| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(b) | Individual #1's physical examination, completed 10/29/2025, was not dated by the physician. The agency's physical examination form did not include a space for the physician to record the date with their signature. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | A physical examination must be completed, signed, and dated by an authorized medical professional (a licensed physician, certified nurse practitioner, or licensed physician's assistant). This regulation is essential for administrative accountability, authenticating the exam's accuracy, establishing a legal health record baseline, ensuring continuity of care, confirming the documented health status is current and validated.
The physical examination form was date on the front page, not immediately accompanying the healthcare provider's signature. To address this, the form was revised on January 9, 2026, to include a dedicated date line adjacent to the signature of the licensed physician, certified nurse practitioner, or licensed physician's assistant. This ensures the date is clearly linked to the professional's attestation. |
01/15/2026
| Implemented |
| 6500.121(c)(4) | Individual #1's physical examination, completed 10/29/2025, did not include a vision screening. This section of the physical examination was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Vision screening during an annual physical exam is crucial because it can help detect silent eye diseases like glaucoma and macular degeneration, as well as systemic conditions such as diabetes, high blood pressure, and high cholesterol before they lead to vision loss or severe complications. It also ensures any vision correction, such as glasses or contacts, is current, which helps prevent eye strain and headaches.
The individual declined a vision screening during the physical examination on October 29, 2025. This refusal was immediately documented by the physician on the examination form. The refusal will be maintained in the individual's record, and education on the importance of routine screening will be provided. |
01/12/2026
| Implemented |
| 6500.121(c)(7) | Individual #1 has no documentation of their most recent gynecological examination. Individual #1's physician indicated on their 10/30/2024 and 10/29/2025 physical examinations that a Pap smear was no longer required due to the individual's age; however, there was no documentation from the individual's physician deferring the annual gynecological examination. | 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. | A gynecological examination, including a breast examination and a Pap test, is required for women 18 years of age or older, unless a licensed physician provides documentation recommending no or less frequent examinations. This regulation is vital for the early detection of serious issues like cervical cancer, addressing debilitating symptoms such as urinary issues and discomfort, managing menopause-related changes, and creating opportunities for personalized care plans.
Documentation from the physician recommending no or less frequent gynecological examinations was not present. The physician immediately documented no gynecological examinations needed. Physicians statement, "Gynecological exam would most likely not be tolerated by patient and potential emotional distress outweighs benefits at this time." |
01/15/2026
| Implemented |
| 6500.136(a)(4) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the name of this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered, name of medication. It's crucial to have the medication name on the medication administration record (MAR) for the individual safety, preventing errors like wrong drugs or doses, ensuring continuity of care. The MAR acts as a vital, real-time log confirming the "right individual" preventing serious harm. The medication was omitted entirely from the MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(5) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the strength of this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered, strength of medication. It is crucial for patient safety, preventing errors like overdosing or wrong concentrations, ensuring accurate dosing, facilitating continuity of care and compliance standards by providing a precise record of treatment. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(6) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the dosage form of this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | A comprehensive medication administration record (MAR) must be maintained for each individual receiving prescription medication. This record is crucial for ensuring individual safety, preventing severe errors, and guiding appropriate care. The MAR must accurately document specific details for each administration, including the medication's dosage form (e.g., tablet, liquid). Administration needs vary by dosage form (e.g., whether a tablet can be crushed or not), which impacts the drug's effectiveness and reduces the risk of toxicity or adverse events. The medication was entirely omitted from an individual's MAR. Corrective actions were immediately taken: the MAR was corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence of the error. |
01/16/2026
| Implemented |
| 6500.136(a)(7) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the dose of this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | A medication record shall be kept, including the dose of medication. It's crucial to have the medication dose on the MAR to ensure individual safety by preventing errors, avoiding overdoses/underdoses, and enabling clear communication among healthcare providers about the exact amount of drug given, which is vital for accurate treatment, monitoring patient responses. Without the specific dose, tracking treatment effectiveness, identifying adverse events, and ensuring continuity of care becomes nearly impossible. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(8) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the route of administration for this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | A complete medication administration record (MAR) is essential for individual safety. It must include the route of administration (e.g., oral, intravenous, intramuscular) to ensure correct delivery, maximize drug efficacy, and prevent serious medication errors. Incorrect routes can lead to contraindications and impact the speed of action. