| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(e)(1) | Individual #1's individual support plan, last updated 6/09/2025, states "[the individual] has a history if spending money as soon as [they] gets paid and does not follow a budget. [The individual] states [they] wants to work on budgeting skills. [Their] life sharing provider is their representative payee and pays their bills for them. [The individual] will work with staff on money and budgeting skills. On 10/16/2025 the agency did not have a separate record of financial resources including the dates and amounts of deposits and withdrawals for Individual #1's spending money. | 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. | Individual has an ISP scheduled 12/10/25. They and team will discuss ways for individual to implement budgeting skills and make an Outcome to support.
Individual will work work with LS Provider to achieve chosen goals.
A record of incoming and outgoing funds will be kept in the home for documentation and educational purposes. |
11/12/2025
| Implemented |
| 6500.24(e)(3) | Individual #1's individual support plan, last updated 6/09/2025, states "[the individual] has a history of spending money as soon as they get paid and does not follow a budget. [The individual] states they want to work on budgeting skills. Life Sharing provider is the representative payee and pays all the bills. [The individual] will work with staff on money and budgeting skills. On 10/16/2025 the agency did not have documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual. | 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. | On the in-home ledger for financial record keeping, all receipts for purchases in excess of $15.00 will be recorded and stored in the home. |
11/12/2025
| Implemented |
| 6500.67 | On 10/16/2025 at approximately 12:42 PM in the basement, there was a floor drain in the middle of the room, covered with a piece of wood approximately 3 feet in length and 1 foot in width, and surrounded by a tube of Chapstick, another piece of wood approximately 10 inches wide x 16 inches in length, a humidifier with a green tube extending from the equipment approximately 3 feet in length, a clear tube extending from the furnace approximately 2 feet in length, and water surrounding the drain appearing to be coming from the dehumidifier. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Wood pieces were immediately removed. Drain inspected to ensure proper functioning. Water mopped up and confirmed to be sourced as a normal part of the functioning of the furnace and the de-humidifier. Tubage was replaced in the least hazardous fashion possible. A sign will be posted to alert occupants of infrastructure of the appliances on the floors and the perimeter of the area will be painted bright yellow to increase visibility. |
11/30/2025
| Implemented |
| 6500.102 | On 10/16/2025 at approximately 12:45 PM there was a large cardboard box, containing single packs of baby wipes, abutted against the water heater. There were six clothing hangers, supporting various clothing items, hanging approximately 8 inches away from water heater | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. | All items will be moved away from the water heater. Storage shelving and clothes line will also be relocated. |
11/12/2025
| Implemented |
| 6500.110(c) | Family Member #2 has no record of being trained in fire safety. | 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). | Family member #2 received standard training and signed documentation to indicate task was completed. |
10/16/2025
| Implemented |
| 6500.121(c)(3) | Individual #1's physical examination completed 3/05/2025 did not include immunizations. This section of the form was blank. | Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Record of up to date immunizations attached to the current physical to show compliance. |
11/12/2025
| Implemented |
| 6500.121(c)(11) | Individual #1's physical examination completed 3/05/2025 did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. These sections of the form were blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Will obtain physician's recommendations and update physical accordingly. |
11/30/2025
| Implemented |
| 6500.121(c)(12) | Individual #1's physical examination completed 3/05/2025 did not include physical limitations of the individual. This section of the form was blank. | The physical examination shall include: Physical limitations of the individual. | Will obtain physician's recommendations and update physical accordingly. |
11/30/2025
| Implemented |
| 6500.121(c)(14) | Individual #1's physical examination completed 3/05/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the form was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Will obtain physician's recommendations and update physical accordingly. |
11/30/2025
| Implemented |
| 6500.121(c)(15) | Individual #1's physical examination completed 3/05/2025 did not include special instructions for the individual's diet. This section of the form was blank. | The physical examination shall include: Special instructions for the individual's diet. | Will obtain physician's recommendations and update physical accordingly. |
11/30/2025
| Implemented |
| 6500.151(e)(4) | Individual #1's assessment completed 10/10/2024 states the individual can be left alone in the home from 4 to 8 hours. Individual #1's individual support plan, last updated 6/06/2025, states the individual can spend up to 6 hours in the community or home. On 10/15/2025 Life Sharing Specialist #1 stated the individual is able to be alone in the home for up to 6 hours. | The assessment must include the following information: The individual's need for supervision. | Functional Assessment updated to show the individual can be left alone in the home for 6 hours. |
11/01/2025
| Implemented |
| 6500.151(e)(5) | Individual #1's assessment completed 10/10/2024 states the individual is not independent in self-medicating and can administer medication with staff supervision. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to take medications independently. On 10/15/2025 Life Sharing Specialist #1 stated the individual does self-administer all medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Assessment updated to reflect individudal's current ability. ISP will be updated accordingly. |
11/01/2025
| Implemented |
| 6500.151(e)(6) | Individual #1's assessment completed 10/10/2024 states the individual needs assistant's intervention with poisonous materials. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to use cleaning products independently. On 10/15/2025 Life Sharing Specialist #1 stated the individual is assessed to be able to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Assessment tool used by provider updated with less confusing wording to be more easily interpreted by the assessor in the future. |
12/31/2025
| Implemented |
| 6500.151(e)(7) | Individual #1's assessment completed 10/10/2024 states the individual needs assistant's intervention with heat sources. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to identify heat sources and use appliances. On 10/15/2025 Life Sharing Specialist #1 stated the individual has knowledge of the danger of heat sources and able to sense and move away quickly from heat sources which exceed 120° F. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Assessment tool used by provider updated with less confusing wording to be more easily interpreted by the assessor in the future. |
