| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(3) | Individual #1's most recent Tdap vaccination was completed on 1/17/2012. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 received his Tdap on 7/22/2022. |
08/15/2022
| Implemented |
| 6400.144 | At Individual #1's dental examination on 9/15/2021, the dentist referred Individual #1 to an oral surgeon to extract five fractured teeth and then return in six to nine months. The extractions were not completed until 4/18/2022. | 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.
| For individual#1 the doctor's letter was sent for verification of delay as well as corresponding hospitalizations, ER visits, wound care appointments cancelled appointments due to hospitalizations, etc. |
08/15/2022
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #2 had a tuberculin skin test that was read on 7/1/2021 by a medical assistant. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | DSW #2 is going to get a new Tuberculin test and have it read by a medical professional with the correct credentials by 08/12/2022. |
08/12/2022
| Implemented |
| 6400.181(a) | Individual #1's assessment was completed on 6/29/2021 and then again on 7/17/2022. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The late assessment has been completed on 7/17/22. |
08/01/2022
| Implemented |
| 6400.52(c)(6) | Program Specialist #1's annual training hours for training from January 1, 2021 to December 31, 2022 did not include implementation of the individual plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The ISP training verification sheets were turned in on 8/8/2022 for verification |
08/08/2022
| Implemented |
| 6400.166(a)(11) | Individual #1's July 2022 Medication Administration Record did not include a purpose or diagnosis for all Individual #1's prescribed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Individual #1's MARs have been corrected by his Direct Support Professionals on 07/27/22 to include the purpose or diagnosis for every medication prescribed. |
08/08/2022
| Implemented |