| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(e)(1) | In Individual #1's assessment dated 1/29/25, it is documented that the individual is not financially independent, and there is not a current and up-to-date financial record for the individual. | 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. | A COH ledger was created for individual 1. The Lifesharing Provider was trained on the COH ledger on 08/28/2025 (Attachment 18), and it will be implemented moving forward. The Lifesharing Provider was also educated on individual 1's ability to carry and spend money independently. Individual 1 can carry up to $20 but needs help with purchases over $2. |
09/30/2025
| Implemented |
| 6500.24(e)(3) | In Individual #1's assessment dated 1/29/25, it is documented that receipts should be kept for the individual's personal record and there are no receipts being kept for the individual's 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. | A COH ledger was created for individual 1. The Lifesharing Provider was trained on the COH ledger on 08/28/2025 (Attachment 18), and it will be implemented moving forward. The Lifesharing Provider was also educated on individual 1's ability to carry and spend money independently. Individual 1 can carry up to $20 but needs help with purchases over $2. |
09/30/2025
| Implemented |
| 6500.151(e)(13)(vii) | On Individual #1's assessment dated 1/29/25, it states that the individual is not able to manage their finances independently, that the individual needs assistance with when making purchases over $2.00 and that receipts should be kept for their personal record. Currently, the individual is not receiving assistance with transactions nor are receipts being kept for the individual's transactions. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. | A COH ledger was created for individual 1. The Lifesharing Provider was trained on the COH ledger on 08/28/2025 (Attachment 18), and it will be implemented moving forward. The Lifesharing Provider was also educated on individual 1's ability to carry and spend money independently. Individual 1 can carry up to $20 but needs help with purchases over $2. |
09/30/2025
| Implemented |
| 6500.124 | Individual #1 is prescribed Fluticasone Propionate nasal spray to be taken as needed. The medication was given a majority of the time since their admission and the reason for giving the medication, and the effectiveness of the medication was not documented on the medication records. | 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. | All MARs have been corrected to add a note regarding reason PRN was given and the effectiveness (Attachment 20). |
09/30/2025
| Implemented |
| 6500.32(c) | -The medication record for Individual #1 for November 2024 does not document if medications were administered for November 1 -November 7, 2024, therefore, it appears that the individual was not administered their medications for this duration.
- For Individual #1, on 12/20/24, the physician had written that the individual was to start taking Vitamin D 1000 units and there is no documentation that the individual had started taking this medication per the physician's orders.
- On 2/3/25, Individual #1 was prescribed Zofran ODT 4 mg as needed for 10 days and Famotidine 20 mg for 10 days and there is no documentation that these medications were given to the individual.
- Staff person #1 did not complete a medication administration course for administering medications and this staff person has been administering medications to Individual #1 without being trained on how to properly administer medications. In addition, Staff person #1 did not complete a medication administration course for "other routes of administration" and Individual #1 is prescribed a daily injection of Forteo/Teriparatide. This medication has been administered by the staff person without having been trained on how to properly administer this medication. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Individual 1's MAR was updated on 11/08/2025 to make needed corrections. The old November MAR documenting 11/1-11/7 was taken from the provider and the new one for 11/08/2024 was provided. The November 1-7 MAR was missing from the record at the time of the inspection but has been returned to the record (Attachment 21). |
09/30/2025
| Implemented |
| 6500.132(a) | Staff person #1 did not complete a medication administration course for administering medications and this staff person has been administering medications to Individual #1 without being trained on how to properly administer medications.
In addition, Staff person #1 did not complete a medication administration course for "other routes of administration" and Individual #1 is prescribed a daily injection of Forteo/Teriparatide. This medication has been administered by the staff person without having been trained on how to properly administer this medication. | Staff persons or others who are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Staff person 1 completed the Modified Med Admin Course (Attachment 22) and had subsequent injection training on 08/28/2025 with an RN (Attachment 23). |
09/30/2025
| Implemented |
| 6500.135(g) | (repeat from 9/3/24 inspection)
-For Individual #1, the 11/6/24 Psychotropic Medication Review Form did not include the reason for prescribing the medication for the Benztropine 50 mg or the Diphenhydramine 0.5mg or the need to continue the medications.
