| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.71 | At the time of the inspection, the phone in Individual #1's bedroom did not have emergency numbers on or near it. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home. | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control centers were placed near Individual #1's phone (Attachment 8). |
09/17/2024
| Implemented |
| 6500.121(c)(1) | Individual #1's physical completed on 11/9/23 does not have an attached medical history. The physical documented "See Attached." There was no LMH attached. | The physical examination shall include: (1.) A review of previous medical history. | On 09/17/2024 Life Sharing Specialist called the doctor's office from the 11/09/2023 visit requesting the attached documentation and information pertinent in an emergency be completed. They followed up via fax requesting the documentation be sent asap (Attachment 12). The provider will follow up weekly until it is obtained. |
09/19/2024
| Implemented |
| 6500.121(c)(4) | Individual #1's date of admission was 5/31/24. They have not had a hearing screening to date. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1's hearing screening will be conducted at their annual physical appointment, which has been scheduled for 09/23/2024 (Attachment 14). |
09/20/2024
| Implemented |
| 6500.121(c)(11) | Every document in the record for Individual #1 that documents the individual's medications documents something different. | 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. | Individual #1's most recent med management appointment was on 08/29/2024 (Attachment 15). Their medications as of that date have been updated on the fact sheet on 09-18-2024 (Attachment 16) and track changes have been sent to the SC (Attachment 17). |
09/18/2024
| Implemented |
| 6500.121(c)(14) | Individual #1's most recent physical completed on 11/9/23 does not document the information pertinent to treat/diagnose in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 09/17/2024, the Life sharing Specialist called the doctor's office from the 11/09/2023 visit requesting the attached documentation and information pertinent in an emergency. They followed up via fax requesting the documentation be sent asap (Attachment 12). The provider will follow up weekly until it is obtained. |
09/20/2024
| Implemented |
| 6500.122(a) | Individual #1's date of admission was 5/31/24. No dental exam has occurred to date. | An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A dental exam is scheduled for individual 1 for 10/02/2024 at 2:30pm (Attachment 18). |
10/02/2024
| Implemented |
| 6500.151(e)(7) | Individual #1's most recent assessment completed on 7/30/24 does not document whether the individual is able to identify heat sources and move away quickly. | 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. | The assessment has been updated to include individual #1's knowledge of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated (Attachment 19). |
09/17/2024
| Implemented |
| 6500.34(a) | Individual #1's rights signed upon admission are missing the following rights: 31a-31g, 32a, and 32r1-32r5. | 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. | The updated individual rights (Attachment #1) will be reviewed with all Residential (Lifesharing and Group Home) VIPs at their October 2024 monthly meetings. |
10/31/2024
| Implemented |
| 6500.135(g) | The psych med review completed on 7/2/24 does not list all psych medications or their diagnosis. | 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. | The psychotropic medication review form from the appointment on 07/02/2024 indicates "current list attached" under "current psychotropic medication and prescribed dosage" but is missing diagnosis on some medications. On 09/19/2024 Life sharing Specialist called the Primary Health Network office from the 07/02/2024 visit requesting the "Current Medication List" documentation be completed to show diagnosis for all medications listed and followed up via fax requesting the documentation be corrected and sent asap, and it was received back on 09/19/2024 (Attachment 24). The office was only able to list diagnoses for the medications they prescribed, so Lifesharing Specialist also faxed this updated copy to the old PCP to request additional information. No fax has been returned from that office yet. The provider will follow up weekly until it is obtained or will receive an updated med list at individual 1's upcoming PCP appointment on 09/23/2024 at 3:30pm. |
09/20/2024
| Implemented |