| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The 11/22/2024 letter to the fire department has not been updated since both individuals moved into the home. It also does not identify the exact location of the individual's bedrooms, and if they need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The fire letter was updated and sent out via certified mail to the fire chief on 10/14/25. The updated letter included the locations of the individuals' bedrooms and the assistance required for each individual to evacuate in the event of an actual fire. |
10/14/2025
| Implemented |
| 6400.141(c)(4) | The 04/25/2025 physical for Individual #2 did not contain vision and hearing screenings, and no supplemental screenings could be found in the individual's record. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The correct physical form was obtained and then sent out to Individual #2's PCP on 9/23/25. A hearing test was scheduled for 10/16/25 and a vision test was scheduled for 10/31/25. |
09/23/2025
| Implemented |
| 6400.141(c)(6) | The record for Individual #2 did not contain a Tuberculin skin test. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | We contacted Individual #2's physician to request a tuberculin skin test which was scheduled for 10/15/25. |
10/13/2025
| Implemented |
| 6400.141(c)(9) | The record for Individual #1 did not contain a prostate examination. The individual is over 40 years old.
The record for Individual #2 did not contain a prostate examination. The individual is over 40 years old. | The physical examination shall include: A prostate examination for men 40 years of age or older. | We contacted Individual #1's physician and scheduled a prostate exam for 10/31/25. |
10/13/2025
| Implemented |
| 6400.141(c)(13) | The 04/25/2025 physical for Individual #2 did not address allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | The correct physical form was sent out to Individual #2's PCP on 9/23/25 to be completed fully. The PCP completed and returned the form to include allergies. |
09/23/2025
| Implemented |
| 6400.141(c)(15) | The 04/25/2025 physical for Individual #2 did not address if the individual has any dietary needs and/or special dietary instructions. | The physical examination shall include:Special instructions for the individual's diet. | The correct physical form was sent out to Individual #2's PCP on 9/23/25 to be completed fully. The PCP completed and returned the form to include any dietary instructions. |
09/23/2025
| Implemented |
| 6400.142(a) | There is no record of Individual #1 participating in a dental exam. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A dental appointment was scheduled for Individual #1 on 9/26/25 which he attended but declined to be examined while there. Documentation of refusal was obtained. |
09/26/2025
| Implemented |
| 6400.151(c)(4) | The physical for Staff #1 does not contain information pertaining to medical problems which might interfere with the health of the individuals. On the physical form, the section to address this was left blank. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Staff #1 returned the form to the physician and had the section completed. |
09/15/2025
| Implemented |
| 6400.166(a)(11) | With the exception of Melatonin, Individual #1's Medication Administration Record and medication labels did not contain the diagnosis or purpose for the 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. | Program specialist contacted the pharmacy and Individual #1's PCP to have the diagnosis/purpose of each medication listed on the MAR. |
10/01/2025
| Implemented |