Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(7) | Individual #1 had a gynecological examination on 4/11/19 and then again on 6/26/20. | 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. | In order to prevent future violation and to ensure compliance, Program Specialist and CEO will monitor 6400.141(a)-(d) regarding Individual Physical Examinations on a monthly basis effective immediately. Documentation of monthly reviews will be kept. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely scheduling and completion of medical appointments including gynecological examinations. (DPOC by AES,HSLS on 2/16/21)] |
02/10/2021
| Implemented |
6400.142(a) | Individual #1 had a dental examination on 4/10/19 and then again 7/14/20. | 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. | Effective immediately, Program Specialist will conduct monthly reviews of Dental care as specified in 6400.142(a)-(h) to ensure compliance and prevent future violations. Documentation of the monthly reviews will be kept and monitored by CEO. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely scheduling and completion of medical appointments including dental examinations. (DPOC by AES,HSLS on 2/16/21)] |
02/10/2021
| Implemented |
6400.181(a) | Individual #1 had an assessment completed on 3/25/19 and then again on 9/9/20. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program Specialist will review 6400.181(a)-(f) regarding Assessments to ensure compliance and prevent future violations. Additionally, Program Specialist and CEO will conduct monthly reviews of each Assessment. Documentation of this review will be kept. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure accurate, up-to-date and timely completion of individual's assessments. (DPOC by AES,HSLS on 2/16/21)] |
02/10/2021
| Implemented |
6400.182(c) | Individual #1's assessment, completed 9/9/20 indicates that Individual #1 needs full assistance to identify, use, and safely be around poisonous materials. Individual #1's ISP, last updated 1/21/21 reads, "[Individual #1] understands precautions for handling and storage of poisonous materials. She also recognizes warning labels and danger signs." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program Specialist will communicate with the plan team (specifically the Supports Coordinator) regarding the assessment and update to the individual plan. The plan team will work together to ensure the individual plan is developed based upon the most current assessment and then when updated annually or revised as individual needs change. [Immediately, the CEO or designee shall develop and implement a tracking system and auditing process to ensure accurate, up-to-date and timely completion of individual's assessments. (DPOC by AES,HSLS on 2/16/21)] |
03/10/2021
| Implemented |