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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(7) | Individual #1's date-of-birth is 12/16/76. Individual #1's content of records did not include documentation of gynecological examinations completed in 2025 and 2026. Individual #1's physical examinations, completed on 2/24/25 and 2/25/26, respectively, included a physician's exemption that read, "Not recommended for an annual PAP. [Individual #1] has never been sexually active and this procedure is stressful for [them]." However, this recommendation did not include an exemption from the required breast examination component of the annual gynecological evaluation. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | On 6/18/2026 UCIP received a letter stating "it is not recommended for Individual #1 to have an annual Pap Smear or breast exam. She has never been sexually active, and the procedures are stressful for her. Please consider this for the well-being of my patient. For any further questions please call our office at 814-275-2264. |
06/18/2026
| Implemented |
| 6500.151(e)(12) | Individual #1's current assessment, completed on 6/13/25, did not include recommendations to foster skill growth with specific areas of training, programming, and services for implementation. The assessment's corresponding field only contained information regarding the requirements of 6500.151e13, reflecting Individual #1's current skill levels in the domains of health, motor and communication skills, activities of residential living, personal adjustment, socialization, recreation, financial independence, and community integration. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | "Individual #1's Assessment has been updated on 6/5/2026. This change now includes a training component in regards to the individuals current skill levels. Individual #1 WILL RECEIVE TRAINING WHEN MAKING A TRANSACTION, TO FIRST TRY TO USE A COMBINATION OF BILLS AND COINS TO PAY FOR ITEMS. STAFF WILL HELP WITH ASSISTANCE FOR Indvidual #1 TO DEVELOP INDEPENDENCE.
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06/05/2026
| Implemented |
| 6500.152(c) | Individual #1's Service Plan, last updated 5/1/26, contained the following discrepancies between their current assessment, completed on 6/13/25, in the following health and safety skill domains: regarding fire evacuation, Individual #1's Service Plan, last updated 5/1/26, explained, "[Individual #1] demonstrates independent and appropriate fire safety skills, including responding to fire alarms and vacating a structure within required time frames." In contrast, Individual #1's assessment, completed on 6/13/25, informed that Individual #1 can evacuate safely with verbal prompting; regarding community supervision, Individual #1's Service Plan, last updated 5/1/26, stated, "[Individual #1] could walk to the Post Office by [themselves], [and] can be left in the car alone for a brief period of time." However, Individual #1's assessment, completed on 6/13/25, indicated that Individual #1 must be within hearing distance when using public restrooms and must be within line-of-sight when in a vehicle and when in all other environments within the community (i.e. restaurants, spectator events, fairs, large crowds, sporting events, dances/ parties, etc.); and regarding oral hygiene, Individual #1's Service Plan, last updated 5/1/26, explained that it is recommended for Individual #1 to use a timer to brush for one-two minutes, twice daily due to poor, overall oral hygiene and that Individual #1 requires assistance as needed. In contrast, Individual #1's assessment, completed on 6/13/25, informed that Individual #1 can independently brush their teeth. [Repeated Violation-5/20/25, et al.] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1's Assessment has been updated on 6/5/2026 this update now mirrors the ISP in Individual #1's Service Plan stating "Individual 1 demonstrates independent and appropriate fire safety skilly including responding to fire alarms and vacating a structure within required time frames. Individual #1's service plan last updated 5/1/2026 stated that the individual could walk to the post office when she lived with her mother. UCIP Program Specialist has sent an email requesting that this be removed since the individual no longer lives with her mother and now lives with the lifesharing provider. Individuals Assessment has been updated to mirror with what individual #1's service states excluding that the individual can walk to the post office when the individual lived with her mother. Individual #1's assessment now states "Individual #1 SHOULD NOT BE LEFT ALONE AND SHOULD BE MINIMALLY MONITORED WITHIN HEARING RANGE IN HER LIFE SHARING HOME. SHE REQUIRES GENERAL MONITORING AND SUPERVISION WHILE IN THE HOME. Individual #1 CAN INDEPENDENTLY BATHE, TOILET, DRESS, AND FEED HERSELF.SHE SHOULD BE WITHIN LINE OF SIGHT IN THE COMMUNITY. HER TEAM AGREES IF SHOPPING IN THE COMMUNITY WITH LIFE SHARING CAREGIVERS AND SHE DOES NOT WANT TO GO INSIDE THE STORE, SHE CAN BE LEFT ALONE IN THE CAR FOR THE BRIEF PERIOD OF TIME." Individual #1's assessment has been updated on 6/5/2026 to mirror the ISP to state"Individual #1 IS RECOMMENDED TO USE A TIMER TO BRUSH FOR 2 MINUTES 2 TIMES PER DAY DUE TO POOR OVERALL ORAL HYGIENE NOTED IN MARCH OF 2026. SUPPORTS SHOULD PROVIDE ASSISTANCE AS NECESSARY. Individual #1 ATTENDS DENTAL APPOINTMENTS EVERY 6 MONTHS FOR AN EXAM AND CLEANING." In addition the annual meeting is scheduled on 7/7/2026 at which time the Program Specialist will review the assessment and ISP with the individuals Supports Coordinator to ensure that all areas match. |
