| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.77 | On 4/19/16, the home did not have antiseptic. | Each home shall have antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and syrup of Ipecac if any individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The Program Specialist will check the first aid kit while doing their monthly monitoring of the Life Sharing site. If any items are needed, the Program Specialist will replace it. She will turn in her monitoring form to her manager at the end of each month for their review. Any areas of concerns will be corrected by the Program Specialist [Within 30 days of receipt of the plan of correction, the family living specialist will educated and provide a list to family living providers on the first aid items that are required to be in each home. Documentation of trainings and monitoring forms and reviews shall be kept. (AS 6/1/16)] |
05/15/2016
| Implemented |
| 6500.125(a) | The Family Living Provider #1 had a physical examination completed on 11/4/13. Individual #1 began living in the home on 7/14/15. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | The Program Specialist will check all paperwork for all new Life Sharing Providers to make sure that they meet the requirements to become a Provider. This will include making sure all paperwork is in the needed time lines. The Program Specialist will then submit that packet to the Manager for their review for any areas of concerns, that will then be corrected. [The Family Living Provider #1 had a physical examination completed XXXXX. Prior to an individual moving into a family living home the program specialist will review documentation including physical examinations to ensure all required information is completed within the required timeframes. Documentation of review shall be kept and reviewed by the program director or designated management staff person. (AS 7/19/16)] |
05/15/2016
| Implemented |
| 6500.131(a) | Individual #1's medications, Metformin 500 mg, 1 tab HS and Benadryl 25 mg, 1 tab HS, were not in their original containers. | Prescription and nonprescription medications of individuals shall be kept in their original containers, except for medications of individuals who self-administer medications and keep their medications in personal daily or weekly dispensing containers. | The Program Specialist will make sure that when medications are picked up, they are accounted for and in the correct container. Any medications being signed out for family visits will be put in an duplicate labeled bottled and transferred to a family member. The Life Sharing Provider will have this form filled out with all visits and turn into Program Specialist. Program Specialist while doing their monthly monitoring will check the medication and turn that completed form into their manager for review.[Within 30 days of the receipt of the plan of correction and continuing at least monthly the program specialist will audit all individuals' medications to ensure medications are kept in their original containers as required. Within 30 days of receipt of the plan of correction, the CEO or designated staff person will train all family living providers on the requirements relating to medications as well as the agency's medication policy and procedures. (AS 6/22/16)] |
05/15/2016
| Implemented |
| 6500.151(a) | Individual #1, date of admission 7/14/15, had an initial assessment completed on 12/8/15. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the family living home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the family living home. | Program Specialist will do an intake checklist for every new person entering the agency. At this time they will add the individual to a chart that will track there assessment and all Program meeting to make sure all time frames are met. They will update when any changes are made and turn the chart into their manager monthly for their review. The Manager will make any needed corrections and go over them with the Program Specialist.[At least quarterly, the Director will review the aforementioned program chart and a 25% sample of assessments to ensure timely completion of assessments. Documentation of reviews of the aforementioned Program Chart shall be kept. (AS 7/7/16)] |
05/15/2016
| Implemented |