| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(a) | The self-assessment completed 5/10/2022 was not complete. The following regulation numbers were left blank: 21a4-22c2, 108d-110d, 125c3-126b, 131e4, 141-144, 165c8-179, and158a-158d. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Mon Yough supervisor will review self-assessment completed by life share specialist to determined it is completed in its entirety prior to filing. Life Share Specialist reviewed the self-assessment and has documentation of completion. |
01/10/2023
| Implemented |
| 6500.133(d) | The first aid kit, which is kept unlocked and accessible in the home, contained over-the counter Non-Aspirin Acetaminophen medication and Individual #1 is assessed to be unable to self-administer medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 0n 1/5/2023, Supervisor purchased lock box for medication. Once the lock box is received, Life Share Specialist will take the lock box to provider and assist them with transferring any and all medication found in the home into the lock box. |
01/18/2023
| Implemented |
| 6500.136(a)(13) | Individual #1's January 2023 medication administration did not include the initials of the person who administered the following medications: Montelukast Tab 10mg on 1/01/2023 at 5:00pm, Cetirizine Tab 10mg on 1/03/2023 at 5:00pm, and Lisinopril Tab 10mg on 1/01/2023 and 1/04/2023 at 8:00am. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Supervisor provided information to the provider on 1/5/2023 regarding the requirements to initial all medication administration.
Supervisor will provide re-education to provider regarding the medication regulatory requirements and will have the provider sign off on the education received. |
01/18/2023
| Implemented |