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(9) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the frequency of administration for this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. Individual #1 is prescribed Docusate Calcium 240mg with instructions to take 240mg orally daily as needed for constipation. Individual #1's January 2026 medication administration record indicated that this medication was a standing order and was to be administered "by mouth once daily." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | A complete medication administration record (MAR) is essential for individual safety. It must include the frequency of administration Including frequency on the MAR is vital for individual safety. Requiring detailed frequency instructions (like "every 4 hours" or "once daily") to prevent errors and ensure effectiveness by maintaining therapeutic levels, preventing overdose, and guiding care for time-sensitive meds like insulin or antibiotics, making it a critical tool for accurate, safe medication delivery. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(10) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the administration time for this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | A medication record shall be kept, including the administration times. Recording these times on a Medication Administration Record (MAR) is critical for preventing errors such as missed or double doses. This practice ensures timely therapeutic effects for time-sensitive drugs. Furthermore, accurately documented times allow clinicians to thoroughly assess a individual's response to treatment, enabling timely adjustments to care plans and preventing potential adverse outcomes like toxicity or treatment failure. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(11) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the disgnosis or purpose for this medication. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | 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. | A medication record shall be kept, including the diagnosis or purpose for all medications administered, including those administered pro re nata (PRN), or "as needed". This is crucial for individual safety and effective care continuity. Recording the specific indication on the MAR, particularly for PRN medications, clarifies why, when, and how much to administer, helping to prevent errors and misuse. Clear documentation aids in symptom management tracking and guides clinical decision-making, as unclear PRN orders are a major source of adverse events and patient risk. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(12) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the dates and times that the medication was administered to Individual #1. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | A medication record shall be kept, including the date and time of medication administration. Recording the date and time on the MAR is key for individual safety, ensuring medications are given at prescribed intervals to maintain effectiveness, prevent dangerous interactions/overdoses, and provide a clear record for continuity of care, tracking trends, and verifying accountability. It supports the "Right Time" principle, preventing errors and optimizing treatment. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(a)(13) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1's January 2026 medication administration record did not include the name and initials of the person administering this medication to Individual #1. This medication was omitted entirely from Individual #1's January 2026 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | A medication administration record (MAR) must be maintained, clearly stating the name and initials of the person who administers the medication. Initialing the MAR is necessary for accountability, individual safety, and continuity of care, as it creates a clear, traceable record of who administered which medication, when, and how, effectively preventing errors like double dosing or missed doses.
This thorough documentation safeguards both the individual receiving the medication and the life sharer by identifying responsibility should any issues arise, enabling quick resolution of errors, and confirming adherence to the "Five Rights" of medication administration (right patient, right drug, right dose, right route, right time).
The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |
| 6500.136(b) | Individual #1 is prescribed Docusate Sodium 100mg Softgel with instructions to take 2 softgels by mouth every morning. Individual #1 is also prescribed Docusate Calcium 240mg with instructions to take 240mg orally daily as needed for constipation. Individual #1's January 2026 medication administration record did not include the order for Individual #1's daily prescription of Docusate Sodium 100mg; however, the medication administration record incorrectly listed Individual #1's Docusate Calcium 240mg as a daily standing order. When administering Individual #1's daily prescription of Docusate Sodium 100mg, Family Living Provider #1 had incorrectly initialed on the January 2026 medication administration record that the Docusate Calcium 240mg softgel had been administered. Individual #1's January 2026 medication administration record did not include the date and time Individual #1 was administered their Docusate Sodium 100mg, nor did it include the name and initials of the person that had administered Individual #1's Docusate Sodium 100mg from 1/1/2026 through 1/7/2026. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | A medication record shall be kept for each individual for whom a prescription medication is administered. Information shall be recorded in the medication record at the time the medication is administered. To ensure individual safety and continuity of care, a detailed MAR must be maintained for each individual receiving prescription medication, with all administration details (medication, dose, time, route, initials) recorded immediately after dispensing to prevent critical errors like missed doses, ensure accuracy for audits, and provide real-time, reliable data for emergencies. The medication was omitted entirely from MAR. The MAR was immediately corrected, and an in-person review by the life sharer and program specialist was conducted to verify accuracy and prevent recurrence. |
01/16/2026
| Implemented |