| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(a) | Individual #1 most recently had a dental examination performed by a licensed dentist on 05/08/24. No documentation of an additional examination more recently was provided. This exceeds the annual requirement. | 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. | The dental exam had already been scheduled, and a new exam date has been established. The next appointment will be set based upon the dental recomendations. |
06/30/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment dated 03/25/25 did not include the following information: preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The individual's assessment will be edited and include more depth and explanation to describe: Functional strengths, needs and preferences of the individual. |
06/30/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment dated 03/25/25 did not include the following information: the individual's need for supervision. This section was completely blank. | The assessment must include the following information: The individual's need for supervision.
| The individual's assessment will be edited and updated to include The individual's need for supervision. |
06/30/2026
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment dated 03/25/25 did not include the following information: the individual's ability to self-administer medication; the assessment simply indicated, "{Individual #1] has completed the necessary training to be self-medicating." The individual does not self-administer medication. | The assessment must include the following information: The individual's ability to self-administer medications. | The individual's assessment will be edited and updated to include: The individual's ability to self-administer medications. |
06/30/2026
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment dated 03/25/25 did not include the following information: the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials; the assessment simply checked a box that the individual had "adequate awareness". | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The individual's assessment will be edited and updated to include: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. |
06/30/2026
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment dated 03/25/25 did not include the following information: The individual's knowledge of water safety and ability to swim; the assessment simply checked a box indicating the individual had an "Adequate Awareness." | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The individual's assessment will be edited and updated to include progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. |
06/30/2026
| Implemented |
| 6400.166(a)(4) | Individual #1's Medication Administration Record for October 2025 did not include the following information for the medications: name of medication for Cyanocobalamin 1,000 MCG and Hydroxyzine HCL 10 MG Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The MAR was edited immediately to include the names of the medications. |
06/30/2026
| Implemented |
| 6400.166(a)(5) | Individual #1's Medication Administration Record for October 2025 did not include the following information for the medications: Strength of medication for Cyanocobalamin 1,000 MCG and Hydroxyzine HCL 10 MG Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The MAR was immediately edited to include: Strength of the medications. |
06/30/2026
| Implemented |
| 6400.166(a)(6) | Individual #1's Medication Administration Record for October 2025 did not include the following information for the medications: Dosage form of medication for Cyanocobalamin 1,000 MCG and Hydroxyzine HCL 10 MG Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The MAR was immediately edited to include: Dosage form. |
06/30/2026
| Implemented |
| 6400.166(a)(9) | Individual #1's Medication Administration Record for October 2025 did not include the following information for the medications: frequence of administration for medication for Cyanocobalamin 1,000 MCG and Hydroxyzine HCL 10 MG Tab. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The MAR was immediately edited to include: Frequency of administration. |
06/30/2026
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Record for October 2025 did not include the following information for the medications: diagnosis or purpose for medication Cyanocobalamin 1,000 MCG and Hydroxyzine HCL 10 MG Tab. | 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 MAR was immediately edited to include Diagnosis or purpose for the medication, including pro re nata. |
06/30/2026
| Implemented |
| 6400.207(5)(I) | On 10/9/25 at 9:35am Individual #2 had an assist bar inserted between the mattress, with legs that extended to the floor. It was explained that the assist bar was purchased after hip surgery to help position the individual in bed. This assist bar was not prescribed by a medical professional. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Post-surgical or wound care. | A doctor's order was given by the PCP and put the usage of the bar in compliance. |
06/30/2026
| Implemented |