| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(d)(2) | (Repeat Violation -- 6/13/22) Individual #1's actual cash balance at the end of 7/2022 was $3.88. At the beginning of 8/2022, the cash ledger begins with an amount of $11.88, an $8 difference. This $8 difference continued through 12/12/22, when a Walmart purchase of $141.23 was deducted from Individual #1's balance as $141.33, making the difference in actual and ledger balances a total of $7.90. This $7.90 difference continues through the 6/13/23 inspection, however the actual cash amount at the home at the time of inspection matched the ledger. It is unclear when or how the error was corrected. | An up-to-date financial and property record shall be kept for each indivudal that includes the disbursements made to or for the individual. | Cash ledgers from August 2022 to May 2023 were revised to reflect accurate calculation on 6/20/23 (see document #1). |
06/20/2023
| Implemented |
| 6500.110(c) | Family Member #4 has not been fire safety trained since 3/2/22. There is no record that Family Member #5 has ever received fire safety training. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | On 6/20/2023 all members of the home completed Fire Safety Training (see document #5). |
06/20/2023
| Implemented |
| 6500.136(a)(2) | Individual #1's Medication Administration Records do not include the prescriber for each medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | On 6/20/23, the pharmacy added the prescribers for each medication to the MAR on our electronic MAR system (see document #2). |
06/20/2023
| Implemented |
| 6500.136(a)(11) | (Repeat Violation -- 6/13/22) Individual #1's Medication Administration Records do not include the diagnosis or purpose for Chlorhexidine 0.12% Rinse. | 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. | On 6/20/23 diagnosis and purpose of medication was added to the MAR record on our electronic MAR system (see document #3). |
06/20/2023
| Implemented |
| 6500.151(a) | (Repeat Violation -- 6/13/22) Individual #1's 1/21/22 and 1/23/23 assessments are almost verbatim, or with little change, therefore not assessing the individual of their needs and/or skills over the previous 365 days. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home. | The assessment for 1/23/2023 was updated on 6/21/23 and resent to team on 6/21/23 (see document 4). |
06/21/2023
| Implemented |