| 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 |