| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | Individual #1's 8/7/25 and their 8/5/24 physical examinations noted NA for hearing. Individual #1 had an audiologist appointment on 6/12/25, and the form noted "could not test". Individual #1 had an audiologist appointment on 6/18/24, and their hearing was within normal limits". Individual #1 did not have a complete hearing examination in 2025. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Medication appointment summary form has been developed specifically for hearing exams. This will indicate the specific outcome of the examination including whether it was successful or unsuccessful.
Individual's desensitization plan was amended to include dates and description of education given to individual for each unsuccessful hearing examination, |
12/19/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination dated 8/7/25 did not include the assessment of the individual's health maintenance needs, medication regimen and the need for bloodwork at recommended intervals as this section(s) were left blank on the form. | 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. | Individual's PCP has since completed the health maintenance needs, medication regimen and the need for bloodwork on the individual's physical assessment document. |
12/22/2025
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination performed on 10/4/25, and then not again until 11/7/25. This exceeds the 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. | Given the difficulty obtaining dental appointments, Program Manager will ensure that the dental office provides documentation indicating that appointment given is the first available. This will prove that appointments exceeding requirements were outside the Agency's control. |
12/19/2025
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Fluticasone Spr 50, use 2 sprays in each nostril daily. The pharmacy label on the medication had a dispense date of 10/22/2025, and the medication box had 120 metered sprays. At the time of the inspection, the bottle of medication was approximately ¾ of the way full and should have used approximately 108 sprays (18 in October, 60 in November, and 31 in December at the time of the inspection). The medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | The Agency has purchased date opened stickers that will be utilized for nasal sprays not opened immediately upon receipt from the pharmacy. |
12/19/2025
| Implemented |