| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | On individual #1's annual physical, dated 11/3/22, under the section that says "special medical info for treatment in an emergency" it states see emergency plan. It appears to have been written by the physician as it is the same ink and handwriting, however the emergency medical plan is not attached to the physical. It is unclear if the emergency plan was reviewed by the physician during the physical appointment. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The provider will attach the emergency plan to the physical. |
10/15/2023
| Implemented |
| 6400.144 | At the time of inspection on 10/11/23, there was no plan in place for administering the PRN medication, hydroxyzine pamoate 25mg, for the diagnosis of anxiety. There was a physician's order for this medication, but it only stated to give as needed for anxiety up to 3 times per day. Symptoms of anxiety are unknown and exactly when the PRN should be administered is unknown. Individual #1 has not been administered this medication at all during the review period. The above information (symptoms, when to administer) failed to be addressed with the prescribing physician during quarterly psychiatric reviews. | 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.
| A PRN protocol was developed and implemented. |
10/15/2023
| Implemented |
| 6400.181(e)(1) | The initial assessment for individual #1, dated 2/26/23, and the updated assessment from 6/25/23, do not address individual's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment was updated and preferences were added under the correct heading in the assessment. |
10/15/2023
| Implemented |
| 6400.181(e)(7) | The initial assessment for individual #1, dated 2/26/23, and the updated assessment from 6/25/23, do not address individual #1's ability to sense and move away from heat sources which exceed 120 degrees and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment was updated to clarify the ability to move away from heat sources that exceed 120 degrees and are not insulated. |
10/15/2023
| Implemented |
| 6400.181(f) | The annual assessment for individual #1 dated 2/26/23 was not sent to all individual plan team members. | 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 assessment was sent to all team members on 10/15/2023. |
10/15/2023
| Implemented |