| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.31(a) | Individual #1 rights dated 6/22/2024 did not include that an individual may be deprived of rights. | An individual may not be deprived of rights as provided under § 6500.32 (relating to rights of the individual). | Provider Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(b) | Individual #1 rights dated 6/22/2024 did not provide the assistance necessary for the individual to understand the individual rights. | An individual shall be provided the assistance necessary for the individual to understand the individual's rights. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25., Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(c) | Individual #1 rights dated 6/22/2024 did not review that an individual may not be reprimanded, punished or retaliated for exercising their rights. | An individual may not be reprimanded, punished or retaliated against for exercising the individual's rights. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(d) | Individual #1 rights dated 6/22/2024 did not describe that a court order is needed if an individuals rights should be restricted. | A court's written order that restricts an individual's rights shall be followed. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(e) | Individual #1 rights dated 6/22/2024 does not review court appointed legal guardian may exercise rights on behalf of the individual. | A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(f) | Individual #1 rights dated 6/22/2024 did not review that if a guardian or court order restricting an individuals rights there shall be involved in the decision making process. | An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.31(g) | Individual #1 rights dated 6/22/2024 did not review that an individual has the right to designate a person to assist in decision making. | An individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |
| 6500.32(v) | Individual #1 rights dated 6/22/2024 did not review and individuals rights to modify an individuals rights. | An individual's rights may only be modified in accordance with § 6500.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | Providers Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/25.
2. All Primary Caregivers will be trained on 6500.31(a)-(g) and 6500.32(v) no later than 7/11/25.
3. The agency Resident Rights Form was revised to include 6500.31(a)-(g) and 6500.32(v) on 6/5/25.
4. All individuals will review and sign the revised agency Resident Rights Form by 7/11/25.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/25.
6. , Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Revised Agency Resident Rights Form (Attachment 2)
3. Completed Agency Resident Rights Form (Attachment 3) |
07/15/2025
| Implemented |