| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(10) | The most recent physical for Individual One did not answer the communicable disease question | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Physical scheduled 1/15/25. Completed physical examination documentation will be obtained. |
01/15/2025
| Implemented |
| 6400.144 | Individual One is prescribed Insulin Lispro Kwikpen U-100 100 units/ML. The sliding scale for this medication is unclear and inconsistent, and needs more thorough documentation as to what amount of insulin was administered and for what reasons.
The amount of insulin is administered based on a combination of how much of a meal was eaten in conjunction with the blood sugar level at that time.
Corresponding documentation needs to reference the specific name of the insulin that is being administered as well as what the dose is. The reasoning for the dose needs to be clearly documented as well given that it is judged based on more than one determining factor.
Additionally, the sliding scale only references how much of the insulin is to administer for blood sugar readings between 200 and 350. What to do for readings outside of those parameters needs to be clearly documented and should not be assumed. | 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.
| An updated clarified script was obtained and will be submitted for review. |
12/18/2024
| Implemented |
| 6400.151(a) | Staff physical for Staff One is past due, with the last completed on 12/8/22. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | staff was contacted on 12/13/24 with instructions to schedule her physical and she said she would - staff was contacted again on 1/13/25 asking for an update |
01/31/2025
| Implemented |
| 6400.181(f) | The assessment mailing letter was not found in Individual One's record. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Director reviewed this requirement with the program manager/specialist. |
12/13/2024
| Implemented |