| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | Vision and hearing were omitted on Ind. 1 physical form dated 07/22/22. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 1. These have been located in the individuals file. Vision was completed on 5/10/22 and hearing completed 1/22/22. |
12/09/2022
| Implemented |
| 6400.141(c)(7) | The gynecological examination including a breast examination and a Pap test was not addressed on the physical address dated 07/22/22 for Ind. 1. | 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. | A GYN was contacted and an appointment has been made for 3/23/23- the first available |
02/23/2022
| Implemented |
| 6400.144 | Based on Ind. 1 MAR the agency provided it cannot be determined if the prescription medication was administered as prescribed from 09/08/2022 through 09/12/2022. The blister packs are not matching the dates on the MAR when medication is being administered. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This was a documentation error on the blister pack. |
12/09/2022
| Implemented |
| 6400.144 | Ind. #1 is prescribed controlled substance medication; the agency does not have a logging system to determine the total count of the medication. The MAR provided does not indicate, show, or provide the controlled substance total as the blister pack is not matching what is administered. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 1. A controlled substance count sheet was implemented at the home. |
12/09/2022
| Implemented |
| 6400.165(b) | Medication(s) FFOLIC ACID TAB 1000mg and VITAMIN B-6 TAB 100mg. Where in Ind. 1 medication box and not listed on the MAR. | A prescription order shall be kept current. | 1. The Area Director contacted the physician for clarification and these have been added to the MAR. |
12/09/2022
| Implemented |