| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(d)(1) | Individual #1's SNAP (Supplemental Nutrition Assistance Program) Benefit Log is not current and up-to-date. From October 2023 through February 2024, the balance on the SNAP Log matched the balance on the attached receipts. Beginning in March 2024, the balance on the SNAP Log was higher than the balance on the receipts. The discrepancy was over $100. | 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. | Management reviewed logs and receipts and were unable to locate receipts to match the discrepancy. CEO had made the decision to reimburse all funds that are unaccounted for during the review. |
09/06/2024
| Implemented |
| 6500.24(e)(3) | Individual #1 has a missing receipt from 10/24/23 for $59.25 and from 10/29/23 for $155.09 for their SNAP transactions. | 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. | Management reviewed logs and receipts and were unable to locate receipts to match the discrepancy. CEO had made the decision to reimburse all funds that are unaccounted for during the review. |
09/06/2024
| Implemented |
| 6500.73 | At the time of the inspection there were no handrails on the steps leading to the basement. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | The life sharing provider is making plans for this handrail to be installed. It will be completed as soon as they can find someone to complete the task |
10/30/2024
| Implemented |
| 6500.74 | At the time of the inspection there were no non-skid strips on the steps leading to the basement. | Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface. | Non skid strips were installed on the basement stairs. Life sharing provider was reminded that all stairs will have non skid strips at all times |
09/06/2024
| Implemented |
| 6500.124 | From October 2023 to 8/5/24, Individual #1 had a bowel protocol that if Individual #1 went three days with no BM (Bowel Movement), they were to receive a dose of Miralax on the morning of Day 4. They were to continue taking a dose of Miralax in the morning and afternoon until the bowel movement occurred. Individual #1 did not have a BM from December 29, 2023, through January 2, 2024. They were only given one dose of Miralax at 9pm on 1/1/24.Individual did not have a BM from February 3-5. They did not receive a dose of Miralax until 8pm on 2/6/24. Individual #1 did not have a BM from March 7-9. They did not receive a dose of Miralax until 7:30pm on March 10. | 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. | Life sharing provider will be retrained on this protocol by BOLD nursing staff. The nurse will review the importance of bowel health with life sharing provider. |
09/27/2024
| Implemented |
| 6500.125(c)(2) | Staff #3's 12/22/22 Physical Exam does not indicate if the Tuberculosis PPD Skin Test was Positive or Negative when the test was read. | 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. | The TB test form was returned to the doctor where it was confirmed that the results were negative and the form was corrected |
09/06/2024
| Implemented |
| 6500.135(b) | Individual #1's "Refresh" eye drops changed from 1 drop in each eye four times a day to 1 drop in each eye 2-4 times a day. No order was provided. | A prescription order shall be kept current. | Life sharing provider confirmed with eye doctor that the eye drops are now to be given daily. |
10/01/2024
| Implemented |
| 6500.135(c) | In October, November, and December 2023 Individual #1 was prescribed "Refresh" eye drops. One drop was to be administered in each eye four times a day. In October and December, the eye drops were only administered twice a day. In November, the eye drops were only administered one time a day. | A prescription medication shall be administered as prescribed. | Life sharing provider was reminded that orders must be followed as written at all times. This order has been corrected and the doctor now recommends refresh drops once daily |
10/01/2024
| Implemented |
| 6500.136(a)(7) | Individual #1 is prescribed Bactrim Tabs, Vitamin C Gummies, Dayquil, and Nyquil. No dose was documented for these medications on the Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Life sharing provider confirmed the dosage of each medication and it is now listed on the MAR. |
10/01/2024
| Implemented |