| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #2 had a breast exam on 11/8/17. She didn't have another breast exam until 12/18/18, which exceeds the annual requirement. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | We added "Breast exam/results (female)" to our annual physical exam form. Please see attached form. |
06/13/2019
| Implemented |
| 6400.163(c) | Individual #2 had psych med reviews on 5/8/18, 9/4/18, 1/3/19 and 4/2/19. The time periods between 5/8-9/4/18 and 9/4-1/3/19 exceed the 3 month requirement. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | FCS Psychiatric Visit form has been revised to indicate next appointment needs to be within 3 months and we have created a spreadsheet called Psychiatric Visit Tracker. See attachment
((Program Specialist and all FCS staff will be trained on the requirements of this regulations to ensure that the need to continue the medication and necessary dosage are included on visit forms. -CH 7/16/19)) |
06/13/2019
| Implemented |
| 6400.181(e)(13)(ii) | Motor skills were not assessed on Individual #2's assessment dated 7/12/2018. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Assessment Form was changed to separate the areas of motor skills and communication skills. See attached Assessment Form. |
06/13/2019
| Implemented |
| 6400.181(f) | Individual #2's ISP meeting was held on 8/10/2018. Her assessment was emailed to her team on 7/18/2018. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| We have created a tracking form with has both the Assessment and the ISP due dates. We will ensure that the ISP is not held until 30 days after the ISP is sent to the SC. See attached tracking sheet |
06/13/2019
| Implemented |