| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | There were purchases made by and on behalf of Individual #1 that should have been included in the room and board expenses, such as multiple purchases for disinfecting wipes on 6/29/24, 8/8/24, 11/30/24, and 12/15/24, deodorant on 1/19/25, and a mattress on 8/13/24. | An individual's funds and property shall be used for the individual's benefit. | Individual #1 was reimbursed for wipes and deodorant. As of 2/19/24. An incident was filed in EIM on 2/14/24 and an investigation is being completed. The mattress was purchased for Individual 1 and the property record was updated to reflect this purchase. |
03/11/2025
| Implemented |
| 6500.24(d)(1) | On 8/13/24, there was a purchase made from Individual #1's Personal Needs account for a mattress in the amount of $180.19; this item is not listed on the individual's property record. | 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. | Property record was updated to include the mattress on 3/3/25 |
03/11/2025
| Implemented |
| 6500.24(e)(3) | (Repeat from last inspection) There are no receipts, or expense reports available for Individual #1 for purchases exceeding $15. | 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. | Receipts will be kept starting March 1, 2025. |
03/11/2025
| Implemented |
| 6500.71 | At the time of the inspection on 2/10/25, emergency numbers were not posted in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home. | Emergency phone numbers were posted in the home on 3/7/25. |
03/11/2025
| Implemented |
| 6500.79(d) | At the time of the inspection on 2/10/25, the window blind in individual #1's room was broken. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | The blind was replaced as of 3/11/25 |
03/11/2025
| Implemented |
| 6500.110(c) | The Fire safety training for Individual #1 was completed 4/2/23 and not again until 6/25/24 which is outside of the annual time frame. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | This time frame can not be corrected. The paperwork was completed as soon was realized that it was missed. |
03/11/2025
| Implemented |
| 6500.121(c)(7) | Individual #1 has not had a gynecological exam since 7/6/21 and there is no documentation supporting that an annual exam is not medically necessary. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual 1 is currently hospitalized and will not be returning to the care of the LSP. Notified Guardian of need for Gyn exam. |
03/07/2025
| Implemented |
| 6500.121(c)(8) | Individual #1 has not had a mammogram completed; individuals are to have a mammogram completed at 40 years of age. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual 1 is currently hospitalized and will not be returning to the care of the LSP. Notified Guardian of need for a mammogram. |
03/07/2025
| Implemented |
| 6500.151(e)(1) | Individual #1's assessment from 5/21/24 does not identify the individual's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual 1's assessment was updated to include preferences and was distributed to the team. |
03/07/2025
| Implemented |
| 6500.151(e)(9) | Individual #1's assessment from 5/21/24 does not identify the individual's functional and medical limits. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual 1's assessment was updated to include functional or medical limitations and was distributed to the team |
03/07/2025
| Implemented |
| 6500.124 | On the quarterly psychiatric/medication management appointment forms for Individual #1 from 2/6/24, 5/17/24, 8/19/24 and 11/25/24, it was notated on each appointment form that blood work was to be completed prior to the next psych appt for the Individual; this action was only completed on 8/2/24. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. | Blood work results were received and filed for visits 2/6/24 and 8/19/24. Doctor has verified that blood work was ordered, and then withdrawn for 5/17/24 and 11/25/24 appointments. |
03/11/2025
| Implemented |
| 6500.125(c)(2) | The family physical exams for staff #3 and family members #5 and #6 did not include an initial TB test as required. | 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. | Present options as noted in ODP Announcement 24-094, Interferon Gamma Release Assay blood test-QFT-Plus or T-spot for family to complete TB testing. TB testing is scheduled to be completed on 3/21 and 3/24/25. |
03/24/2025
| Implemented |
| 6500.125(c)(4) | The physical exam for family member #6 does not include the following: information of medical problems which might interfere with the health of the individuals. The medical conditions question on the physical ("Is there any medical condition that would interfere with the health of a client or another in the home?") is left blank. | The physical examination shall include: (4) Information of medical problems which might interfere with the health of the individuals. | Staff #6's physician was able to re-evaluate them and completed the form on 3/11/25 |
03/11/2025
| Implemented |
| 6500.34(a) | The individual Rights for Individual #1 were signed 3/27/23 and not again until 6/25/24, which is outside of the annual timeframe. | 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. | This time frame can not be corrected. The paperwork was completed as soon was realized that it was missed. |
03/11/2025
| Implemented |
| 6500.48(b)(1) | The last person-centered practices training staff #3 completed was on 10/11/23. There is no documented training in this area for the 2024 training year. | The annual training hours specified in subsection (a) must encompass the following areas: The application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships. | Person Centered Training was completed on 3/13/25 for 2025. |
03/13/2025
| Implemented |
| 6500.133(h) | Oxybutynin ER 10 mg was discontinued for Individual #1 on 1/29/25, however, at the time of the inspection on 2/10/25, the medication was still available in the home and had not been discarded. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medication was discarded on 2/10/25 |
03/11/2025
| Implemented |