Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(1) | Individual #1's physical examination, completed 6/17/2024 did not include a review of past medical history. | The physical examination shall include: A review of previous medical history. | Residential supervisors addressed the missing documentation in the physical examination by coordinating with healthcare providers to gather the necessary information. Once retrieved, they attached the missing documentation to the physical examination form. |
10/25/2024
| Implemented |
6400.141(c)(11) | Individual #1's physical examination, completed 6/17/2024 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 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. | Residential supervisors addressed the missing documentation in the physical examination by taking action to retrieve the necessary information. They worked with healthcare providers involved in the patient's care to gather the undocumented details. Once the missing documentation was obtained, supervisors attached it to the physical examination form. |
10/25/2024
| Implemented |
6400.181(e)(1) | Individual #1's assessment, completed 5/9/2024 did not include functional strengths, needs, preferences of the individual. This section was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The program specialist took the initiative to review all skills assessments for any incomplete sections. After identifying the missing information in Individuals assessment, she quickly filled in the blank with detailed insights about the individual's strengths, needs, and preferences. Once this important information was updated, the program specialist informed the treatment team of the changes. |
10/25/2024
| Implemented |
6400.181(e)(10) | Individual #1's assessment, completed 5/9/2024 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The program specialist reviewed all skills assessments for any incomplete sections. Upon discovering the missing lifetime medical history, she used the new form to document this essential information within the assessment. After updating the details, the program specialist quickly informed the treatment team of the changes. |
10/25/2024
| Implemented |
6400.181(e)(12) | Individual #1's assessment, completed 5/9/2024 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. | The program specialist proactively reviewed all skills assessments for any incomplete areas. Upon discovering that recommendations for specific training, programming, and services were missing, she completed all relevant sections of the assessment. After updating the necessary details, the program specialist promptly informed the treatment team of the changes. |
10/25/2024
| Implemented |
6400.182(c) | Individual #1's assessment, completed 5/9/2024 indicates Individual #1 independently tempers water. Individual #1's Individual Plan, last updated 9/20/2024 reads that Individual #1 may require assistance to properly temper water. [Repeated Violation, 10/31/23-11/1/23 et al.] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist updated the Individual Plan to accurately reflect the current assessment findings. This involved modifying the language to align with the assessment results, ensuring clear communication regarding the support required by Individual #1. After making the necessary changes, the program specialist promptly informed the treatment team about the updates, ensuring that all team members were aware of the revised information and could adjust their strategies accordingly. |
10/25/2024
| Implemented |