| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.73 | The exterior handrail in the middle of the steps leading to the front porch of the home is not well secured and wobbles when in use. | 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 exterior handrail is scheduled to be repaired by a contractor.
The receipt of the repair will be turned in as proof the handrail has been fixed
The Life Sharing Program Director Ryan Stumph and Life Sharing Specialist Renee Kutchman visit the Life Sharing homes quarterly.
These visits will include an inspection of the inside and outside of the homes to make sure there are no regulatory compliance issues.
The Life Sharing Program Director Ryan Stumph and Life Sharing Specialist Renee Kutchamn will complete a home checklist during each visit to a Life Sharing location. |
09/02/2022
| Implemented |
| 6500.121(c)(8) | Individual #1, date of birth 3/17/1965, had an annual mammogram on 4/22/2021 and then again on 5/25/2022. | 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 mammogram was completed but was late.
The life Sharing Program Director Ryan Stumph and Life Sharing Specialist Renee Kutchman are completing a master check list of medical appointments for all individuals.
The check list will be shared with all Life Sharing families and individuals.
the Executive Director will also be keeping track of the checklist to ensure compliance with dates and regulations. |
09/02/2022
| Implemented |
| 6500.121(c)(14) | Individual #1's physical examination, completed 3/23/2022 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1 physical examination was taken back to the doctor who checked the box indicating there is no medication information pertinent to diagnosis and treatment in case of an emergency.
Community Living & Learning has extensively created and updated a physical examination form that is user friendly and simple for physicians to complete. In this case the physician forgot to check a box indicating there was no medical information pertinent to diagnosis and treatment in case of an emergency.
The Life Sharing Program Director Ryan Stumph and LIfe Sharing Specialist Renee Kutchman will thoroughly review each physical form that is completed by the physician. Any issues on the physical form will be addressed immediately with the physician or physician office. |
09/02/2022
| Implemented |
| 6500.17(a) | The completed self-assessment was not dated so compliance was unable to be measured. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | The date the self-assessment was completed has now been put in the correct location.
The Life Sharing Program Director Ryan Stumph has marked on his yearly calendars the timeframe for completing future self-assessments within the regulatory requirement.
The Life Sharing Program Director Ryan Stumph will complete a self-assessment for each licensed facility. Ryan will then present the completed self-assessment to the Executive Director Nathaniel Haggerty for review and accuracy.
A checklist form has been developed to use when reviewing self-assessments for accuracy. The Program Director and Executive Director will use and complete the form when reviewing and completing the self-assessments. |
09/02/2022
| Implemented |