| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.110(a) | At the time of the inspection, there was no written fire safety training plan developed for all family members to be trained on. | A written fire safety training plan shall be developed for all family members and individuals including children. | Abound Health will develop a fire safety training plan standard operating procedure for Family Living Providers. The procedure will outline all required elements of the fire safety training plan.
· The fire safety training plan will be developed at the start of services following Fire Safety Training and signed by all household members.
· The plan will be revised whenever there are changes to exit routes, the designated meeting place, or the household layout.
· The plan will be reviewed and signed annually by all members of the household to confirm continued understanding and compliance. |
10/12/2026
| Implemented |
| 6500.110(b) | The fire safety training dated 1/15/26 for individual #1 did not include the following required topic areas: use of fire extinguishers and smoke detectors or notification of the local fire department as soon as possible after a fire is discovered. | The training plan shall include training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the home, smoking safety procedures if any individuals or family members smoke in the home, the use of fire extinguishers and smoke detectors and notification of the local fire department as soon as possible after a fire is discovered. | Abound Health team will revise the fire safety training sign-off for individuals receiving life sharing to include required topic areas including use of fire extinguishers, smoke detectors, and notification to local fire department. These are topic areas covered in the external Fire Safety Training completed by individuals and family living providers prior to starting services. The fire safety training sign-off will be updated and signed off on by the provider's correction date. The fire safety training sign-off will be electronically filed in the provider's electronic health record system and a copy will be kept in the life sharing binder on site. |
10/12/2026
| Implemented |
| 6500.34(a) | Individual #1 was not informed of the following rights: 32r1-r5 and 32s1-s3 upon their admission. | 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. | Abound Health will revise the Individual Rights section of the client consent packet to include rights 32r1--r5 and 32s1--s3. Once updated, Abound Health will review and explain the revised Individual Rights with each individual (currently living in a licensed Life Sharing home) and any person designated by the individual by the provider's correction date.
Abound Health will review with the individual or their designated person the corrected Individual Rights before the individual moves into the licensed 6500 home and annually thereafter. |
10/23/2026
| Implemented |
| 6500.135(g) | Individual #1 had a psychotropic medication review on 2/24/26 and not again until 8/24/26 which is outside the required every 90 day timeframe. | 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. | Abound Health team will provide a review and provide a copy of the 6500 regulations re: psychotropic medications and standard operating procedure related to this regulation with all Family Living Providers who provide service to an individual who takes psychotropic medication to ensure the psychotropic are reviewed at least quarterly by the prescribing provider. The prescribing provider must review the medication, name, dosage, reason for prescribing (diagnosis) and document the need to continue the medication. Abound Health currently has a medication monitoring form that will be used by family living providers to ensure this regulation is met. |
10/23/2026
| Implemented |
| 6500.151(a) | Individual #1's assessment dated 1/15/26 does not address all required topic areas such as 151e9 (disability, functional, medical limits), 151e13iii (daily living), 181e13viii (managing personal property), and 181e13ix (community integration). | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the 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 home. | Abound Health team will revise the internal agency assessment tool to add missing required topic areas per regulatory requirements. Regulation numbers will be added to the corresponding fields throughout the assessment. The assessment will be completed on the updated and correct form. That information will be shared with the individual's support team. |
10/23/2026
| Implemented |