| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual 1 physical on 10/12/23 did capture all the necessary information that included pertinent information as it relates to case of emergency, record of immunizations, and/or communicable disease. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The CEO updated the agency¿s policies and procedures to include the updated annual physical form, which captures all of the pertinent information, including information as it related to case of emergency, record of immunizations, and/or communicable disease (See attachment #1). On 1/5/2024 all staff were retrained by the CEO on implementation of the mandatory physician form (see attachment 2). The quarterly review document was updated to include monitoring of ongoing compliance (See attachment 3). |
01/05/2024
| Implemented |
| 6400.142(c) | Individual 1 dental examination on 1-18-23, did not capture the dentist's name or what procedure was completed.. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | The CEO updated the dental form to include pertinent information, such as the date of examination, dentist¿s name, procedures completed and any recommended follow-up treatments (See attachment 6). On 1/5/2024 the CEO retrained all staff on utilizing the updated for, regulatory and agency requirements to ensure compliance, and the required information to make the document complete (see attachment 2). The CEO also updated the quarterly review to ensure ongoing compliance with the requirement (see attachment 3). |
01/05/2024
| Implemented |
| 6400.181(c) | The assessment for individual 1 that was completed on 7/14/23, did not list the source of the information.. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The CEO updated the annual assessment to include a specific section on where information was obtained from and the program specialist will indicate assessment instruments, interviews, progress notes or observations when completing the annual assessment (see attachment 4). On 1/4/2024, the CEO retrained the Program Specialist and director on the updated assessment (see attachment 5). To maintain ongoing compliance, the CEO updated the quarterly review assessment to include ongoing compliance review of active charts (see attachment 3). |
01/04/2024
| Implemented |