| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual#1'a funds are not being used for his individual's benefit. On 7/1/25 and 9/12/25, Individual #1 purchased a 12 count of Diet Pepsi from the Family Dollar for $8.25. On 10/7/25 and 10/28/25 Individual #1 purchased a 12 count of Diet Pepsi from Family Dollar. On 12/9/25, at Dollar General Individual #1 for $8.95. On 2/13/16, Individual #1 purchased Diet Pepsi for $8.50. On 1/20/26, Individual #1 purchased Diet Pepsi 12 pack for $8.95, and on 2/13/26 Individual #1 also purchased 12 pack of Diet Pepsi at a Dollar General for $8.50. On 3/16/2, at Dollar General Individual #1 purchased Diet Pepsi 12 pack for $8.95. On 6/23/26, 6/8/26, 5/26/26, 4/21/26, and 4/7/26, Individual #1 purchased Diet Pepsi 12 count for $8.75. Staff #1 report that she supplies water and sparking water, but the Individuals buy their own soda and snacks. These items should not be purchased using individuals' funds as they would be included in Room and Board. | An individual's funds and property shall be used for the individual's benefit. | On 7/23/26, Program Specialist/AVP met with Life share provider and discussed and trained the life share provider that soda is part of Room and Board and the Life share provider must purchase this for the individual according to the individuals' preferences. - FCS reimbursed Denise for the 12 packs of soda and Lifeshare provider was trained on the need to provide the individuals' with their choice of beverages and snacks. See attached for reimbursement |
07/24/2026
| Implemented |
| 6500.62(c) | At the time of the inspection, located on upstairs bathroom sink was a white and gray decorative soap dispenser without a manufacturer's label filled with a white/cream liquid that presumably was a type of hand soap. It was not possible to determine if the liquid was toxic or non-toxic since it was not in the original labeled container. | Poisonous materials shall be stored in their original, labeled containers. | Lifeshare provider was visited by the Program Specialist/AVP on 7/23/26 and verified that the LS provider had a soap dispenser with a label and was nontoxic that met the regulation requirements. |
07/24/2026
| Implemented |
| 6500.78(b) | At the time of the inspection, the yard had grass and weeds that ranged from as high as the Licensing Representatives (LR) ankle to calf. | The yard and outside of the home shall be well maintained and free from unsafe conditions. | The Lifeshare Provider will maintain the grass and ensure it is cut weekly and kept short. |
07/24/2026
| Implemented |
| 6500.121(c)(1) | Individual #1's physical examination dated 1/28/26 did not contain a review of their previous medical history as this section of the exam form noted " See attached" however there was nothing further included or uploaded in the electronic file/record. | The physical examination shall include: (1.) A review of previous medical history. | FCS Manager's and Program Specialist were retrained on "see attached" and told that any document that says "see attached must have the attachments scanned into the CONNECT system. |
07/24/2026
| Implemented |
| 6500.121(c)(7) | Individual #1 had a gynecological appointment on 9/15/23, and the form noted under the was a pap smear done "No". Results: "NA hyster, normal prior ". Individual #1 had a gynecological appointment on 10/23/24 and the form noted under the was a pap smear done "No". Results: "No longer needed". Individual #1's gynecological appointment was late in 2024 | 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. | Program Specialist will remind the Life share provider of upcoming appointments at monthly monitoring. If an appointment is no longer needed or required, the lifeshare provider will request the physician explain on the physicians form why the appointments are no longer needed or if there is a time variance needed. |
07/29/2026
| Implemented |
| 6500.123(a) | Individual #1 had a dental appointment on 3/21/25, and under the follow up dental work needed section of the form it noted "patient refused the extractions at this time." There is no record or documentation that Individual #1 was trained on the importance of having the extractions performed on 3/21/25. Individual #1 had a dental examination completed on 11/26/25, and the written in the date of next appointment section of the form is noted *currently refusing* 1/22/26. There is no record or documentation that Individual #1 was trained on the importance of attending dental appointments. | 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. | COO updated the Medical Appointment Refusal form to include a section for training and Education of the individual. |
08/05/2026
| Implemented |
| 6500.124 | Individual #1 had an eye appointment on 8/4/25, and the form noted "yes" for a return visit required, and the date of the next appointment was noted as "4 months". Individual #1 should have had an eye appointment in December 2025 as that is 4 months from 8/4/25, but the next eye appointment in Individual #1's record on 5/8/26. There was no record or documentation that Individual #1 had an eye appointment 4 months after their 8/4/25 appointment as prescribed. Individual #1's record indicated that they had a dermatology appointment on 10/14/24, and the form noted under the date of next appointment "PRN/Yearly". Individual #1's next appointment occurred on 11/10/25, which was over a year since their previous appointment. | 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. | Program Specialist will remind the Life share provider of upcoming appointments at monthly monitoring. If an appointment is no longer needed or required, the lifeshare provider will request the physician explain on the physicians form why the appointments are no longer needed or if there is a time variance needed. |
08/05/2026
| Implemented |
| 6500.133(d) | At the time of inspection, Individual #1's prescription medications were stored unsecured in a black zipper fabric bag, and Staff #1 reported that the bag is kept in a closet which is not locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 7/24/26, Program specialist/AVP completed a Life share monitoring and verified that the life share provider had the individual's medications locked in a cabinet. |
07/24/2026
| Implemented |
| 6500.135(c) | Individual #1 is prescribed Trelegy Ellipta 100-62.5-25, inhale one puff by mouth daily. The pharmacy label on the medication had a date filled of 6/7/26, and the box stated, "inhale contain 30 dose." At the time of the inspection, the inhale had number 12 on the inhaler count window of the medication/inhaler. The medication is not being administered as prescribed. Individual #1 is prescribed Pantoprazole Sod Dr 40 mg, take 1 tablet by mouth every day. The pharmacy label on the medication had a date filled of 4/4/26, and QTY 90. At the time of the inspection, the medication/pill bottle contained approximately 26 pills. The medication is not being administered as prescribed. Individual #1 is prescribed Systane Ultra PF 0.4-0.3% eye, instill 1 drop into both eyes twice a day. The pharmacy label on the medication had a date filled of 4/24/26, and QTY 20. At the time of the inspection, and the bottle was approximately between ¾ and ½ way full of the medication at the time of the inspection. | A prescription medication shall be administered as prescribed. | Life share provider reported that medications are auto refilled and she uses multiple bottles for the same medications. Life share provider was educated to use one bottle of medication until finished before opening a new bottle and to consider ending automatic refills. |
08/05/2026
| Implemented |
| 6500.139(a) | Lifesharing providers who administer medications require bi-annually Modified Medication Administration Training. Staff #1 completed the Modified Medication Administration Training on 4/24/24, and not again until 5/4/26. Staff medication administration training is not being conducted as prescribed by the medication administration training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration). | Program Specialist will remind the Life share provider of upcoming trainings at monthly monitoring. Program specialist will assist with having the modified medication administration class assigned 60 days prior to due day. |
08/05/2026
| Implemented |