Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.109(b) | Fire drills for this site occurred on 05/31/2021 and 12/16/2021, with an intervening time exceeding 6 months. | A fire drill shall be held at least every 6 months if all individuals have the ability to evacuate as specified in subsection (a). | Program Coordinator (PC) created Fire drill schedule for all Lifesharing homes to follow to ensure that a fire drill is held every 6 months. |
02/24/2022
| Implemented |
6500.121(c)(7) | Individual 1's most recent OB/GYN appointment occurred on 10/20/2020; there is no evidence of a more recent appointment within the Individual Record. Individual 1 was not seen by an OB/GYN annually as required. | 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. | LSP completed annual GYN appointment on 2/15/22. Next appointment scheduled for 2/21/2023. |
02/15/2022
| Implemented |
6500.151(e)(14) | Individual 1's Individual Assessment, dated 08/23/2021, does not contain information regarding the individual's ability to swim. Although the assessment does capture the increased level of supervision the individual requires around pools or bodies of water, it does not explicitly state whether this is due the individual lacking the ability to swim or due to other health or safety concerns related to the setting, e.g., a tripping hazard, mobility issue, seizure disorder, etc. Based purely upon the text of the Individual Assessment, it could not be reasonably determined whether Individual 1's increased supervision needs are related to the individual's level of swimming ability. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | WATER SAFETY:
ADDENDUM 2/24/22: It is unknown if individual #1 is able to swim and if she can it is unknown to what level. Individual #1 does not usually choose to go in and fully swim in pools and other bodies of water. Therefore, it is best that individual #1 is in line of sight when at the pool or other bodies of water with her providers/ other staff/or natural supports. If individual #1 chooses to go into the water past putting her toes in the water, her provider or other support will be in the water with her. |
02/24/2022
| Implemented |