| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.143(a) | Individual #1's 08/14/25 Physical Examination does not include a gynecological or breast examination 141c7. The form states "declined/deferred" without a description of the attempts to train the Individual in the need for the procedure. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The program supervisor ensured that the appointment for gynecological and breast exam was made, the individual is on the cancellation list. A HCQU referral was made to educate the individual on this type of an appointment to ensure education and health awareness is completed. Going forward all supervisors and program specialists were retrained on the importance of ensuring all areas of the physical are completed, that individuals receive education if certain procedures or appointments are deferred, as well as desensitization plans in place when warranted for refuses or trauma. |
02/23/2026
| Implemented |
| 6400.144 | (Repeat violation from 05/12/25) Individual #1 had a "necrotic tooth" discovered during a dental examination on 6/17/25; a referral was made on that date to an oral surgeon, however, no removal has been completed or scheduled as of 02/19/26. | 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.
| Due to the complications of getting into oral surgeons in a timely manner, the plan of correction includes a UBO (Unusual Behavioral Observation report), regular doctor and dentist visits to ensure person is free from infection or if they are in need of antibiotics and appointment is scheduled and they are on the cancellation list to get in sooner if possible. The UBO is completed every awake shift and ensures that staff are ensuring the individual is remaining healthy. Individual #1 has an appointment scheduled for 3/9/26. |
02/23/2026
| Implemented |
| 6400.181(e)(3)(ii) | The 01/29/26 Annual Assessment does not include a review of "acquisition of functional skill". | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | The assessment was updated to reflect the communication section of the Functioning Skills section. The PS was retrained on the template of the assessment and the checklists to ensure all sections are accounted for and meeting the standard of the regulation.
The addendum was sent to the team, reviewed with the individual and staff were trained. |
02/24/2026
| Implemented |
| 6400.181(e)(7) | The 01/29/26 Annual Assessment does not clearly state if Individual #1 can sense and move away quickly from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment was updated to reflect the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F. The addendum was sent to the team, reviewed with the individual and staff were trained. |
02/24/2026
| Implemented |
| 6400.181(e)(12) | Individual #1 01/29/26 Annual Assessment does not include a review of "Programming" or "Services", these sections reference the needs of another Individual. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment was updated to reflect individuals training, programming and services. Individual has started CPS services and this now is reflected in their abilities of programming services. All staff were retrained on the addendum. |
02/24/2026
| Implemented |
| 6400.212(a) | Individual #1's 01/29/26 Annual Assessment includes information for a different Individual. | A separate record shall be kept for each individual.
| The assessment was updated and the other individuals information was extracted from the assessment.
The PS was retrained on the importance of not using others folks assessments as a template and always using the empty template submitted in the corrective action piece. |
02/24/2026
| Implemented |
| 6400.166(b) | Staff did not document on Individual #1's MAR that they received their 8pm meds on 2/8/26. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff were retained to go back through the Point Click Care system to ensure their med pass is documented. If there is a glitch in the system it can then be addressed in real time to prevent documentation errors going forward. If the computer is having issues a paper MAR can be competed. All materials are submitted to show no further issues on documentation. |
02/24/2026
| Implemented |
| 6400.181(f) | (Repeat violation from 05/12/25) Individual #1 Annual Assessment was sent to the Individual Support Plan (ISP) team on 02/04/26, not more than 30 days prior to the scheduled ISP meeting on 02/25/26. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The PS, updated their tracking form and ensured all dates are updated and correct future compliance. They were retrained on the importance of keeping these documentation as part of their responsibility for overseeing the assessment and compliance. |
02/24/2026
| Implemented |