| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The agency did not submit written notification to the local fire department for this home to address the following: the home's address and the exact bedroom location(s) of any individual(s) who require assistance to evacuate in an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A letter to the local fire departments in the locations of our homes received a letter with the following information:
a. Name of the home
b. The address of the home
c. The municipality of the home
d. A description of the services provided
e. The location of the person's bedroom
f. The capabilities of the person who resides in the home to exit in case of a fire |
03/05/2026
| Implemented |
| 6400.141(c)(7) | Individual #1 had annual gynecological examinations performed on 2/16/23, and then again on 4/24/25. This exceeds the annual requirement. 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. | This person's GYN exam was completed on 02/16/2023. Per the recommendation of the gynecologist documented on our medical form, this person was to return in 2-3 years for a repeat exam and pap smear. The appointment card given by the GYN office said call in February 2024 to schedule a February 2025 appointment. The Program Specialist called in February of 2024 to schedule a follow up. The first available appointment was on 04/24/2025 which fell within the 2-3 year time frame that was recommended and documented by the gynecologist. This person attended their April 2025 appointment and had a pap smear and annual GYN exam. Documentation on the April 2025 GYN exam was provided. |
03/10/2026
| Implemented |
| 6400.144 | Individual #1 had a physical examination completed on 2/15/24, when a vision screening was conducted. The attending physician's recommendations included a referral to an optometrist. However, these physician health recommendations were not arranged for or provided by the agency until 2/27/25, when Individual #1 had a vision examination completed by an optometrist. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This person had an eye examination while at their annual physical in February of 2024 which was documented on their physical paperwork where the doctor circled "WNL" on the paper stating this person's vision fell within normal limits. This person had an eye examination in February 2025 along with their physical again stating their vision was "WNL" on their annual physical evaluation. A call was made to the eye doctor requesting a copy of the 2024 eye examination paperwork. |
03/02/2026
| Implemented |