| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.68(b) | The water temperature in the bathroom of the home read at 132.8 degrees on the thermometer. This was corrected on the date of inspection. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The Life Sharing Provider of this home is required to check the hot water temperatures in her home weekly and document these temperatures on her monthly system check forms. In addition, a water temperature check is completed by the Life Sharing Program Coordinator during their monthly home visit. This check is documented via their Monthly Home Visit Checklist. A review of the last six months of the system checks for this home, completed by our Program Compliance Coordinator, noted no significant issues with fluctuation in the temperatures. Individual #3 who resides in this home is independent in regulating his water temperature for bathing, showering and hand washing as is identified in his 2024 ISP (Attachment # 4).
The water temperature in the bathroom of the home was checked on 4/5/24 and noted to be 119. |
04/05/2024
| Implemented |
| 6500.121(c)(6) | Individual #3 had a QuantiFERON-TB Gold Test completed on 9/8/23. The individual's last TB test was completed on 7/16/21 and read negative on 7/19/21. This exceeds the requirement that TB tests be done every two years by 1 month and 24 days. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | The Life Sharing Provider for Individual # 3 will be retrained to her responsibility to ensure that all required follow-up related to a medical appointment needs to be addressed within one week of the appointment no later than 5/31/24.
Life Sharing Program Coordinators will ensure that all other Life Sharing Providers are retrained to this responsibility no later than 6/15/24. |
06/15/2024
| Implemented |
| 6500.121(c)(9) | The last prostate exam for individual #3 was completed on 7/29/22, as documented in Lifetime medical history, which exceeds the annual requirement. | The physical examination shall include: A prostate examination for men 40 years of age or older. | A review of Individual #3¿s Annual Physical Examination forms for both July of 2022 and 2023 revealed that his Primary Care Physician indicated that the manual testicular examination is not recommended for Individual #3 at this stage of his life, but also notes that the exam was completed. The results of this review are very unclear as to what the physician¿s line of thinking is regarding this area. Our Clinical Coordinator will contact the Primary Physician to discuss our regulatory requirements related to prostate examinations and his current treatment plan for Individual #3 no later than 6/14/24 to determine the best resolution to this area of concern. |
06/14/2024
| Implemented |
| 6500.133(f) | Insulin injections for individual #3 are being kept in the refrigerator on the shelf in the door, but not within a locked container. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | A Vaultz money bag with locking capabilities was purchased on 3/20/24 (Attachment #5) for the storage of Individual #3¿s insulin in the refrigerator. |
06/14/2024
| Implemented |