| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(11) | Individual #1's annual physical dated 2/4/25 did not include recommendations for health maintenance. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The provider will ensure that the Physical exam is complete, including recommendations for health maintenance. NLHS will ensure that all the boxes are checked and all recommendations are completed by the physician completing the form. If the physician doesn't complete the form prior to moving into our agency, NLHS will ensure a new physical is completed by urgent care or a new physician. |
01/21/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's annual physical dated 2/4/25 did not include information pertinent to treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The provider will ensure that Physical exam is complete, including recommendations for health maintenance. NLHS will ensure that all the boxes are checked and all recommendations and information pertinent to treatment in case of an emergency are completed by the physician completing the form. If the physician doesn't complete the form prior to moving into our agency, NLHS will ensure a new physical is completed by urgent care or a new physician. |
01/21/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment completed on 6/20/25 did not include recommendations for specific areas of training. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The personal planning section of the assessment will be completed on the initial assessment annually. |
01/09/2026
| Implemented |
| 6400.165(c) | Individual #1's prescribed PRN Acetaminophen 400 mg and PRN Acetaminophen 500 mg per the Medication Administration Record. The medication available in the home was a 325 mg pill with instructions to take two pills as needed (650 mg). | A prescription medication shall be administered as prescribed. | The provider corrected the documentation error on the Medication Administration Record, reflecting the Acetaminophen 325 mg PRN. Medication Certified Staff were all reminded of the importance of paying attention to detail when administering medications. |
01/09/2026
| Implemented |