| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Direct Serviced Worker #1's most recent physical examination was completed on 1/14/19. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The DSP whose physical was out of date scheduled an appointment on 8/27/21 to complete the physical and TB. |
08/24/2021
| Implemented |
| 6400.151(c)(2) | Direct Serviced Worker #1's most recent Tuberculin skin testing by Mantoux method with negative results was completed on 1/16/19. | 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. | The DSP whose TB was out of date scheduled an appointment on 8/27/21 to complete the physical and TB. |
08/27/2021
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication review completed 11/16/20 did not include medications, dosages, or reasons for prescribing the medications. The documentation read "No med changes everything was fine". | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Executive Director provided prefilled Psychiatric Medication Review appointment forms to the House Manager and will continue to provide them as needed. |
08/13/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's August 2021 medication administration record did not include the purpose or diagnosis for the following medications: Vitamin D3 Cap, Calcium Citrate/Vitamin D, Clonazepam Tab, Divalproex Tab, Escitalopram Tab, and Vitamin B12. | 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. | The Executive Director wrote the diagnosis for each medication onto the MAR in the box with the name of the medication, rather than just being at the bottom of the MAR. |
08/12/2021
| Implemented |