| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1's most recent gynecological examination was completed on 10/17/2006. The physician noted on the examination form that an annual Pap smear was no longer required unless the individual were to experience breakthrough vaginal bleeding; however, there was no documentation deferring the annual gynecological examination, including a breast examination. 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. | Staff will obtain proper documentation from physician deferring gynecological exam, unless individual experiences breakthrough vaginal bleeding. |
01/09/2026
| Implemented |
| 6400.141(c)(8) | Individual #1's annual mammograms were completed on 9/20/2024 and again on 10/14/2025. This exceeds the annual mammogram examination requirement for women 50 years of age or older. Individual #1 is 50 years of age or older. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual #1's next mammogram will be scheduled for completion within 12 months of the previous exam (10/14/25) |
12/05/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment, completed by Program Specialist #1 on 4/25/2025, did not include recommendations for specific areas of training, programming and services. This section of the assessment stated, "Nothing more right now." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist will revise Individual #1's assessment to include specific recommendations for trainings, programming and services. |
12/29/2025
| Implemented |
| 6400.182(c) | Individual #1's annual assessment, completed by Program Specialist #1 on 4/25/2025, indicated that the individual was an assistance level "A, total assistance without any participation from the individual," for regulating water temperature; however, Individual #1's support plan, last updated 8/27/2025 indicated that, "[Individual #1] adjusts [their] water temperature when washing hands or showering. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. |
12/12/2025
| Implemented |