| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(c) | Individual#1's funds are not being used for this individual's benefit. On 9/18/25, Individual #1 purchased at Burlington two 2.7 oz. deodorant solids at $3.99 each and three 6 packs of disposable razors at $2.79 each. These items should not be purchased using the individual's funds as the purchases should be included in Room and Board.
**As part of the plan of correction, the agency reimbursed the individual for the cost of the disposable razors on 12/09/2025 but have not yet reimbursed for the cost of the two deodorant solids. | An individual's funds and property shall be used for the individual's benefit. | An EIM was entered upon discovery of this incident. A check request was submitted to the rep payee technician for reimbursement. Reimbursement was received on 12/24/2025. The amount of reimbursement to the client totaled $8.37. On 12/11/25 The Program Specialist met with the individual and the Life Sharing Provider to council each of them on what is included in the room and board. She advised the LSP that razors and deodorant are to be provided by her. |
12/24/2025
| Implemented |
| 6500.103 | Furnaces shall be cleaned at least annually, and written documentation of the cleaning shall be kept. The home has a gas furnace and there was no documentation of annual cleanings. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | The Life Sharing provider was counseled on the need to clean her gas furnace annually. The Life Sharing provider submitted proof of cleaning to the Operations Director on 12/16/25. |
12/16/2025
| Implemented |
| 6500.136(a)(11) | A medication record shall be kept and include a diagnosis or purpose for the medications, including pro re nata medications. Individual #1 is prescribed the following medications which are listed on the medication record, Aspirin EC 81 mg. tablets, Hydrochlorothiazide 25 mg. tablets, Latanoprost eye drops, Levothyroxine 100 mcg. tablets, Lisinopril 10 mg. tablets and Potassium Chloride ER 20 MEQ tablets. The medication record did not include a diagnosis or purpose for any of the medications. | 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. | All diagnoses were added to the medication records. The Life Sharing Program Specialist contacted the pharmacy to request they include the diagnosis on the print outs provided by the pharmacy; at this time they are not able to, so diagnoses were handwritten in. |
12/11/2025
| Implemented |