| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.62(a) | On 5/21/25, at 12:41 PM, spray bottles of Clorox Bleach Cleaner, Oxi Clean, Windex, Awesome Cleaner and bottles of Lysol were unlocked and accessible in the cabinet under the sink in the kitchen of the home. At 12:54PM, a bottle of Bleach was unlocked and accessible on the floor next to the washing machine in the laundry room of the home. Individual #1's assessment states that [Individual #1] cannot store or use cleaning products safely and appropriately. These are locked at [Individual #1's] home and at day program due to regulations." | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 5-21-25, the Life Sharing Provider placed the cleaning products in a locked area that was inaccessible to individual #1. |
06/06/2025
| Implemented |
| 6500.121(c)(8) | Individual #1 completed a mammogram on 6/9/2023 and then it was next attempted on 7/17/2024. This exceeds the annual requirement. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual # 1¿s mammogram was attempted late on 7-17-24 (refusal was documented) and was rescheduled and completed on 10-30-24. The next mammogram will be completed by 10-30-25. |
06/06/2025
| Implemented |
| 6500.121(c)(12) | On 5/21/25, at 12:50 PM, there was a hospital bed with partial bedrails on each side of the bed in Individual #1's bedroom on the first floor of the home. There were no physician's orders for this adaptive equipment. | The physical examination shall include: Physical limitations of the individual. | A physician¿s order for the hospital bed with partial bedrails was obtained from the physician on 5-30-25 for individual #1. |
06/06/2025
| Implemented |
| 6500.122(c) | Individual #1's dental examination, completed 8/7/2024, does not include procedures completed. | A written record of the dental examination, including the date of the examination, dentist's name, procedures completed and follow-up treatment recommended shall be kept. | A letter was obtained from the dental office regarding the cancellation of the dental examination on 8-7-24 due to individual #1 exhibiting behaviors (refusal). The letter also indicated the appointment was rescheduled at the earliest available date. The documentation of the provider¿s attempt to address the refusal is also included with the documentation. |
06/06/2025
| Implemented |
| 6500.183 | On 5/21/25, at 11:40 AM, a copy of Individual #1's most recent Service Plan was not kept at the family living home. [repeat violation 06/03/24 et al] | Copies of the most current record information required in § 6500.182(c)(1)-(14) (relating to individual records) shall be kept in the family living home. | Individual # 1¿s most recent Service Plan was placed in her home book on 5-22-25. |
06/06/2025
| Implemented |
| 6500.136(a)(10) | Individual #1's May 2025 Medication Administration Record did not include the time of administration for Perphenazine 4 MG. [repeat violation 06/03/24 et al] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The administration time for Individual # 1¿s Perphenazine 4 mg was added to the Medication Administration record on 5-21-25. |
06/06/2025
| Implemented |
| 6500.136(a)(11) | Individual #1 is prescribed Rosuvastatin. The medication label states that the medication is for cholesterol. Individual #1's May 2025 Medication Administration Record states that Rosuvastatin is for sleep. [repeat violation 06/03/24 et al] | 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. | Individual # 1¿s medication record was corrected to include the correct diagnosis for Rosuvastatin on 5-21-25. |
06/06/2025
| Implemented |
| 6500.136(b) | Individual #1's prescribed 4PM and 8PM medications were not initialed as administered on 5/20/2025. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Life Sharing Provider confirmed that Individual # 1¿s prescribed medications were administered on 5-20-25, and the documentation error was corrected. The administration of the 4pm and 8pm medication was documented on the MAR. |
06/06/2025
| Implemented |
| 6500.152(c) | Individual #1's assessment, completed 9/30/2024, states that physical assistance is needed to exit the building within 2.5 minutes and use an alternate exit. Individual #1's service plan, last updated, 2/12/2025, reads, "the annual assessment states that [individual 1] is independently able to recognize sound or visual cue of fire alarm, exit the building using a correct exit, use an alternate exit, and do so within 2.5 minutes." Individual #1's assessment, completed 9/30/2024, states that Individual #1 can independently use and avoid poisons. Individual #1's service plan, last updated 2/12/2025, reads, "the team feels [they] would not ingest products if they are properly labeled. However, the assessment states that they cannot store or use cleaning products safely and appropriately. These are locked at home and at day program due to regulations." [repeat violation 06/03/24 et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Life Sharing Program Specialist emailed the Supports Coordinator on 5-30-25 to request the ISP revised to reflect the information in the annual assessment regarding evacuation and on 6-6-25 to request the ISP be revised to reflect the current information in the assessment related to poisonous substances. |
06/06/2025
| Implemented |