| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(11) | Individual #1's physical examination, completed 5/16/25 did not include an assessment of Individual #1's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank. | 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. | - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. |
01/12/2026
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, completed 5/16/25 did not include physical limitations. This section was left blank. | The physical examination shall include: Physical limitations of the individual. | - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. |
01/12/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 5/16/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. |
01/12/2026
| Implemented |