| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.31(a) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that they may not be deprived of rights. | An individual may not be deprived of rights as provided under § 6500.32 (relating to rights of the individual). | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/11/2025
| Implemented |
| 6500.31(b) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that they shall be provided the assistance necessary to understand their rights. | An individual shall be provided the assistance necessary for the individual to understand the individual's rights. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/11/2025
| Implemented |
| 6500.31(c) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that they may not be reprimanded, punished or retaliated against for exercising their rights. | An individual may not be reprimanded, punished or retaliated against for exercising the individual's rights. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(d) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that a court's written order that restricts their rights must be followed. | A court's written order that restricts an individual's rights shall be followed. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(e) | Individual #1's Individual Rights statement signed on 10/5/2024 does not that a court-appointed legal guardian may exercise rights and make decisions on behalf of an induvial. | A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order. | Provider Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(f) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that a court-appointment legal guardian shall be involved in decision making in accordance with the court order. | An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(g) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that they have the right to designate persons to assist in decision making in accordance with the court order. | An individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.32(v) | Individual #1's Individual Rights statement signed on 10/5/2024 does not include that they have the right to designate persons to assist in decision making and exercising rights on behalf of the individual. | An individual's rights may only be modified in accordance with § 6500.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.152(a) | Individual #1's current ISP dated 2/17/2025 states that all household cleaning products and toxic substances in the home are securely locked when not in use. At the time of the inspection (6/4/2025) cleaning products and toxic substances were found unlocked in the home. The Individual's current assessment states that poisons do NOT have to be locked in the home, and they are poison safe. The ISP has not been updated to reflect the correct information. | The life sharing specialists shall coordinate the development of the individual plan, including revisions, with the individual and the individual plan team. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.152(a) no later than 7/11/25.
3. All homes that were not already inspected by ODP will be checked for compliance with 6500.152(a) no later than 7/11/25.
4. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
5. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Program check for compliance with 6500.152(a) (Attachment 5) |
07/15/2025
| Implemented |