| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual #1 financial records submitted contained multiple entries of meals for "Brent and Provider." Each entry was the purchase of a meal for Individual #1 and Staff #1or "Provider" that Individual #1 paid for both meals. Receipts show a total of 39 transactions spanning a six-month period: an average of 6.5 meals per month. Individual funds shall be used for the individual's benefit.
Suave Body wash was purchased on 2/24/21 in the amount of $2.94. Equate lotion was purchased on 1/10/21 in the amount of $6.96. The purchase of standard toiletries is included in room and board paid and is to be furnished by the Provider. | An individual's funds and property shall be used for the individual's benefit. | The Provider initiated a misuse of funds (8827528) incident and investigated this matter. Individual 1 will be reimbursed $990.98.
Training has been completed on 4/5/21 for all Lifesharing Providers regarding appropriate use of individual funds. See attached training documentation.
See attached (internal) request for reimbursement |
05/31/2021
| Implemented |
| 6500.123(a) | Individual #1 has a documented history of refusals of dental care. The refusals are addressed in a Desensitization Plan dated 2/19/21. Dental exams and cleaning are recommended to occur at three-month intervals in the Dental Hygiene Plan completed by the Dentist on 9/24/20 and 12/20/19. A refusal with education was documented on 2/5/20. A successful cleaning was completed on 9/24/20. One cancelation by Dentist due to COVID was noted on 3/30/20. No other documentation of attempts to schedule or complete exams between 3/30/20-9/24/20 were found. No documentation of continued attempts to train Individual #1 about the need for health care were located in Individual #1's record provided for the timeframe of 2/5/20-9/24/20 or after. A successful exam with cleaning was completed on 3/11/21. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Desensitization plans will be completed for ongoing refusals at least annually and documented in the assessment and ISP.
Individual #1 Desensitization Plan is updated to reflect Individual #1 specific needs and documented monthly by the LifeSharing Provider.
See attached updated Desensitization Plan.
See attached Monthly Documentation form |
04/30/2021
| Implemented |
| 6500.151(e)(9) | Individual #1 had a new feeding plan put into place with doctor's order of a "Chopped" diet as of 10/22/20. The Limitations, Restrictions or Special Diet section of the physical for Individual #1 dated 10/22/20 was marked with an "X" in the box and noted "See attached feeding plan." This is a change from the physical dated 10/18/19 which indicated a "reg diet" in the Limitations, Restrictions or Special Diet section.
Additional notation on the feeding plan includes "Posture during meals upright and must remain upright for 30 minutes after eating, drinking or receiving medications." The assessment for Individual #1 was completed on 12/28/20. There are no notations to reflect the change in diet in the functional/medical limitations section of the Assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The Assessment for Individual # 1 has been updated and dated 4/16/21 by the Program Specialists to reflect the change in diet and medical limitation.
See Attached updated Assessment. |
05/31/2021
| Implemented |
| 6500.124 | A "chopped" diet was prescribed for Individual #1 at his annual physical on 10/22/20. Documentation provided does not support that the diet is being followed as prescribed. The assessment for Individual #1 dated 12/28/20 does not note the change in diet or reflect that a change in the functional status/medical limitations of Individual #1 occurred. Receipts submitted indicate that no changes were made to food items purchased after the change in diet occurred. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. | LifeSharing Provider received immediate verbal retraining on 3/26/2021 regarding update in diet restrictions.
Individual #1 Assessment was updated on 4/16/2021.
On 4/5/2021, all LifeSharing Providers received training to assure that Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged.
See attached Training Record |
05/31/2021
| Implemented |
| 6500.34(a) | Individual rights were reviewed on 1/19/21. 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. Additionally, Individual rights signed by Individual #1 does include that locked bedrooms and locked areas for personal possessions are provided, however, the right does not include: (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 4/23/2021.
See attached signed Rights Policy Statement |
06/15/2021
| Implemented |
| 6500.135(g) | Individual medical records provided included record of three-month medication reviews that occurred on 2/17/20, 5/27/20 and 3/18/21. No medication reviews were conducted between 5/27/20 and 3/18/21 which spans a ten-month period. The regulated time between reviews was exceeded. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Future appointments will be scheduled at the at the time of existing appointments and placed on scheduling calendar. |
05/31/2021
| Implemented |
| 6500.151(f) | Individual #1's assessment presented for review was dated 12/28/20. Annual review meeting date of the Individual Support Plan (ISP) meeting was entered in the ISP as 1/12/2021. A timeframe of 15 calendar days. This does not allow the assessment to have been provided to plan team members within at least 30 calendar days prior to the ISP review meeting. | 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 |