12/31/2025
| Implemented |
| 6500.183 | On 10/16/2025 copies of Individual #1's personal information, incident reports related to the individual, current physical examination, current dental examination, current assessment, individual plan documents required by this chapter, psychological evaluations were not kept in the family living home. | Copies of the most current record information required in § 6500.182(c)(1)-(14) (relating to individual records) shall be kept in the family living home. | All records required by 6500.183 will be kept in the home. |
11/30/2025
| Implemented |
| 6500.34(a) | Individual #1 was informed of individual rights 9/15/2025 and the following rights were not included: 6500.32(a) An individual may not be discriminated against because of race, color, creed, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age., 6500.32(b) An individual has the right to speak freely, 6500.32(c) An individual may not be exploited, abandoned, 6500.32(d) An individual shall be treated with dignity and respect, 6500.32(e) An individual has the right to make choices and accept risks, 6500.32(f) An individual has the right to refuse to participate in activities and services, 6500.32(g) An individual has the right to control the individual's own schedule and activities, 6500.32(h) An individual has the right to privacy of person and possessions, 6500.32(j) An individual has the right to voice concerns about the services the individual receives, 6500.32(p) An individual has the right to choose persons with whom to share a bedroom, 6500.32(q) An individual has the right to furnish and decorate the individual's bedroom in accordance with § 6500.33 (relating to negotiation of choices), 6500.32(r) An individual has the right to lock the individual's bedroom door, 6500.32 (r)(1) Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door, 6500.32(r)(2) Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, 6500.32(r)(3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance, 6500.32(r)(4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, 6500.32(r)(5) The primary caregiver shall have the key or entry device to lock and unlock the door, 6500.32(s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home 6500.32(t) An individual has the right to access food at any time, 6500.32(u) An individual has the right to make health care decisions, and 6500.32(v) 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. | 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. | Individual rights document used by provider agency updated to accurately reflect those rights defined by 6500.34(a) |
11/12/2025
| Implemented |
| 6500.133(h) | On 10/16/2025 at approximately 12:34 PM there were 4 single use packets of Aspirin, each containing 2 tablets, with an expiration date of May 2025, identified in the first aid kit. On 10/16/2025 at approximately 12:50 PM, there was 500 caplet bottle Acetaminophen 500mg, with an expiration date of October 2022, identified in the hallway closet. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Expired medications were disposed of in a safe manner. |
11/12/2025
| Implemented |
| 6500.135(g) | Individual #1 had a psychotropic medication review conducted 10/16/2024 and then again 2/19/2025. This exceeds the every 3-month requirement. The following psychotropic medication reviews conducted did not include the reason for prescribing the medication: 10/16/2024, 2/19/2025, 3/17/2025, 6/09/2025, and 9/08/2025. | 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. | Individual was enrolled in telehealth services to increase convenience, access and dependability of services.
Reason for prescribing medications will be included on med review paperwork. |
02/19/2025
| Implemented |
| 6500.152(c) | Individual #1's assessment completed 10/10/2024 states the individual can be left alone in the home from 4 to 8 hours. Individual #1's individual support plan, last updated 6/06/2025, states the individual can spend up to 6 hours in the community or home. Individual #1's assessment completed 10/10/2024 states the individual is not independent in self-medicating and can administer medication with staff supervision. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to take medications independently. Individual #1's assessment completed 10/10/2024 states the individual needs assistant's intervention with poisonous materials. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to use cleaning products independently. Individual #1's assessment completed 10/10/2024 states the individual needs assistant's intervention with heat sources. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to identify heat sources and use appliances. Individual #1's individual support plan, last updated 6/06/2025, states the individual has a behavior supports plan. On 10/15/2025 Life Sharing Specialist #1 stated the individual had a behavior support plan that was discontinued, but has not had one since day of admission. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Assessment tool used by provider updated with less confusing wording to be more easily interpreted by the assessor in the future.
Assessor will perform double checks to ensure both the assessment and ISP documents are in agreement in reflecting the individual's needs and abilities. |
12/31/2025
| Implemented |
| 6500.156 | Individual #1's assessment completed 10/10/2024 states the individual can be left alone in the home from 4 to 8 hours. Individual #1's individual support plan, last updated 6/06/2025, states the individual can spend up to 6 hours in the community or home. Individual #1's assessment completed 10/10/2024 states the individual is not independent in self-medicating and can administer medication with staff supervision. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to take medications independently. Individual #1's assessment completed 10/10/2024 states the individual needs assistant's intervention with poisonous materials. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to use cleaning products independently. Individual #1's assessment completed 10/10/2024 states the individual needs assistant's intervention with heat sources. Individual #1's individual support plan, last updated 6/06/2025, states the individual is able to identify heat sources and use appliances. Individual #1's individual support plan, last updated 6/06/2025, states the individual has a behavior supports plan. On 10/15/2025 Life Sharing Specialist #1 stated the individual had a behavior support plan that was discontinued, but has not had one since day of admission. | The home and the agency shall implement the individual plan, including revisions. | Assessment tool used by provider updated with less confusing wording to be more easily interpreted by the assessor in the future.
Assessor will perform double checks to ensure both the assessment and ISP documents are in agreement in reflecting the individual's needs and abilities.
PS investigated Behavioral supports status. SC reports she sent out a referral to an agency in January because the agency individual was originally using did not have the staff to provide the service.
PS met with SC, Individual and Lifesharing Provider on 12/10. Individual and Provider decided that individual had grown significantly in the area of concern and chose to discontinue the Behavioral Support Services. |
11/12/2025
| Implemented |