| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.73 | At 11:21AM on 6/4/2024, there was no railing along the four exterior steps leading to the deck in the back of the home. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | The Life Sharing Provider will have a railing installed on the four steps leading off the side of the deck in the back of the home by 7-21-24. There is a ramp from the other side of the deck is used by the individual living in the home and the ramp has a railing. |
07/21/2024
| Implemented |
| 6500.121(a) | Individual #1 had a physical examination on 5/18/2022 and then again on 8/8/2023. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | Individual # 1 was scheduled to have a physical on 5-19-23, however the Life Sharing Provider tested positive for COVID, so the appointment was rescheduled for the earliest available appointment on 8-8-23. Individual # 1¿s next physical is scheduled for 8-12-24 within the required timeframe. |
06/20/2024
| Implemented |
| 6500.121(c)(4) | Individual #1's most recent vision examination was completed on 5/18/2022. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 was hospitalized on 5-31-24 and remained hospitalized through 6-18-24. Once he returned home a vision exam was scheduled for the earliest available appointment on 7-12-24. |
07/12/2024
| Implemented |
| 6500.121(c)(13) | Individual #1's most recent physical examination, completed 8/8/2023, reads, "NKDA" for the allergy section and the Individual #1's appointment summary and other medical documents on file state that he is allergic to Vancomycin. | The physical examination shall include: Allergies or contraindicated medications. | Individual # 1¿s most recent physical examination for 8-8-23 was corrected to include that the individual is allergic to Vancomycin on 6-20-24. |
06/20/2024
| Implemented |
| 6500.121(c)(14) | Individual #1's most recent physical examination, completed 8/8/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1¿s physical examination dated 8-8-23 was updated to include medical information pertinent to diagnosis and treatment in case of an emergency on 6-20-24. |
06/20/2024
| Implemented |
| 6500.151(e)(12) | Individual #1's assessment, completed 12/5/2023, did not address recommendations for specific areas of programming, services and training. This section only states, "[Individual #1] does what he is able." [Repeat Violation, 6/28/2023] | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1's assessment was updated on 6-20-24 to address recommendations for specific areas of training, programming and services. The updated assessment was sent to plan team members on 6-20-24. |
07/13/2024
| Implemented |
| 6500.183 | The most recent copies of Individual #1's physical examination and assessment were not present at the home. [Repeat Violation, 6/28/2023] | 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 physical examination and assessment were placed in the record at the home on 6-7-24. |
06/20/2024
| Implemented |
| 6500.136(a)(4) | Individual #1's June 2024 Medication Administration Record did not include the name of Fiber Therapy and Stool Softener. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(5) | Individual #1's June 2024 Medication Administration Record did not include the strength of Fiber Therapy and Stool Softener. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(6) | Individual #1's June 2024 Medication Administration Record did not include the dosage form of Fiber Therapy and Stool Softener. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(7) | Individual #1's June 2024 Medication Administration Record did not include the dose of Fiber Therapy and Stool Softener. Individual #1 is prescribed Warfarin Sodium 4mg Tablets with instructions to, "take 1 tablet by mouth as directed." Individual #1's June 2024 Medication Administration Record reads, "Take 1 tablet by mouth on Monday, Wednesday, and Friday, 2 tablets by mouth Sunday, Tuesday, Thursday and Saturday." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(8) | Individual #1's June 2024 Medication Administration Record did not include the strength of Fiber Therapy and Stool Softener. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(9) | Individual #1's June 2024 Medication Administration Record did not include the frequency of administration for Fiber Therapy and Stool Softener. Individual #1 is prescribed Warfarin Sodium 4mg Tablets with instructions to, "take 1 tablet by mouth as directed." Individual #1's June 2024 Medication Administration Record reads, "Take 1 tablet by mouth on Monday, Wednesday, and Friday, 2 tablets by mouth Sunday, Tuesday, Thursday and Saturday." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(10) | Individual #1's June 2024 Medication Administration Record did not include the administration times of Fiber Therapy and Stool Softener. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Individual #1 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.136(a)(11) | Individual #1's June 2024 Medication Administration Record did not include the diagnosis or purpose for Fiber Therapy and Stool Softener. | 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 was hospitalized on 5-31-24 prior to licensing and was discharged on 6-18-24. Multiple medication changes were made during the hospitalization, and the Fiber Therapy (OTC), Stool Softener (OTC) and Warfarin Sodium were discontinued. When Individual #1 was discharged from the hospital, all medications were reconciled with the Medication Administration Record, including Over the Counter medications that were recommended. The Life Sharing Provider and the Life Sharing Supervisor ensured that the Medication Record contains all of the required information including the individual¿s name, the name of the prescriber, drug allergies, name of medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, administration times and diagnosis or purpose for the medication, including pro re nata. |
06/20/2024
| Implemented |
| 6500.151(f) | The life sharing specialist provided Individual #1's assessment to the plan team members on 12/5/2023 for the Individual Plan meeting held on 1/3/2024. | 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. | The Life Sharing Program Specialist created a spreadsheet on 6-20-24 with assessment due dates based upon the previous year¿s ISP date and the assessment updates will be completed and sent to team members at least 60 days, but not more than 180 days prior to last year¿s ISP date. |
06/20/2024
| Implemented |