| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(f) | Review of Individual #2's financial records indicates a comingling of the individual's funds with the family living provider. Many receipts have purchases for takeout with a written note stating "staff ½". | There may not be commingling of the individual's personal funds with agency or household funds. | The Provider initiated an Misuse of Funds Investigation (8827795). When determined, the individual will be reimbursed.
Training was completed on 4/5/21 for all Lifesharing Providers regarding no comingling of funds.
See attached training documentation. |
04/05/2021
| Implemented |
| 6500.68(b) | The water temperature at the residence was 127 degrees. This was corrected at the time of the inspection. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The water temperature was corrected on the day of inspection 3/24/21 by turning down hot water heater temperature gauge.
See attached photograph. |
04/30/2021
| Implemented |
| 6500.151(e)(3)(i) | The assessment for Individual #2 does not include the individual's progress or lack of, in the following required areas: acquisition of functional skills. | The assessment must include the following information:The individual's current level of performance and progress in the areas:Acquisition of functional skills. | Assessment has been corrected to include progress in the stated area of functional skills. Completed on 4/16/21.
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(3)(ii) | The assessment for Individual #2 does not include the individual's progress or lack of, in the following required areas: communication. | The assessment must include the following information:The individual's current level of performance and progress in the areas:Communication. | Assessment has been corrected to include progress in the stated area of communication. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(3)(iii) | The assessment for Individual #2 does not include the individual's progress or lack of, in the following required areas: personal adjustment. | The assessment must include the following information:The individual's current level of performance and progress in the areas: Personal adjustment. | Assessment has been corrected to include progress in the stated area of personal adjustment. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(3)(iv) | The assessment for Individual #2 does not include the individual's progress or lack of, in the following required areas: personal needs with or without assistance from others. | The assessment must include the following information:The individual's current level of performance and progress in the areas: Personal needs with or without assistance from others. | Assessment has been corrected to include progress in the stated area of personal needs. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(i) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: Health. | Assessment has been corrected to include progress in the stated areas of health, motor and communication skills, activities of residential living, personal adjustment, socialization, recreation, financial independence, managing personal property, community integration. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(ii) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Assessment has been corrected to include progress in the stated areas of health, motor and communication skills, activities of residential living, personal adjustment, socialization, recreation, financial independence, managing personal property, community integration. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(iii) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Assessment has been corrected to include progress in the stated area of activities of residential living. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(iv) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Assessment has been corrected include progress in the stated area of Personal adjustment. Completed on 4/16/21
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(v) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Assessment has been corrected to include progress in the stated area of Socialization. Completed on 4/16/21.
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(vi) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Assessment has been corrected to include progress in the stated area of Recreation. Completed on 4/16/21.
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(vii) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. | Assessment has been corrected to include progress in the stated area of Financial Independence. Completed on 4/16/21.
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(viii) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas : Managing personal property. | Assessment has been corrected to include progress in the stated area of Managing. personal property. Completed on 4/16/21.
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.151(e)(13)(ix) | The assessment for Individual #2 does not include the individual's progress, or lack of, in the following required areas: (i) Health,(ii) Motor and communication skills,(iii) Activities of residential living,(iv) Personal adjustment,(v) Socialization,(vi) Recreation,(vii) Financial independence,(viii) Managing personal property,(ix) Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration. | Assessment has been corrected to include progress in the stated area of Community Integration. Completed on 4/16/21.
See attached Assessment. |
05/31/2021
| Implemented |
| 6500.34(a) | Individual rights were reviewed with Individual #2 on 1/21/21. The rights reviewed did not encompass all items as outlined in 6500.32. The following rights were not reviewed: An individual has the right to civil and legal rights afforded by law, An individual has the right to make choices and accept risks, An individual has the right to refuse to participate in activities and services, An individual has the right to control the individual's own schedule and activities, An individual has the right to choose persons with whom to share a bedroom, An individual has the right to furnish and decorate the individual's bedroom in accordance with § 6500.33 (relating to negotiation of choices), An individual has the right to access food at any time and an individual has the right to make health care decisions. An individual has the right to lock the individual's bedroom door. (1) Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock
and unlock the door. (2) Access to an individual's bedroom shall be provided only in a life safety emergency or with the express permission of the individual for each incidence of access. (3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. (4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. (5) The primary caregiver shall have the key or entry device to lock and unlock the door. Full review is required to satisfy regulation. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | Threshold will review and update the Rights Statement and Policy regarding individuals¿ rights by 4/22/2021.
See attached signed Rights Policy Statement. |
06/15/2021
| Implemented |
| 6500.133(d) | Individual #2's medications were stored in a clear tote and kept in an unlocked cabinet above the stove at the residence. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Medications will be locked in a suitable lockbox by 4/22/2021.
See attached Photo. |
05/31/2021
| Implemented |
| 6500.135(c) | Individual #2 has medication listed on the MAR for Debrox Ear drops to be administered the first 7 days of the month. Medication label indicates the medication should be administered AS NEEDED the first 7 days of the month. | A prescription medication shall be administered as prescribed. | Individual #2 physician gave additional clarification that Debrox Ear Drops is to be administered the first 7 days of month. This matches the MAR record.
See attached Photo of Prescription and MAR |
05/31/2021
| Implemented |
| 6500.136(a)(11) | Individual #2's medication administration record does not include the diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The provider will request from each individual doctor¿s their diagnosis for each of their medication.
The pharmacy will add the diagnosis to MAR¿S.
See attached documentation of request.
See attached March MAR, which includes diagnosis or purpose of medication. |
06/15/2021
| Implemented |
| 6500.151(f) | Individual's annual ISP review was held on 1/28/21. Individual's assessment was not completed until 1/6/21, less than the 30 days required. Additionally, there is no indication that the assessment was sent to the team prior to the annual review. | The life sharing specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Going forward, all assessments will be sent via email to the team no less than 30 days prior to the Annual ISP. |
04/30/2021
| Implemented |