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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.133(a) | At time of inspection Individual #4 had a PRN Albuterol inhaler. When asked for the medication two inhalers in pharmacy labeled boxes were produced and one was presented out of the box. Staff#2 was asked for the missing pharmacy labeled box several times with them stating that they did not have the box, that Individual #4 takes the inhaler to and from program on their person and not in the original labeled container. A pharmacy box was later produced and reported to belong to the inhaler in question. The inhaler was not maintained in its original labeled container. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Agency Nurse will conduct monthly house visits and audit of medications to ensure all medications are labeled. HRC to allow the option to the individuals that are not self-medicating and if in agreement Tarrytown to provide medications to those individuals. |
11/01/2025
| Implemented |
| 6500.135(c) | Individual #4 is prescribed Haloperidol 5mg tablet to be administered "Take 1 tablet by mouth every day." The bottle presented as in use at the time of inspection was pharmacy labeled as filled on 8/8/25. The pharmacy label noted the quantity in the bottle to be 14. The count in the bottle at time of inspection was 16.
Individual #4 is prescribed Fluticasone Prop 50 mcg nasal spray to be administered "Spray 2 sprays into each nostril every day. At the time of inspection one of the bottles of the nasal spray in the home was dated as filled on 1/18/25 and noting the quantity to be 16 or one bottle. Had the medication been administered as prescribed the medication would have been finished prior to the end of 2/25.
Individual #4 is prescribed Budesonide and Formoterol Dihydrate Inhalation Aerosol for Asthma and to be administered 2 puffs by mouth twice a day. One inhaler at the home was unused and had a pharmacy filled date of 11/18/24 and was one of three. Had the medication been administered as prescribed, all three inhalers dispensed on 11/18/24 would have been used by the end of 2/25. An additional box of the medication presented at the time of inspection on 8/14/25 was dated as filled on 5/10/25 and was one of three dispensed. Administered properly the three boxes of medication would be used by the end of 8/25. One of the three was presented as in use at the time of inspection and was unused with 120 inhalations of the 120 in the container showing on the dial as remaining. The medication was not administered as prescribed.
Individual #4 is prescribed Latanoprost Ophthalmic Solution eye drops dispensed in a three-month supply and to be administered "Instill 1 drop into both eyes at bedtime." At the time of inspection the bottle presented as in use had a pharmacy fill date of 4/5/25. The bottle was factory sealed. When asked if there were any other bottles Staff #5 noted that there was and that it was upstairs as Individual #4 uses it before bedtime. There was a limited amount of solution remaining of that bottle presented. Had the medication been administered as prescribed all three bottles would have been used by mid July 25. At the time of inspection on 8/14/25 one unopened bottle remained.
Additional issues are suspected with the prescribed Lurasidone and Topiramate due to fill dates, number of bottles in the home and lack of pharmacy records discrepancies but could not be determined. | A prescription medication shall be administered as prescribed. | Agency Nurse will conduct monthly house visits and audit of medications to ensure all medications are being administered as prescribed. HRC to allow the option to the individuals that are not self-medicating and if in agreement Tarrytown to provide medications to those individuals. |
11/01/2025
| Implemented |
| 6500.156 | The Individual Support Plan (ISP) for Individual #4 last updated on 7/18/25 noted that they are to follow a "high fiber, low carb, renal diet." The physical dated 12/2/24 for Individual #4 documented his diet as "High Fiber/Low Carb/No Caffeine Diet." At the time of inspection on 8/14/25 Staff #4 was asked if Individual #4 had any special dietary needs or restrictions. Staff #5 answered "no special diet," and "no sweets." Staff #5 did not provide accurate information to indicate clear knowledge of the prescribed diet and that the dietary needs of Individual #4 included in the ISP were being followed. | The home and the agency shall implement the individual plan, including revisions. | Each LSP will be trained on the individual¿s specific diet. Training form on diet to be created and reviewed by LSP and Specialist by 9/30/2025. A form was created to allow the individuals to have the diet posed on the refrigerator in the individuals¿ home. Each LSP will be trained on the specific diet of the individual. Training form on diet to be created and reviewed by LSP and Specialist by 9/30/2025. A form was created to allow the individuals to have the diet posed on the refrigerator in the individuals¿ home. |
09/30/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | During a review of Individual#1's financial records it was noted that Individual#1 had been charged additional amounts for the laundering of personal belongings. It was reported that these items (bedding) were too large to fit into the washer/dryer in the Life Sharing home. However, the cost of laundering towels, bedding and the individual's clothing is included in room and board costs. Amounts were recorded as 9/18/19 Wash Wearhouse $16.25, 10/18/19 Laundry $10.00, 11/1/19 Laundry $10.00, 2/1/19 Laundry $10.00, 2/21/20 Laundry $10.00, 3/1/20 Laundry $10.00, 4/1/20 Laundry $10.00. Total of additional fees charged for laundry services was $76.25. | An individual's funds and property shall be used for the individual's benefit. | Following the exit conference held on November 2, 2020, the Lifesharer was notified of the need for reimbursement of funds to the individual who paid for her blankets laundered at a laundry mat. This will occur now that the official violations have been received as part of the plan of correction and the amount of $76.25 has been confirmed. |
11/24/2020
| Implemented |
| 6500.136(b) | A remote inspection was conducted on 11/02/20 at 10:30am. November medication administration records were reviewed. It was noted that all medications, Atorvastatin 10mg, Topiramate 100mg, RA Central Vite, Furosemide 4omg, Potassium 20meg, Lipo Flavonoid, Omeprazole 20mg, Budesonide, Montelukast 10mg, had been initialed as being administered up to and including the morning doses of 11/03/2020. Afternoon and evening doses on 11/02/20 and morning doses on 11/03/20 were initialed as having been administered although those administration times were in the future. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Lifesharer was immediately notified of the medication documentation error, corrected the charting error, and reminded the medications shall be recorded in the medication record at the time the medication is administered. The Lifesharer did complete the required Medication training on 1/29/2020. |
11/03/2020
| Implemented |
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