| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 date of admission 10/3/2025 had an initial physical examination on 10/6/2025. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical examinations will be obtained within 12 months prior to admission as part of the admission process. The admission process will include verification that the required physical examination has been completed prior to the individual's admission. |
09/04/2026
| Implemented |
| 6400.141(c)(5) | Individual #1 date of admission 10/3/2025 had a Tdap immunization booster on 10/6/2025. | The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. | Physical examinations, including Tetanus and Mantoux, will be obtained within 12 months prior to admission as part of the admission process. The admission process will include verification that the required physical examination has been completed prior to the individual's admission. |
09/04/2026
| Implemented |
| 6400.141(c)(6) | Individual #1 date of admission 10/3/2025 had a Tuberculin skin test completed on 10/9/2025. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Physical examinations, including Tetanus and Mantoux, will be obtained within 12 months prior to admission as part of the admission process. The admission process will include verification that the required physical examination has been completed prior to the individual's admission. |
09/04/2026
| Implemented |
| 6400.142(a) | Individual #1 date of admission 10/3/2025 has not had a dental examination. | 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 LPN contacted the individual's previous dental provider and was informed that the provider no longer accepts the individual's insurance. The LPN is coordinating with a new dental provider to schedule the individual's dental examination. Documentation of the completed dental examination will be obtained and maintained in the individual's medical record. [As per LPN and Residential Director on 9/17/2026, Individual has dental appointment scheduled 9/24/2026. (AES,HSLS on 9/17/2026)] |
09/04/2026
| Implemented |