| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual #5 requires assistance to complete financial transactions. The February 2025 ending balance on the cash spending report for Individual #5 was recorded as $118.25 by T.S. The starting balance on the March 2025 cash spending report for Individual #5 was recorded as $100.77 with a notation in red "starting bal differs from Feb ending balance." The ending balance on that March 2025 report was $150.78. An additional March 25 cash spending report notes the starting balance to be $150.00 and ending balance $112.78. A third March 25 cash spending report begins with a balance of $112.78 and ends with a balance of $72.78. A red pen notation at the bottom of this report indicates "$18.26 missing in March." No deposits were noted to illustrate that the missing funds were returned to Individual #5. Individual #5's funds shall be used for their benefit. | An individual's funds and property shall be used for the individual's benefit. | Incident/investigation occurred on 8/14/25. Incident entered into EIM system on 8/14/25. Results founded and HRC to reimburse the LS individual the $18.26. LSP was retrained on 8/18/25 on the ISP. All LSP providers will be trained in the financial process along with room and board on 9/23/25 and 9/24/25. Check mailed to LS individual on 8/29/25 for $18.26. |
08/29/2025
| Implemented |
| 6500.20(a)(6) | Provider notation on the April and March 2025 cash spending reports for Individual #5 note a discrepancy of $18.26 in the starting and ending balances. The $18.26 was noted to be missing at the bottom of the third March 2025 cash report. This report indicates "$18.26 missing in March." As of 8/14/25 there was no report entered into the Enterprise Incident Management system to report the missing funds. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Exploitation
. | Incident/investigation founded on 8/13/25. Incident entered into EIM system on 8/14/25. Results founded and HRC to reimburse the LS individual the $18.26. LSP was retrained on 8/18/25 on the ISP. All LSP providers will be trained in the financial process along with room and board on 9/23/25 and 9/24/25. |
09/30/2025
| Implemented |
| 6500.20(g) | There was no evidence to support that the missing funds noted in violation 6500.20(a)(6) were investigated as required. Provider notation on the February and March 2025 cash records for Individual #5 indicate that $18.26 was missing. An investigation of an incident, alleged incident or suspected incident shall be initiated within 24 hours of discovery by a staff person. | An investigation of an incident, alleged incident or suspected incident shall be initiated within 24 hours of discovery by a staff person. | Incident/investigation occurred on 8/14/25. Incident entered into EIM system on 8/14/25. Results founded and HRC to reimburse the LS individual the $18.26. LSP was retrained on 8/18/25 on the ISP. All LSP providers will be trained in the financial process along with room and board on 9/23/25 and 9/24/25. |
09/30/2025
| Implemented |
| 6500.156 | The Individual Support Plan (ISP) for Individual #5 last updated on 8/8/25 noted that they are to follow a "low carb" diet. At the time of inspection on 8/14/25 Staff #6 was asked if Individual #5 had any special dietary needs or restrictions. Staff #6 answered "not really," "that they just can't eat too much" and they are careful with acidic foods as it may contribute to reflux. Staff #6 did not provide accurate information to indicate clear knowledge of the diet and that the dietary needs of Individual #5 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 posted on the refrigerator in the individuals¿ home. |
09/30/2025
| Implemented |