| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.109(g) | Fire drills shall be held on different days of the week and at different times of the day and night. The sleeping drill were conducted on 1/9/23 at 6:30 AM and the other sleeping fire drill was conducted on 1/6/22 at 6:12 AM. | Fire drills shall be held on different days of the week and at different times of the day and night. | All providers were trained on fire drill procedures. And notified that the sleep drill times need to alternate. |
12/11/2023
| Implemented |
| 6500.121(c)(4) | Individual #1's physical examination dated 3/30/23 did not include a hearing screening as it was noted as "N/A and not checked in office" on the form. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | All coordinators were trained on how to review annual physical forms to ensure all required areas are completed. |
12/08/2023
| Implemented |
| 6500.121(c)(11) | Individual #1's physical examination dated 3/30/23 an assessment of the individual's health maintenance needs was left blank on the form. | 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 coordinators were retrained on reviewing annual physicals to ensure that all areas are fully completed.. |
12/08/2023
| Implemented |
| 6500.151(e)(13)(iii) | Individual #1's assessment dated 9/20/23 did not include progress over the last 365 calendar days and current level in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The annual assessment was updated to incorporate the activities of residential living. And coordinators trained on how to complete this section properly. |
12/08/2023
| Implemented |