Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.81(k)(6) | There was no mirror in individual 1 and individual 2's bedroom. | In bedrooms, each individual shall have the following: A mirror. | The bedroom mirrors were missed during house setup. |
10/01/2022
| Implemented |
6400.141(a) | There is no current up-to-date physical for individual 1. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | We sent individual 1 for a physical. |
10/01/2022
| Implemented |
6400.217 | There is no release of information form signed by individual 1. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| This was missed during intake. |
10/01/2022
| Implemented |
6400.217 | There is no release of information form signed by individual 2. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| This was missed during intake. |
10/01/2022
| Implemented |
6400.165(g) | Individual 2 had a gap in his psychiatric medication reviews greater than three months. He had appointments on 2/10/22 and 8/17/22 | 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. | We plan to track doctors appointments and visits for each individual. |
10/01/2022
| Implemented |
6400.166(b) | Synthroid 15 mg was not initialed on September 14, 2022. Vitamin b-12 500 mg was not signed September 14, 2022 | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | We have retrained staff on documenting correctly. |
12/01/2022
| Implemented |