| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(h) | 6400.163 (h) Medication Ciclopriox Sol. 8% found with the current medications, but it was not listed on the MAR. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Immediately upon discovery, the medication was removed from the home and brought to the Director of Nursing for proper disposal. |
03/07/2025
| Implemented |
| 6400.181(f) | 6400.181(f) - The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting, there was no record of this at the time of the review for individual number one. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | An assessment letter and ISP checklist was created by the CEO, for our IDT that will be referenced 60 days prior to the ISP meeting being held. This checklist outlines requirements as it relates to: Pre ISP Preparations, Required Materials for the ISP Meeting, During the ISP and Post ISP.
Assessment letters will be included |
04/21/2025
| Implemented |
| 6400.181(f) | The assessment was not sent to the plan team at least 30 calendar days prior to the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | An assessment letter and ISP checklist was created by the CEO, for our IDT that will be referenced 60 days prior to the ISP meeting being held. This checklist outlines requirements as it relates to: Pre ISP Preparations, Required Materials for the ISP Meeting, During the ISP and Post ISP.
Assessment letters will be included |
04/21/2025
| Implemented |