesharing providers was created and distributed to the providers. |
04/10/2023
| Implemented |
| 6500.48(b)(6) | The 24 hours of annual training completed by Staff #1 during training year 2022 did not include training in the implementation of the individual plan. | The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan. | Created a new checklist of mandatory trainings required for life sharing providers that included training on the implementation of the individual plan. Reminded Program Specialist to ensure that when the plan is reviewed that the provider sign off. |
04/06/2023
| Implemented |
| 6500.135(g) | The psychiatric medication review for Individual #1 completed on 2/22/2023 did not document the reason for prescribing the medication Prozac. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The provider was reminded of the required documentation when it includes a Psychiatric medication. The necessary dosage, reason for prescribing and the need to continue the medication. Program Specialist will ensure that all of the required information is completed on the doctor report forms. |
03/27/2023
| Implemented |