06/05/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.64(a) | At 11:32 AM on 5/21/25, the bathmat in the tub of the home's only bathroom was covered in several black areas of what appeared to be mold and/or mildew. The surrounding bathing area had a pungent, musty odor. The bathroom's mechanical exhaust fan vent was covered with thick areas of dust and debris. | Clean conditions shall be maintained in all areas of the home. | The bathmat in the home has been replaced with a brand new bathmat that is clean with no mold and/or mildew. There is no longer a pungent, musty odor. The bathroom's exhaust mechanical fan vent was cleaned and no longer has areas of dust and debris. A picture of both will be sent for review. |
06/09/2025
| Implemented |
| 6500.66 | At 11:50 AM on 5/21/25, the basement's only exterior exit did not have an outside lighting fixture or sufficient lighting source located nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents. | As of 6/9/2025 an exterior light has been added to the basement's exterior. This lighting provides sufficient visibility to assure safety and to avoid accidents. UCIP will send a picture to prove that the lighting sources has been added. |
06/09/2025
| Implemented |
| 6500.32(e) | Individual #1 signed a bedroom door lock declination form on 5/6/25. However, at 11:41 AM on 5/21/25, Individual #1's bedroom door was equipped with a lock requiring a key to unlock it from the outside. In addition, during an interview, Life Sharing Provider #1 revealed that neither they, nor Individual #1 has a key to unlock Individual #1's bedroom door if the door lock was engaged. | An individual has the right to make choices and accept risks. | The individuals door handle has been replaced with a door handle that has no mechanical locking mechanism per the individuals signed bedroom door lock declination form from 5/6/2025. UCIP will send a picture of proof that the door handle has been replaced. |
06/09/2025
| Implemented |
| 6500.32(r)(4) | At 11:41 AM on 5/21/25, Individual #1's bedroom door was equipped with lock requiring a key to unlock it from the outside. During an interview, Life Sharing Provider #1 revealed that neither they, nor Individual #1 has a key to unlock Individual #1's bedroom door if the door lock was engaged. Therefore, this bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | An individual has the right to lock the individual's bedroom door. The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Individual #1's bedroom door has been replaced with a door handle with no locking mechanism. This is to align with the individual's choice to have no locking mechanism on their bedroom door. The bedroom door handle now allows for easy and immediate access by the individual and staff persons in the event of an emergency. UCIP will send a picture of proof that the door handle has been updated to have no locking mechanism on the individual's bedroom door. |
06/09/2025
| Implemented |
| 6500.133(h) | On 5/21/25, the following of Individual #1's prescribed pro re nata medications were expired: Albuterol Sul 2.5 MG/ 3 ML with an expiration date of 11/2024; Acetaminophen (Tylenol) 500 MG with an expiration date of 7/2022; and Ibuprofen 200 MG with an expiration date of 3/2023. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Individual #1's Acetaminophen (Tylenol) 500 MG with an expiration date of 7/2022 has been disposed of and replaced with Acetaminophen (Tylenol) 500 MG that is not expired. ; and Individual #1's Ibuprofen 200 MG with an expiration date of 3/2023 has been disposed of and replaced with Ibuprofen 200 MG that is not expired. Individuals Albuterol Sul 2.5 MG/ 3 ML with an expiration date of 11/2024 has been disposed of by the Pharmacy. Individuals Albuterol Sul 2.5 MG/ 3 ML has been discontinued by the PCP at this time. A letter with the discontinuation for the Albuterol will be sent. |
06/09/2025
| Implemented |
| 6500.136(a)(14) | On 5/21/25, Individual #1's May 2025 Medication Administration Record was missing the duration of treatment for the prescribed pro re nata, Albuterol Sul 2.5 MG/ 3 ML---Use 1 vial x (3 ML) via nebulizer every 6 hours as needed for cough or shortness of breath. However, the medication label for this medication read: "Albuterol Sul 2.5 MG/ 3 ML---Use 1 vial x (3 ML) via nebulizer every 6 hours as needed for cough or shortness of breath for 10 days." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | UCIP Program Specialist for Individual #1 reached out to the PCP that prescribed the medication. The PCP decided to discontinue the medication since it was not needed at this time. Therefore, the medication record now matches as the prescribed pro re nata, Albuterol Sul 2.5 MG/ 3 ML---Use 1 vial x (3 ML) via nebulizer every 6 hours as needed for cough or shortness of breath has been discontinued. The medication has been disposed of by the pharmacy, and the electronic medication record has been updated to reflect this change. |
06/09/2025
| Implemented |
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