| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1's, date of birth 12/28/2003, only gynecological examination on file was conducted on 3/28/2025. There is no documentation of a pap smear being completed for Individual #1. | 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. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. If a pap smear, breast examination, and/or gynecological examination is not conducted by a medical provider, ABDD will request documentation for a recommendation from the doctor on letterhead specifically to those three procedures. Otherwise, it will be completed annually. |
12/12/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 9/9/2025, did not include medication information pertinent to diagnosis and treatment in case of an emergency. This section was left blank on the physical examination form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. Those attending appointments will ensure that the medical office completes forms in their entirety without blanks. |
12/12/2025
| Implemented |
| 6400.142(a) | Individual #1's dental examinations were completed on 9/8/2023 and then again on 2/12/2025. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. |
12/12/2025
| Implemented |
| 6400.143(a) | Individual #1 refused a dental examination on 11/12/2025 but the continued attempts to train the individual about the need for health care were not documented in the individual's record. Individual #1 refused a physical examination on 9/4/2025 but the continued attempts to train the individual about the need for health care were not documented in the individual's record. Individual #1 refused a psychiatric medication review on 5/12/2025 but the continued attempts to train the individual about the need for health care were not documented in the individual's record. | 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 Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. Dental appointments will be scheduled within 1 year of the last appointment. Program Managers will document any refusals on Therap with any correlating education and counseling, Program Specialists will meet with the individual monthly to provide education and counseling on the importance of attending appointments. This will be documented on the quarterly review. |
12/12/2025
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication review completed on 9/22/2025 did not include the need to continue the prescribed medications. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. Those attending appointments will ensure that the medical office completes forms in their entirety without blanks. |
12/12/2025
| Implemented |
| 6400.169(a) | Direct Service Worker #1, date of hire 2/17/2025, completed their initial medication administration training on 5/29/2024, prior to their hire at this agency. Upon hire, the agency's medication administration trainer failed to complete the Practicum Summary prior to the staff administering medications. Since their date of hire on 2/17/2025, Direct Service Worker #1 has been observed administering medications five times; twice on 3/31/2025, twice on 4/1/2025, and once on 8/3/2025, however only one medication administration record review was completed. Direct Service Worker #1 did not complete all renewal requirements to be recertified to administer medications on 5/29/2025. Direct Service Worker #1, who is not qualified to administer prescription medications, administered Citalopram Tab 20 MG with directions to take 1 and ½ tables by mouth once daily for depression to Individual #1 on 11/6/2025, 11/9/2025, 11/10/2025, 11/11/2025, 11/20/2025, and 11/24/2025 at 8:00 AM. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | HR was retrained on the regulation. The provider will have all newly hired staff complete the department's medication administration training within the first 6 months of employment. Direct Service worker #1 will be attending a medication administration training on December 16-17, 2025. |
12/11/2025
| Implemented |