| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual 1 had annual physicals completed on 1/8/25 and 2/11/26. The time between these two dates exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual 1 has a documented history of non-compliance with medical appointments. He continues to receive care from his established primary care physician, who conducts visits at his brother's residence. Due to limited provider availability, the physician was unable to complete the annual physical within January 2026, resulting in the appointment being scheduled and completed in February 2026. The Program Specialist will closely monitor Individual 1's medical appointment schedule to ensure timely completion of annual physical examinations. |
03/08/2026
| Implemented |
| 6400.141(c)(6) | Individual 1 was admitted on 8/8/23, did not have a TB test within a year prior to admission and has not had one to date. | 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. | Individual 1 has demonstrated a pattern of non-compliance with attending medical appointments to include TB testing. As a corrective action, the Program Specialist immediately after inspection coordinated with LabCorp to arrange an in-home lab visit to ensure the completion of the required testing. The TB test is currently scheduled for 4/14/26. |
03/05/2026
| Implemented |
| 6400.163(a) | The prescribed medication Carbamazepine Extended Release 300mg tablets for Individual 1 does not have a label on it. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | It was discovered after the inspections that the pharmacy label had fallen off the pill bottle. The Program Specialist contacted the pharmacy on 3/4/2026, following inspections and requested a replacement label. It was obtained and affixed to the bottle on 3/5/2026. |
03/05/2026
| Implemented |
| 6400.166(a)(4) | The medication storage included a prescription for Cephalexin 500mg for Individual 1 which was not found listed on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The medication had been administered for 14 days prior. At the time of inspections, the medication was no longer in use but left in the med box. Staff failed to record the Medication on the Medication Administration Record (MAR). at the time it was administered and could therefore not discontinue it on the MAR after the prescribed period ended. As a corrective action, the medication was removed from the medication box immediately on 3/4/2025 and returned to the pharmacy. Staff had retraining on Medication administration: The specific areas of retraining were Lesson 5: -Recording and Storing of Medication and Lesson 8: - Documentation. The med retraining was conducted by PPHS medication administration trainer. |
03/04/2026
| Implemented |