| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(a) | Individual. #1 had a Dental Examination on 02/02/2022, and no documentation of any examinations after that were presented during inspection to measure compliance. This exceeds the annual requirement. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Residential house manager will maintain an electronic calendar with reminders set to help ensure compliance with all annual regulatory appointments. |
10/27/2023
| Implemented |
| 6400.142(g) | Individual #1's Dental Hygiene Plan was written and reviewed on 06/01/22, and then again on 07/07/23. This exceeds the annual requirement. | A dental hygiene plan shall be rewritten at least annually. | Programs specialists will maintain a spreadsheet documenting due dates of all annuals plans to ensure compliance. |
10/27/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness Individual #1 had a psychiatric medication review completed by a physician on 09/15/22, and then again on 01/26/23. This exceeds the every 3-month requirement. Individual #1 psychiatric medication reviews completed on 01/26/23, 04/06/23, 06/01/23, and 09/05/23 did not include the reason for prescribing the following medications: Sertraline 100mg and 50mg tablets and Lorazepam 2 mg tablet. | 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. | Residential homes managers will be retrained on the importance of health report forms for psych med reviews being completed appropriately prior to leaving med review appointments. |
10/27/2023
| Implemented |