| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(d)(1) | Individual #1 does not have an accurate record of possessions; a 07/15/24 form states "declined" but doesn't state what was declined or who declined it. | 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. | Possessions Inventory was reviewed with Individual #1 on 3/3/25. Individual #1 did not wish to complete this document but permitted PS to do so. (See attachment 5) |
03/07/2025
| Implemented |
| 6500.24(e)(1) | Individual #1's record contains an expense of $257.95 on 09/05/24 labeled as "flight receipt" but there is no receipt in the record; the information provided is not sufficient for licensing staff to determine what was purchased or who it was purchased from. The January 2024 financial log has a $150.00 deposit listed but does not list who the money came from or why. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals. | Receipts will be kept as of 2/17/25 for all purchases over $15. January's spending log was updated to include that the deposit was for monthly spending money from the repayee. |
03/07/2025
| Implemented |
| 6500.67 | At the time of the inspection on 2/10/25, there was a tennis ball sized amount of lint in the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Lint was removed from the dryer at the time of inspection. |
03/07/2025
| Implemented |
| 6500.121(c)(7) | Individual #1's 1/2/24 physical states "N/A" for gynecological examination. Their 01/07/25 Physical states that the gynecological examination is "no longer needed". There is a note in the record from 02/13/15 that Individual #1 does not need to have one done due to "not being cooperative". | 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's doctor was contacted and completed a deferment letter for them on 3/3/25 with a medical reason for no longer needing a gynecological exam. |
03/07/2025
| Implemented |
| 6500.121(c)(14) | The 1/7/25 Annual Physical states that Individual #1 has "none" for information pertinent to diagnosis in case of an emergency, which does not align with the information provided in the Annual Assessment and Individual Support Plan. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's doctor was able to complete a letter on 3/3/25 stating that they are unable to read, has dementia, and benefits from having a trusted supporter with them as information pertinent to diagnosis in case of emergency. |
03/07/2025
| Implemented |
| 6500.151(e)(1) | Individual #1's 08/15/24 Assessment does not include a review of Individual #1 "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. (Attachment 7) |
03/07/2025
| Implemented |
| 6500.151(e)(9) | Individual #1's 08/15/24 Assessment does not include functional or medical limitations. | 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 (Attachment 7) |
03/07/2025
| Implemented |