| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(11) | Individual #1, date of admission 3/17/23, had a physical examination completed on 9/21/22, which did not include an assessment of their health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Program Specialist will obtain the missing information from the PCP that outlines an assessment of their health maintenance needs, medication regimen and the need for blood work at recommended intervals. |
09/29/2023
| Implemented |
| 6400.141(c)(12) | Individual #1, date of admission 3/17/23, had a physical examination completed on 9/21/22, which did not include their physical limitations. | The physical examination shall include: Physical limitations of the individual. | The Program Specialist will obtain the missing information from the PCP that outlines individuals physical limitations. |
09/29/2023
| Implemented |
| 6400.141(c)(14) | Individual #1, date of admission 3/17/23, had a physical examination completed on 9/21/22, which did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist will obtain the missing information from the PCP that outlines medical information pertinent to diagnosis and treatment in case of an emergency. |
09/29/2023
| Implemented |
| 6400.165(g) | Individual #1, date of admission 3/17/23, is prescribed psychotropic medication. Their record did not include any documentation of every having any 3-month medication reviews conducted. | 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 Specialist has scheduled individual with psychiatrist. This appointment is scheduled for 9/13/2023. |
09/29/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's August 2023 Medication Administration Record did not include the diagnosis or purpose for the prescribed Furosemide 20 MG Tab, Desmopressin Tab .2 MG, and Ear Drops DRO 6.5%. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Individual's Medication Administration Record was corrected to include the diagnosis and purpose for the prescribed Furosemide 20MG Tab, Desmopressin Tab .2 MG, and Ear Drops DRO 6.5%. All other medications and Medication Administration Records were checked for accurate information and were accurate. |
09/01/2023
| Implemented |