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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(7) | Individual #1 has no record of a gynecological examination being completed. Individual #1 is 18 years of age or older. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1's PCP issued a letter dated October 20, 2025 on her office's letterhead stating that they should be exempt from any future gynecological or pap examinations. The letter further states to contact the Doctor's office with any questions. |
10/20/2025
| Implemented |
| 6500.34(a) | Individual #1 was informed of individual rights 1/15/2025 and the following rights were not included: 6500.32(a) An individual may not be discriminated against because of race, color, creed, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age., 6500.32(b) An individual has the right to speak freely, 6500.32(c) An individual may not be exploited, abandoned, 6500.32(d) An individual shall be treated with dignity and respect, 6500.32(e) An individual has the right to make choices and accept risks, 6500.32(f) An individual has the right to refuse to participate in activities and services, 6500.32(g) An individual has the right to control the individual's own schedule and activities, 6500.32(h) An individual has the right to privacy of person and possessions, 6500.32(j) An individual has the right to voice concerns about the services the individual receives, 6500.32(p) An individual has the right to choose persons with whom to share a bedroom, 6500.32(q) An individual has the right to furnish and decorate the individual's bedroom in accordance with § 6500.33 (relating to negotiation of choices), 6500.32(r) An individual has the right to lock the individual's bedroom door, 6500.32 (r)(1) Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door, 6500.32(r)(2) Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, 6500.32(r)(3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance, 6500.32(r)(4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, 6500.32(r)(5) The primary caregiver shall have the key or entry device to lock and unlock the door, 6500.32(s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home 6500.32(t) An individual has the right to access food at any time, 6500.32(u) An individual has the right to make health care decisions, and 6500.32(v) An individual's rights may only be modified in accordance with §6500.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | A new Individual Rights Form has been created by copying and pasting the exact text from the regulations. Therefore, the new form now meets the exact, detailed rights as denoted in the code. The new form was reviewed with the individual and they signed the form attesting that the rights have been reviewed with them. |
11/05/2025
| Implemented |
| 6500.135(g) | Individual #1 had a psychotropic medication review conducted 8/22/2024 and then again 2/18/2025. This exceeds the every 3-month requirement. The following psychotropic medication reviews conducted did not include the reason for prescribing the medication: 10/9/25, 9/5/25, 7/15/25, 5/5/25, 2/18/25, 8/22/24 | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A new form was created for medication reviews that includes the medication(s) with corresponding diagnoses. The form also denotes the date by which the next review must be completed. |
11/05/2025
| Implemented |
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