| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(12) | Individual #1's physical examination completed on 9/29/2025 did not address physical limitations of the individual. This section was left blank. | The physical examination shall include: Physical limitations of the individual. | The physical examination form for Individual #1 was taken to the PCP on 4/27/2026 and the PCP reviewed the form and verified that all sections of the form were updated and complete. There are no longer blanks on Individual #1's physical examination form. |
05/29/2026
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination completed on 9/29/2025 did not address allergies of the individual. This section was left blank. | The physical examination shall include: Allergies or contraindicated medications. | The physical examination form for Individual #1 was taken to the PCP on 4/27/2026 and the PCP reviewed the form and verified that all sections of the form were updated and complete. There are no longer blanks on Individual #1's physical examination form. |
05/29/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 9/29/2025 did not address medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination form for Individual #1 was taken to the PCP on 4/27/2026 and the PCP reviewed the form and verified that all sections of the form were updated and complete. There are no longer blanks on Individual #1's physical examination form. |
05/29/2026
| Implemented |
| 6400.181(a) | Individual #1's annual assessments were completed on 6/09/2024 and then again on 6/25/2025. This exceeds the annual requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual #1's annual assessment will be completed and reviewed with them by 6/25/26. The Program Director reviewed documentation with the program specialist in regard to the deadline and that it must be submitted to the program director for review by that date prior to being sent to the rest of the team. |
06/25/2026
| Implemented |