| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 has not had a physical exam completed in the last 12 months. The last exam was completed on 5/25/21. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Director contacted a provider of In Home Medical Care regarding Individual#1. Individual #1 has a history of refusing to leave her home for medical appointments. On 9/28/2022 the provider was contacted. The Provider is contacting the individual's insurance companies to set up transfer of information so services can begin. When the in home appointment is completed, documentation will be provided. |
10/31/2022
| Implemented |
| 6400.141(c)(6) | Individual #1 last tuberculosis test was completed on 10/4/18, over three years ago. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Program Director contacted a provider of In Home Medical Care regarding Individual#1. Individual #1 has a history of refusing to leave her home for medical appointments. On 9/28/2022 the provider was contacted. The Provider is contacting the individual's insurance companies to set up transfer of information so services can begin. When the in home appointment is completed, documentation will be provided. |
10/31/2022
| Implemented |
| 6400.217 | Individual #1's file was missing signed consent for information release to include photographs | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Form was developed to authorize consent for photographs. Site Supervisor reviewed the Photography Release Form with the individual. Document will be attached. |
10/04/2022
| Implemented |
| 6400.165(g) | Individual #1 last psychotropic medication review was completed in March 2022. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Site supervisor will work along with Med Coordinator to ensure that reviews are scheduled and paperwork forward to physician and returned in a timely manner. Individual had a Telehealth Appointment on 8/29/2022. |
08/29/2022
| Implemented |