| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(d) | Individual #1's, date of admission 10/28/24,. initial dental examination, completed on 11/7/24, did not include teeth cleaning or gums and dentures checks. | The dental examination shall include teeth cleaning or checking gums and dentures. | The dental examination shall include teeth cleaning or checking gums and dentures.
The individual will have a cleaning at their next dentist appointment on June 30, 2025.
The dentist will preform teeth cleaning at the next appointment June 30, 2025 |
06/30/2025
| Implemented |
| 6400.151(c)(2) | Direct Support Professional #1, date-of-hire is 3/1/24, had a tuberculin evaluation completed on 3/4/24. This is not prior to employment. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Tuberculin skin testing will be completed prior to employee's dates of hire.
HR and the registered nurse will make the change.
Changes have already been implemented. New employees beginning Monday, February 17, 2025, had a tuberculin skin test placed and read by their date of hire.
Employees are unable to start employment until Tuberculin skin test has been read. Corrective actions are in the process of being written for all current employees and should be completed by 2/21/25.
In-service training detailing regulation 6400.151(c)(2) has been provided to the HR department and nursing department. |
02/21/2025
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment, completed on 11/30/24, did not address their supervision needs. Regarding supervision in the home, Individual #1's assessment indicated only that they can be left alone for less than two hours but neither specified the area(s) within the home where Individual #1 can be unsupervised nor the type(s) of supervision that should be applied when Individual #1 requires it. Individual #1's assessment did not address supervision needs in the community. | The assessment must include the following information: The individual's need for supervision.
| The individual's need for supervision will be updated in the functional assessment.
The PS will update the functional assessment to included more details of what supervision is needed in the home and community.
The PS will have the assessment updated by 2/28/25 to have clear details about the supervision needs.
The provider is updating the functional assessment to ask more questions and clarify supervision needs. |
02/28/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's current assessment, completed on 11/30/24, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Lifetime medical history will be completed for the individual and included in the assessment.
PS will update the assessment to complete the lifetime medical history portion of the assessment.
The lifetime medical history will be added to the assessment by 2/28/25 for this individual.
The functional assessment document is being updated to include the lifetime medical history instead of it being it's own form. |
02/28/2025
| Implemented |