| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.72(b) | Screens, windows and doors shall be in good repair. At the time of inspection, the screen located on the window to the left of the garage was ripped in the left corner approximately and 5 inches long and 3 inches wide. The screen located in the window in the attic at the top of the steps as ripped at the bottom approximately 14 inches long and 10 inches wide. | Screens, windows and doors shall be in good repair. | The Life Share provider has been tasked with repairing the two window screens by the next physical site visit conducted by the Life Share Specialist in November. |
11/30/2023
| Implemented |
| 6500.101 | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. The door going up to the attic had a turn lock on the door. When the door is locked an individual would not be able to exit from the attic as you would be locked in the attic. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | The Life Share provider has been tasked with replacing the locking doorknob leading to the attic with a non-locking knob by the next physical site visit conducted by the Life Share Specialist in November. |
11/30/2023
| Implemented |
| 6500.121(c)(10) | Individual #1's physical examination dated 1/17/23 did not include if the individual was free from communicable disease or Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The Life Share Provider was given the approved physical evaluation form to update their master documentation binder provided by the Life Share Specialist which contains all approved documents needed for program operation. |
10/31/2023
| Implemented |
| 6500.121(c)(11) | Individual #1's physical examination dated 1/17/23 did not include or address an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Life Share Provider was given the approved physical evaluation form to update their master documentation binder provided by the Life Share Specialist which contains all approved documents needed for program operation |
10/31/2023
| Implemented |
| 6500.121(c)(13) | Individual #1's physical examination dated 1/17/23 did not include allergies or contraindicated medications as this section of the examination was left blank. | The physical examination shall include: Allergies or contraindicated medications. | The Life Share Provider was given the approved physical evaluation form to update their master documentation binder provided by the Life Share Specialist which contains all approved documents needed for program operation. |
10/31/2023
| Implemented |
| 6500.121(c)(14) | Individual #1's physical examination dated 1/17/23 did not include or address medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Life Share Provider was given the approved physical evaluation form to update their master documentation binder provided by the Life Share Specialist which contains all approved documents needed for program operation. |
10/31/2023
| Implemented |
| 6500.124 | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 is prescribed Invega ER 6 MG tablet, take 1 tablet by mouth once daily at 8pm. The medication bottle had a discard after date of 12/29/22 on the pharmacy label and Staff #1 has been administering the medication to Individual #1 from the expired medication bottle. Pharmaceutical services are not being planned or followed. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. | The Life share Provider has disposed of expired/discontinued meds at their local pharmacy. Current medications also reviewed to document future expiration dates. |
10/31/2023
| Implemented |
| 6500.133(d) | Prescription medications shall be kept in an area or container that is locked. At the time of the inspection, Staff #1 obtained Individual #1's additional/extra medications (Paliperidone ER 6 mg, Invega ER 3 mg, Invega 6 mg, Midodrine HCL 5 mg, and pro re nata medications (CVS Senna Plus and Acetaminophen) that were stored in a wooden unlocked cabinet/bench. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The Life Share Provider has discarded the medications that were unlocked and has ensured and confirmed that all medication are all locked in their identified area. |
10/31/2023
| Implemented |
| 6500.133(h) | Prescription medications that are discontinued or expired shall be destroyed in a safe manner. Individual #1 is prescribed Acetaminophen 325mg tablet, take 2 tablets every 3 hours as needed for pain or fever over 99. Call MD after 5 days if still sick. The bottle had a discard date of 9/10/21 on the pharmacy label. Individual #1's is prescribed Invega ER 6 MG tablet, take 1 tablet by mouth once daily at 8pm. There were two bottles of the medication in the home. One of the b unopened with a discard after date of 12/29/22 on the pharmacy label. Invega ER 3 mg, take 1 tablet by mouth at bedtime and the discard date on the pharmacy label on medication bottle was 8/7/23. Midodrine HCL 5 mg tablet, take 1 tablet by mouth twice a day at 8am and 8pm. The bottle of medication in the home had discard after 10/4/23 on the pharmacy label. CVS Purelax Powder, take one capful (17 grams) in liquid at 8pm every day by mouth. The pharmacy label had date filled of 2/19/21 for the medication. Benefiber Powder, take 2 tablespoonsful by mouth at 8am with breakfast and 5pm with dinner daily. The date filled on the pharmacy label was 2/10/21. These medications remained in the home and have not been disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Life share Provider has disposed of expired/discontinued meds at their local pharmacy. Current medications also reviewed to document future expiration dates |
10/31/2023
| Implemented |
| 6500.135(g) | Individual #1 is prescribed medications to treat symptoms of a diagnosed psychiatric illness. Individual #1 had a 3 month psychiatric medication reviews on 3/27/23, 5/18/23, and 8/7/23 and the form used did not include the reason for prescribing the medication. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Life Share Specialist have been trained on documentation of medication within the center¿s new electronic health record on 11/09/2023. All medications noted as active for individuals have been updated to reflect reason medication is prescribed. |
10/31/2023
| Implemented |