| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1, date of admission 11/8/2023, did not have a physical examination completed within one year prior to admission. Individual #1's physical examinations were completed on 3/20/2022 and 12/8/2023. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physicals will be obtained within 12 months prior to admission as part of the admission process. |
09/30/2024
| Implemented |
| 6400.181(e)(11) | Individual #1's annual assessment, completed 12/18/2023, did not include a copy of the individual's psychological evaluation. Individual #1's psychological evaluation was completed on 3/15/2004 and was available at the agency office; however, the evaluation was not attached to the assessment and documentation could not be provided to verify that the evaluation was sent to the plan team. | The assessment must include the following information: Psychological evaluations, if applicable. | Corrected during inspection. Psychological evaluation obtained and placed in individuals file. |
09/26/2024
| Implemented |
| 6400.182(c) | Individual #2's record includes an order for an upper, right-side bedrail that is dated 10/11/2023. The bedrail has been ordered to prevent Individual #2 from falling out of bed. On 9/26/2025 at 12:15pm, Individual #2 demonstrated that he can utilize the bedrail independently and does not require assistance to engage or disengage the device. Individual #2's support plan, last updated 7/3/2024, does not include the need for the bedrail or the individual's ability to utilize the device independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program specialist contacted individuals SC to schedule meeting for ISP to be updated to include the need for a bedrail and his ability to utilize the device independently. Awaiting response regarding available dates for the meeting. |
10/16/2024
| Implemented |