| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual #2's funds are not being used for her benefit. On 2/1/23, Individual #2 made a purchase at Pizza hut. The receipt for Pizza hut Dine in was for $71.61 (total $61.61 and $10.00 tip), included on the receipt was 1 large pan, 1 large stuffed TO GO, 3 medium diet Pep, 2 orders of break stx, and 1 salad bar with meal. Individual #2's financial log for the withdrawal states Pizza Hut B'day. It was reported by the Life Sharing Provider that the individual chose to make these pizza purchases. According to Individual #2's Individual Support Plan they are diagnosed with dementia, their confusion has appeared to increase, and they lack the understanding of money management skills. | An individual's funds and property shall be used for the individual's benefit. | Individual #2 has been diagnosed with dementia but she is still aware of what it means to celebrate her birthday and buying things. Individual #2's assessment and ISP stated that she lacks the understanding of money management skills. Individual #2 will be reassessed and her plan will more specifically state what she is able to understand. |
04/21/2023
| Implemented |
| 6500.24(d)(1) | The home did not keep a personal possession/property record for Individual #2. | An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency. | Individual #2 was placed there as an emergency placement that became permanent. There is now a current financial and property record of her belongings. A letter was sent to all providers stating that they must keep this current and that anything over $50.00 should be recorded within 3 business days. |
03/24/2023
| Implemented |
| 6500.24(e)(3) | On 10/22/22, a Dollar General receipt had a payment method with cash on the receipt, at the top the receipt it had Individua #2's initials and a total of $16.48 ($15.55 and $0.93 for tax), but the receipt did not distinguish what items on the receipt could have been specific to Individual #2. A withdrawal for Dollar General-cold items on 10/22/22 was noted on Individual #2's financial ledger. The licensing representative was unable to distinguish what items on the receipt could have been specific to cold items and total $16.48 for Individual #2. The home did not keep an accurate expense record for this purchase. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by family members or agency staff. | A letter was sent to all providers stating that all individuals must have separate receipts when purchasing items. If that is impossible they must accurately label what item is for who. |
03/24/2023
| Implemented |
| 6500.72(b) | Doors shall be in good repair. At the time of inspections, Individual #2's bedroom doorknob handle was missing from their door. Individual #5's bedroom door had approximately 3 holes in it. | Screens, windows and doors shall be in good repair. | The door was fixed and door knob was put on. |
03/28/2023
| Implemented |
| 6500.101 | Exits from rooms shall be unobstructed. At the time of inspection, Individual #5's bedroom door had eye hook locks located on both sides of her bedroom door. One eye hook was located on the side of the door in the hallway and the other eye hook lock was located on the inside of the door in Individual #5's bedroom. When the eye hook from either side of the door would be locked it would be an obstruction of the exit from individual #5's bedroom door. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | Eye hooks were removed. Reminded provider that they cannot use eye hooks. |
03/24/2023
| Implemented |
| 6500.121(c)(6) | Tuberculin skin testing by Mantoux method with negative results every 2 years. Individual #2 had a Tuberculin skin testing by Mantoux method with negative results on 1/7/21 and their next one occurred on 3/15/23. Individual #2 did have an appointment scheduled for 2/28/23 with their physician, but this rescheduled by the office. The 2/28/23 initial appointment would have still exceeded the requirement. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | Letter to providers was sent out and stated that they are responsible for ensuring that all appointments are maintained in accordance with regulations. Program Specialists will also monitor monthly to ensure that appointments are made and attended. |
03/24/2023
| Implemented |
| 6500.34(a) | Individual #2 was informed of her rights on 1/5/2023. The rights haven't been updated to reflect the current Chapter 6500 regulations. The individual was not informed that the primary caregiver is required to have the key or entry device to lock and unlock the door. | 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. | The rights were revised to include that the primary caregiver is required to have the key or entry device to lock and unlock the doors. |
03/24/2023
| Implemented |
| 6500.132(a) | Staff persons or others who are qualified to administer medications for an individual who is unable to self-administer the individual's prescribed medication. Staff #2 has been administering medications since approximately September 2021, and Staff #2 did not complete the required medication administration course until 3/1/23. | Staff persons or others who are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | A checklist was developed to include all of the mandatory trainings, physicals, etc for a new life sharing provider. The program specialist will go through this checklist any time there is a new provider or there are any changes in the home in regards to make sure if someone becomes unable to self medicate that the provider is trained prior. |
04/10/2023
| Implemented |
| 6500.135(c) | Individual #2 is prescribed Mupirocin 2% ointment, apply to affected area three times daily. There were no initials on the Medication Administration Record (MAR) for the current month (3/1/23-3/22/23) to indicate that the medication was administered three times daily as ordered to Individual #2. Individual #2 is prescribed and the pharmacy label on the medication reads Clotrimazole-Bethameth Dip, apply to affected area once daily. The corresponding entry on the MAR documents Clotrimazole-Bethameth Dip, apply to feet twice daily as needed PRN. There were no initials on the MAR for the current month (3/1/23-3/22/23) to indicate that the medication Clotrimazole-Bethameth Dip was administered once daily as prescribed. | A prescription medication shall be administered as prescribed. | This prescription was a PRN but the PRN was not added to the medication log. Both program specialist have now received the ODP modified administration course so that they know what is needed on the medication logs. They have also started typing them so that there is less room for error. |
04/11/2023
| Implemented |