-For Individual #1, the 1/29/25 Psychotropic Medication Review Form did not include the reason for prescribing the medications or the need to continue the medications.
-For Individual #1, there was a psychiatric medication review completed on 1/29/25 and then not again until 7/16/25, which was outside of the in 3-month time frame that an individual needs to have a review completed. | 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 psych med review forms for 11/06/24 and 01/29/25 were faxed to the doctor's office on 08/29/25, requesting the doctor indicate the reason for prescribing the medications and the need to continue all of the medications on the appointment forms (Attachment 26). Individual 1 had a psychotropic med review appointment on 04/09/2025 but only the bloodwork form was present during the inspection. This was discovered by CARES of 08/15/2025 and the doctor's office was faxed requesting a CARES Psychotropic Medication form be filled out by the physician. A fax back with the print-out from the appointment was obtained on 08/18/2025 (Attachment 24). |
09/30/2025
| Implemented |
| 6500.136(a)(5) | Individual #1 is prescribed Forteo/Teriparatide 560mcg/2.24 ml injection for osteoporosis; however, on the MAR, it is documented that the injection strength is 600mcg/2.4 ml, which is incorrect. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The MAR was updated to include the correct Forteo/Teriparatide injection strength of 560mcg/2.24 ml. (Attachment 27) |
09/30/2025
| Implemented |
| 6500.136(a)(12) | The medication record for Individual #1 for November 2024 does not document if medications were administered for November 1 -November 7, 2024, therefore, it appears that the individual was not administered their medications for this duration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Individual 1's MAR was updated on 11/08/2025 to make needed corrections. The old November MAR documenting 11/1-11/7 was taken from the provider and the new one for 11/08/2024 was provided. The November 1-7 MAR was missing from the record at the time of the inspection but has been returned to the record (Attachment 21). |
09/30/2025
| Implemented |
| 6500.136(b) | The medication record for Individual #1 for November 2024 does not document if medications were administered for November 1 - November 7, 2024, therefore, it appears that the individual was not administered their medications for this duration. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Individual 1's MAR was updated on 11/08/2025 to make needed corrections. The old November MAR documenting 11/1-11/7 was taken from the provider and the new one for 11/08/2024 was provided. The November 1-7 MAR was missing from the record at the time of the inspection but has been returned to the record (Attachment 21). |
09/30/2025
| Implemented |
| 6500.137(a)(1) | -The medication record for Individual #1 for November 2024 does not document if medications were administered for November 1 - November 7, 2024, therefore, it appears that the individual was not administered their medications for this duration.
- For Individual #1, on 12/20/24, the physician had written that the individual was to start taking Vitamin D 1000 units and there is no documentation that the individual had started taking this medication per the physician's orders.
- On 2/3/25, Individual #1 was prescribed Zofran ODT 4 mg as needed for 10 days and Famotidine 20 mg for 10 days and there is no documentation that these medications were given to the individual. | Medication errors include the following: Failure to administer a medication. | Medication errors include the following: Failure to administer a medication. |
09/30/2025
| Implemented |
| 6500.151(a) | The new admission assessment for Individual #1 was completed 10/10/24, which was not completed within 60-calendar days of the individual's date of admission of 7/22/24. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home. | DPOC-9/5/25-JC
The admission date for Individual #1 has been corrected in the official records to reflect the accurate date of 9/1/2024. All related documentation, including assessments and care plans, has been updated to align with the corrected admission date.
All staff involved in data entry and admissions will undergo re-training on:
Accurate documentation of admission dates.
Verification procedures prior to data entry.
Importance of data accuracy in regulatory compliance.
Training will be documented and maintained in employee files.
A standardized Admission Documentation Audit Checklist will be implemented.
This checklist will include verification of admission date, signed documentation, and data entry accuracy.
All new admissions will be reviewed by a designated supervisor or QA team member within 5 business days of entry. |
10/05/2025
| Implemented |