| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 had annual physical examinations completed on 01/18/24 and 02/06/25, which exceeds the maximum timeframe for annual completion. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The agency acknowledges the citation regarding the timeframe between Individual #1's annual physical examinations. The most recent annual physical examination was completed on 02/06/2025, ensuring the individual currently has an updated physical on file. |
03/12/2026
| Implemented |
| 6400.181(d) | The 12/12/25 Individual Assessment was not signed and dated by the Program Specialist. | The program specialist shall sign and date the assessment. | Halia acknowledges the citation regarding the 12/12/2025 Individual Assessment not being signed and dated by the Program Specialist.
Corrective Action Completed:
The assessment was reviewed, signed, and dated by the Program Specialist immediately upon identification of the deficiency, bringing the document into compliance with ODP requirements. |
01/26/2026
| Implemented |
| 6400.181(e)(1) | The 12/13/24 and 12/12/25 Annual Assessments for individual #1 were completely identical in content. Assessments cannot be completed simply to meet the regulatory or programmatic requirements. Providers must develop assessments that are meaningful, accurate, and useful. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The agency acknowledges that the citations regarding the Annual Assessments dated 12/13/2024 and 12/12/2025 are identical in content.
Corrective Action Completed:
The 12/12/2025 Annual Assessment was reviewed and updated by the Program Specialist to accurately reflect the individual's current functional strengths, needs, and preferences, ensuring the assessment is individualized and meaningful in accordance with ODP requirements. |
01/26/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of psychiatric illness which require review by a licensed professional every 3 months. A review was completed on 04/11/25, and the next review took place on 12/02/25, over 7 ½ months later. | 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. | The agency acknowledges the citation regarding the delay between psychiatric medication reviews for Individual #1. The delay occurred due to the abrupt closure of Chester Crozer and Taylor Hospitals, which significantly limited access to psychiatric providers in the area and made it difficult to secure timely appointments.
Corrective Action Completed:
A psychiatric intake and medication review was successfully completed on 12/02/2025 by a licensed professional, bringing the individual's medication monitoring back into compliance. |
12/02/2025
| Implemented |