| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1's annual physical exam was completed later than 1 year apart.
The dates of those exams were 5/3/23 and 5/31/24 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | NOTE: The Individual¿s annual exams were conducted on May 3, 2023 and May 31, 2024. The 2024 physical was conducted less than thirty days after the 2023 physical expired because it was difficult to get an appointment with the PCP.
Correction ¿ Immediate Cure (Exhibits I, Training Record)
WHO:
Regulatory Compliance Specialist
Residential Director
Office Manager
WHAT:
We need to ensure that all appointments are scheduled and completed in a timely manner.
HOW:
We reviewed each Individual¿s health record to ensure that all the appointments are timely. We cured any deficiencies we encountered. |
06/30/2024
| Implemented |
| 6400.143(a) | Individual #1 is refusing dental appointments. Documentation needs to be provided showing continued efforts to provide training to the individual concerning attending appointments. | 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. | Correction ¿ Immediate Cure (Exhibits I, II and XIV)
WHO:
Residential Director
Regulatory Specialist
House Leads
WHAT:
We need to ensure that there is evidence of continued attempts to provide resources and guidance to Individuals who refuse routine medical and dental examinations.
HOW:
We provided additional resources to Individual #1, and he had several documented conversations with his support team regarding dental appointments. The problem is that Individual #1 does not want any additional services (dentures) other than routine dental cleaning. Therefore, we spoke to Individua #1¿s dentist about Individual #1¿s concerns. The dentist will not bring up the issue of dentures to Individual #1. Individual #1 is scheduled for a dental appointment on July 11, 2024. |
06/30/2024
| Implemented |
| 6400.181(e)(13)(i) | The annual assessment for individual #1 Dated 2/20/24 Does not reflect progress over the last year | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| NOTE: Prior to the licensing inspection on June 3, 2024, we used the Assessment and Lifetime Medical History to capture the progress of our Individuals within the year. The Lifetime Medical History is referenced as part of the Assessment under paragraph 8.
Correction ¿ Immediate Cure
WHO:
Regulatory Compliance Specialist
Program Specialist
WHAT:
We need to ensure that all assessments include the Individual¿s progress over a one year period, including their current level as it relates to health.
HOW:
We updated the assessments by merging the Lifetime Medical History with the assessment. All Individuals now have an updated assessment with 365 review and current information related to the Individual¿s health. |
06/30/2024
| Implemented |
| 6400.216(a) | There were individual program and medical records unlocked in the living room of the house. | An individual's records shall be kept locked when unattended.
| Correction ¿ Immediate Cure (Exhibits I, III and XV)
WHO:
Regulatory Specialist
Residential Director
House Leads
WHAT:
We need to ensure that each Individual¿s records are kept under lock when unattended.
HOW:
Each Individual¿s health record and program book has been placed under lock, and will remain under lock while not being used. |
06/30/2024
| Implemented |