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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.105(b) | The wood stove at this residence was cleaned on 8/15/2024 and again on 9/1/2025. | Wood and coal burning stoves, including chimneys and flues, shall be cleaned at least every year if used more frequently than once per week during the winter season. Written documentation of the cleaning shall be kept. | Wood and coal burning stoves, including chimneys and flues, must be cleaned at least annually if used more frequently than once per week during the winter season. The annual professional cleaning is crucial for preventing dangerous chimney fires caused by creosote buildup, ensuring heating efficiency and proper airflow, and identifying hazards like blockages or structural damage, thereby protecting residents from fire and carbon monoxide risks. Written documentation of the cleaning is required.
At this residence, the wood stove was cleaned on September 1, 2025. This cleaning occurred after a 15-day grace period had passed from the previous year's cleaning on August 15, 2024. The stove was cleaned before being used for the season. Documentation of all cleanings, including more frequent cleaning, should be maintained on the fire drill log in accordance with the manufacturer's instructions |
01/15/2026
| Implemented |
| 6500.121(b) | Individual #1's physical examination, completed 9/11/2025, was not dated by the physician. The agency's physical examination form did not include a space for the physician to record the date with their signature. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | A physical examination must be completed, signed, and dated by an authorized medical professional (a licensed physician, certified nurse practitioner, or licensed physician's assistant). This regulation is essential for administrative accountability, authenticating the exam's accuracy, establishing a legal health record baseline, ensuring continuity of care, confirming the documented health status is current and validated.
The physical examination form was date on the front page, not immediately accompanying the healthcare provider's signature. To address this, the form was revised on January 9, 2026, to include a dedicated date line adjacent to the signature of the licensed physician, certified nurse practitioner, or licensed physician's assistant. This ensures the date is clearly linked to the professional's attestation. |
01/15/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.109(d) | The home conducted a fire drill on 10/12/22; however, the fire drill record did not indicate the exit used during the fire drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the smoke detector was operative. | February 21, 2023, the Life Sharing Program Manager completed retraining with the Life Sharing Provide, on the following, fire safety procedures and documentation of regulatory requirements § 6500.109.
The record was reviewed by the Life Sharing Program Manager and Provider for areas of improvement. |
02/21/2023
| Implemented |
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