| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | An individual shall have a physical exam prior to admission and annually thereafter. Individual #1 had a preadmission exam on 3.21.24 and the following exam was not until 4.15.25, this exceeds the annual time frame. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Provider will ensure that individual's physical exam will be completed annually and within required timeframe |
03/10/2026
| Implemented |
| 6400.141(c)(14) | The annual physical dated 4.15.25 did not list medical information pertinent to diagnosis and treatment in case of an emergency. This area of the physical was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The annual physical paper was returned back to the provider and correction was made listing medical information pertinent to diagnosis and treatment in case of emergency. |
03/10/2026
| Implemented |
| 6400.142(g) | The individual shall have a dental hygiene plan written annually. There was not one. | A dental hygiene plan shall be rewritten at least annually. | Provider already had a dental hygiene form that will be submitted to the dentist to complete in the next dentist appointment scheduled on June 18, 2026. |
03/10/2026
| Implemented |
| 6400.144 | Health services such as dental shall be provided for. Individuals had a dental exam on 4.15.25 with a 6 month follow-up. Individual did not go back to the dentist until 12.15.25, this exceeds the time frame. | 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.
| Provider will ensure that the next dental appointment ( scheduled on 6/18/26) will take place. All future appointments will be completed within the required 6 months time frame. |
03/10/2026
| Implemented |
| 6400.211(b)(1) | The emergency record shall reflect the name address and telephone number and relationship of a designated person to be contacted in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| The emergency information record sheet has been created and all required data entered: the name, address, telephone number and relationship of a designated person to be contacted in case of emergency.
(Emergency Information face sheet is attached in the email) |
03/05/2026
| Implemented |