| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | (Repeat from Inspection completed 1/29/24) From February 2024 to the present, Individual #1's money was used to purchase items that are to be included in room and board at least a dozen times. | Individual funds and property shall be used for the individual's benefit. | This regulation is important because it ensures an individual's funds are used for their benefit.
Individual #1 purchased several items that should have been covered by their room and board payment.
Team members allowed individual #1 to purchase the items that should be covered by their room and board payment. The program specialist did not thoroughly review the receipts each month.
Immediately following the inspection, the team members supporting Individual #1 were informed of the items that room and board cover and the importance of ensuring Individual #1 does not purchase these items with their own money.
The program specialist completed an audit of all their receipts and will be sending them to the finance team for Individual #1 to be reimbursed. The reimbursement will occur by 3/31/2025.
Program specialists completed an audit of all individuals from February 2024 to now. Any purchases made for items covered by room and board will be reimbursed. All individuals will receive reimbursement by 3/31/2025. The Assistant Director will be working with the Administrative Assistants to determine another level of oversight on purchases being made. This will likely include a monthly audit sample. |
02/21/2025
| Implemented |
| 6400.22(d)(1) | (repeat from 1/29/24 inspection) Individual #1's Snap benefit log is not current and up to date. The actual FS balance on 8/31/24 was 166.54. The beginning balance on the September log was documented as zero. Individual #1 had a cash balance on their EBT card. There is no log documenting the money and how it was spent. Individual #1 has multiple gift cards. All of the gift cards are being tracked on one ledger, making it impossible to tell the balance of any of the gift cards. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | This regulation is important because it ensures that the provider is protecting the individual's funds.
The SNAP benefits were captured for the entire home on one form, making it difficult to distinguish whose funds were spent. In addition, Individual #1's gift cards were tracked on one form, making it difficult to distinguish how gift cards were being used and the remaining balance for each of them. |
02/21/2025
| Implemented |
| 6400.32(o) | Individual #1 signed a document indicating they did not give permission for their Snap benefits to be used by housemates, staff, and visitors. At the time of the inspection, Individual #1's food purchases were not kept separate from the rest of the food in the home. | An individual has the right to manage and access the individual's finances. | This regulation is important to ensure the people supported decisions to share or not to share their food stamps benefits are being followed.
Individual #1 indicated that they did not want to share their food stamp benefits. However, when Individual #1 moved to a new home, the process to label their specific food and keep their food stamps separate was not followed. This was discovered during the inspection.
The individual was asked if they wished to continue not to share food stamps benefits with other people since recently moving to a new program. The individual would like to share food stamps benefits moving forward. The individual completed a new food stamps form to reflect the new decision to share. See Attachment #24.
Program specialists completed an audit of all people supported. During the audit, it was determined that no one else indicated they did not want to share their SNAP benefits. |
02/21/2025
| Implemented |
| 6400.213(1)(i) | Individual #1's demographic information documents the date of admission as 8/27/85; which is actually the individual's date of birth. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | This regulation is important because it allows for immediate access of pertinent information if an individual is missing or experiences a medical or behavioral emergency requiring immediate treatment.
During the inspection, it was determined that Individual #1's admission date was the birthdate.
An audit was completed on 1/31/2025 to review the individual's first ISP, previous face sheets, and other historical documentation to identify the admission date. The correct date was added to the individuals face sheet on 2/10/2025. See Attachment #25.
Program specialists completed an audit of all people supported to ensure all facesheets included an accurate admission date for residential programs. This was completed by 2/24/2025. |
02/21/2025
| Implemented |