| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(f) | There were no paper or cloth towels in bathroom- they were replaced during inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Paper towels were replaced at the time of inspection. |
04/11/2022
| Implemented |
| 6400.141(c)(1) | The physical examination form for Individual #1, dated 06/15/2021, does not indicate if the physician reviewed the individual's medical history, this portion was left blank. | The physical examination shall include: A review of previous medical history. | The Physical form was corrected by the Physician. Please refer to attachment 11 |
04/11/2022
| Implemented |
| 6400.141(c)(6) | On the Annual Physical Examination form for Individual #1, dated 06/15/21, the Tuberculosis (TB) was not indicated on the form of when the last test was given or read. The exam form dated 6/18/20 also states see attached and nothing is attached. | 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. | The physician has been contacted for an appointment for individual #1 to have TB test completed. Individual #1 can only have labs when under anesthesia. Special Smiles contacted for an appointment set for 07/13/2022, which was the soonest available. Individual #1 will be under anesthesia and TB test along with labs will be performed. |
04/11/2022
| Implemented |
| 6400.165(b) | The following medications for Individual #1 were not available:
Vitamin D3-provider states last one taken today and discarded in dumpster outside not in the home trashcan-not in med box at inspection
Melatonin 2.5mg 2 gummies (5mg) by mouth at bedtime not in med box at inspection, however, 3/28 dosage given- waiting for script according to provider | A prescription order shall be kept current. | Medication blister packages will remain onsite and only be disposed of when new packages are on site. Please refer to attachment 5 |
04/16/2022
| Implemented |
| 6400.181(f) | Staff did not provide the assessment to the ISP team members at least 30 calendar days prior to the plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Annual assessment has been sent to Supports coordinator. |
04/11/2022
| Implemented |