| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(a) | The date of the self assessment 4/1/17 did not fall within the regulatory window from the license date which is 6/22/17. | If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home 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. | The Manager of Residential Services will conduct a retraining with the Lifesharing Program Specialist and Lifesharing providers to ensure that self assessment for each family living home the agency is licensed to operate, is completed within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The Manager of Residential Services will send a request for assessments at least 6 months prior to the certificate of compliance expiration date with a due date for submission by the Program Specialist at least 4 months prior to the expiration date. Training will be completed by 12/10/2017 and a record of training will be kept in staff records. |
12/10/2017
| Implemented |
| 6500.24(e)(3) | From 6/3/17 through 10/23/17 there were purchases made for individual #1 over the amount of 15.00 and there was no receipt on record. the dates were 7/6/17, 7/10/17, 7/24/17, 9/5/17, 9/22/17 and 10/16/17. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by family members or agency staff. | The Manager of Residential Services will conducted training with the Program Specialist and Lifesharing Providers focused on a simplified procedure of tracking, collecting and keeping receipts of expenditures made on behalf of the individuals. Records of all receipts will be kept by the Lifesharing Provider at the residence, and all receipts will indicate the dollar amount, location, and description of purchase. The Program Specialist will review receipts and ledgers of all individuals on a monthly basis and will make notation on the monthly checklists. Training will be completed by 12/10/2017 and a record of training will be kept in staff records. |
12/10/2017
| Implemented |
| 6500.121(c)(14) | Individual #1's annual physical dated 12/22/16 did not list information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Manager of Health services will complete training with Nurse Case Managers to ensure that physical exam reports are reviewed to ensure completion in compliance with regulations. The Manager of Health Services will review client physicals when issues are identified by Nurse Case Managers. Training will be completed by 12/10/2017 and a record of training will be kept in staff records. Internal audit staff will complete a 100% review of client physicals for compliance and will follow up with the Manager of Health Services if issues are identified. This review will be completed by 12/31/2017. |
12/31/2017
| Implemented |
| 6500.151(a) | Individual #1's annual assessments dated 3/5/16 and 5/1/17 were completed more than one year apart. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the family living 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 family living home. | The Manager of Residential Services will conduct retraining with the Life Sharing Program Specialist to ensure that annual assessments are completed within regulatory timelines. In June 2017 the program began using an electronic assessment which allows for tracking due dates electronically. The Lifesharing Program Specialist and the Manager of Residential Services will review the report quarterly individual annual assessments quarterly to monitor due dates. Training will be completed by 12/10/2017 and a record of training will be kept in staff records. |
12/10/2017
| Implemented |