| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(c) | The home's self-assessment, completed on 3/17/24, identified regulation item 6500.45a as a violation. However, the agency did not provide a corresponding written summary of corrections. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept for at least 1 year. | There is no way to "immediately correct" the issue.
The Life Sharing Director is now more aware of how to complete the self assessment after discussion with the very knowledgeable inspector. |
07/31/2024
| Implemented |
| 6500.65 | At 10:16AM on 7/2/2024, there was not mechanical ventilation or window in the bathroom on the main level of the home. | Living areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. | The Life Sharing provider immediately contacted a contractor to put in a mechanical ventilation in the main level bathroom. |
08/31/2024
| Implemented |
| 6500.101 | At 10:43AM on 7/2/2024, the attached garage's only man door exit to the outside had a door lock assembly surrounded by two sliding latch locks, one installed above it, and one installed below it. In addition, the man door could not be opened from the inside of the garage even when all three locks were disengaged because there was another sliding latch lock installed on the outside obstructing egress from the garage. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | The Life Sharing Provider immediately removed the door lock assembly and sliding latch locks on the garage door to ensure compliance with the regulation. |
07/03/2024
| Implemented |
| 6500.121(a) | Individual #1, date of admission 3/17/2024 had an initial physical examination on 6/10/2024. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | There is no way to "immediately correct" this situation. Individual # 1 did have a physical prior to moving into Community Living & Learning however with her sister passing the physical could not be ascertained. |
07/15/2024
| Implemented |
| 6500.45(a) | Life Sharing Provider #1, date of hire 3/17/2024, completed training in first aid, cardiopulmonary resuscitation, and Heimlich techniques on 4/25/2024. Individual #1's date-of-admission was 3/17/2024. | The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter. | There is no way to "immediately correct" this situation.
The Life Sharing provider was working for another agency which let her cpr/first aid lapse.
She did complete cpr/first aid training with Community Living & Learning on 4/25/2024 and will complete it again prior to 4/25/2026. |
07/03/2024
| Implemented |
| 6500.132(a) | Life Sharing Provider #1 most recently completed the Department's modified medication administration course on 6/12/2020. Life Sharing Provider #1 administered Levothyroxine 50 mg Tab.; Levothyroxine 75 mg Tab.; Omeprazole DR 20 mg Cap.; and Simvastatin 20 mg Tab to Individual #1 at 8:00 AM from June 1 through June 30, 2024, and July 1 and 2, 2024. Life Sharing Provider #1 administered Ibandronate Sodium 150 mg Tab to Individual #1 at 4:00 PM on June 24, 2024. | 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. | The provider completed the department's modified medication training on July 22, 2024 and will be complete recertification as required. |
07/22/2024
| Implemented |
| 6500.152(c) | The initial assessment completed 5/16/24 for Individual #1, date of admission 3/17/2024, indicates Individual #1 requires verbal prompting to evacuate safely in the event of a fire. Individual #1's Individual Plan last updated 6/27/24, reads, "[Individual #1] is aware of the dangers of fire, can ambulate independently, and could evacuate in the case of an emergency." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Community Living & Learning worked with Individual # 1's supports coordinator to make sure the assessment and Individual's Plan are updated and accurate and that there is no conflicting information. |
07/11/2024
| Implemented |