| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1 had a late gynecological examination. Individual #1 had a gynecological examination completed on 1/19/22 and did not have another until 2/23/23. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Client Services will schedule annual appointments immediately following this years appointment. |
08/01/2023
| Implemented |
| 6400.142(f) | Individual #1 did not have a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Client services called all dentists on record and received recommendations (8/1/23) |
08/15/2023
| Implemented |
| 6400.144 | Health services are not being planned for and arranged for Individual #1. Individual #1 had a dental examination on 8/24/22 and the documentation states, "patients has a deep cavity; tooth needs root canal and fill," There was an appointment scheduled for 12/29/22 that was missed for a dental extraction and a note on the document stated, "Staff will call next week to reschedule." There are no documented attempts to reschedule the appointment. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| ANy recommendations that re unable to be scheduled due to wait lists or refusals will receive mandatory documented monthly attempts (7/31/23 and ongoing, Client Services)
((Individual #1 had dental work completed 8/1/23 -CH 8/17/23)) |
07/31/2023
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment dated 7/16/22 did not assess the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | 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. | Poison Safety question was added retroactively to all 2022/2023 Annual Assessments. |
07/24/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment dated 7/16/22 did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Assessments that did not have a recommendation were updated to include recommendations
Training was completed with Client Services to ensure that there was understanding for what was required in the annual assessment. |
08/04/2023
| Implemented |
| 6400.32(r) | Individual #2's bedroom door lock was "coin key" lock, this type of lock does not provide the level of privacy and security of person and possessions as expected by the regulation. | An individual has the right to lock the individual's bedroom door. | Operations will make lock changes to all possible doors |
08/31/2023
| Implemented |
| 6400.34(a) | Individual #1 was not informed of individual rights. Individual #1 was informed of the individuals rights on 11/27/20 and was not informed of the individual's rights again until 1/6/22. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | All records were reviewed to check for any additional missing documentation. |
07/31/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. These medications were reviewed by a licensed physician on 1/11/23, 2/8/23, 2/22/23, 3/8/23, 4/12/23 and 7/12/23, these medication reviews did not include the necessary dosage of medications. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Medication lists will be attached to all psych notes for physician review and available when viewed in the scanned BOX paperwork (7/19/23 and ongoing)
Medical note updated to reflect Psychiatric med review of medications and the symptoms requiring ongoing treatment. |
07/21/2023
| Implemented |