| 6500.109(i) | According to the written fire drill record submitted from 9/7/2025 to 5/23/2026, for the drills performed on the following dates: 9/7/2025; 12/4/2025; 3/2/2026; 4/19/2026; and 5/23/2026, there was no documentation that at least one smoke detector was set off during these drills, as there was neither a corresponding field, nor such correlating information provided within the agency's monthly smoke detector testing reports. | At least one smoke detector shall be set off during each fire drill. | The Quality Specialist retrained all Lifesharing Specialists (LSSs) on Regulation 6500.109(i). Additionally, the VP of Lifesharing updated the ICM form used by all Lifesharing providers during drills to include documentation verifying whether the fire alarm is operable - this is mandatory. |
06/23/2026
| Implemented |
| 6500.152(c) | Individual #1's Service Plan, last updated 6/3/2026, and their current assessment, completed on 9/19/2025, contained discrepancies in the following areas; regarding home supervision, Individual #1's Service Plan, last updated 6/3/2026, informed that Individual #1 requires 18 hours of daily supervision and is very capable of spending time alone in the home as well as being safe for up to eight hours a day. In addition, Individual #1's Service Plan, last updated 6/3/2026, explained that Individual #1 cannot be outside on the home's property when alone. In contrast, Individual #1's assessment, completed on 9/19/2025, indicated that Individual #1 requires 13 hours of daily supervision (16 hours if not working that day) with a 1:1 staffing ratio and included no information relative to supervision on the property outside of home; and regarding community supervision, Individual #1's Service Plan, last updated 6/3/2026, explained that "[Individual #1] [is] accompanied by staff or another adult when in the community [and] is able to be alone for up to 30 minutes in a community location if instructions have been clearly explained prior to [Individual #1's] arrival." In addition, Individual #1's Service Plan, last updated 6/3/2026, stated that "[Individual #1] can independently navigate traffic in the country setting where [they] grew up. However, [Individual #1] is constantly accompanied by staff when negotiating traffic in the city." In contrast, Individual #1's assessment, completed on 9/19/2025, provided that Individual #1 requires a 1:1 staffing ratio of supervision in the community, but can be at work for up to three hours unsupervised and that Individual #1 can independently negotiate traffic. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | All Lifesharing Specialists were retrained on regulation 6500.152(c) by the Quality Specialist. |
06/24/2026
| Implemented |