| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(4) | Individual #1's physical examination, completed on 9/3/2025, did not include vision and hearing screenings. Individual #1's most recent vision screening was completed on 8/29/2024 and Individual #1's most recent hearing screening was completed on 10/16/2024. This exceeds the annual requirement. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | · Family Living Program Specialist was trained by program director on reg 6500.121c4 on_7.18.2026
· Family Living Provider will be trained by Family Living Program Specialist on reg 6500.121c4 by 8.15.2026.
· Family Living Program Specialist will modify the Annual Physical Form to include check boxes for vision and hearing assessments to ensure the doctor assesses for vision and hearing concerns and has space to make recommendations for follow up appointments.
· Life Sharing Program Specialist will provide a list of all medical appointments and vaccinations due dates to each Life Sharing Provider with for the year by January 31. |
07/20/2026
| Implemented |
| 6500.121(c)(7) | Individual #1's annual gynecological examinations were completed on 12/4/2024, and again on 12/31/2025. This exceeds the annual requirement. | 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. | · Family Living Program Specialist was trained by program director on reg 6500.121c7 on_7.18.2026
· Family Living Provider will be trained by Family Living Program Specialist on reg 6500.121c7 by 8.15.2026.
· Family Living Provider will ensure a gynecological examination, including a breast examination and a Pap test, is completed within the annual timeline requirement. If there is documentation from a licensed physician recommending no or less frequent gynecological examinations, FLP will present such evidence.
· Family Living Program Specialist will modify the Annual Physical Form to include check boxes for vision and hearing assessments to ensure the doctor assesses for vision and hearing concerns and has space to make recommendations for follow up appointments.
· Life Sharing Program Specialist will provide a list of all medical appointments and vaccinations due dates to each Life Sharing Provider with for the year by January 31. |
07/20/2026
| Implemented |
| 6500.121(c)(8) | Individual #1, date of birth 2/14/1979, had their biennial mammograms completed on 12/22/2023 and again on 1/8/2025. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | · Family Living Program Specialist was trained by program director on reg 6500.121c8 on_7.18.2026
· Family Living Provider will be trained by Family Living Program Specialist on reg 6500.121c8 by 8.15.2026.
· Family Living Provider will ensure a gynecological examination, including a breast examination and a Pap test, is completed within the annual time line requirement. If there is documentation from a licensed physician recommending no or less frequent gynecological examinations, FLP will present such evidence.
· Family Living Provider will ensure a mammogram is completed at least every 2 years until 2/24/2029 when turning the age of 50. At that point a mammogram will be conducted yearly.
· Family Living Program Specialist will modify the Annual Physical Form to include check boxes for vision and hearing assessments to ensure the doctor assesses for vision and hearing concerns and has space to make recommendations for follow up appointments.
· Life Sharing Program Specialist will provide a list of all medical appointments and vaccinations due dates to each Life Sharing Provider with for the year by January 31. |
07/20/2026
| Implemented |
| 6500.121(c)(12) | Individual #1's physical examination, completed on 9/3/2025, did not include physical limitations of the individual. The only documentation on-file from Individual #1's physical examination was an after-visit summary which did not include the agency's physical examination form. | The physical examination shall include: Physical limitations of the individual. | · Family Living Program Specialist was trained by program director on reg 6500.121c12 on_7.18.2026
· Family Living Provider will be trained by Family Living Program Specialist on reg 6500.121c12 by 8.15.2026.
· Family Living Provider will ensure all sections of the physical examination are completed including physical limitations of the individual. FLP will review with physician to ensure authenticity.
· Life Sharing Program Specialist will provide a list of all medical appointments and vaccinations due dates to each Life Sharing Provider with for the year by January 31. |
07/20/2026
| Implemented |
| 6500.121(c)(14) | Individual #1's physical examination, completed on 9/3/2025, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The only documentation on-file from Individual #1's physical examination was an after-visit summary which did not include the agency's physical examination form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | · Family Living Program Specialist was trained by program director on reg 6500.121c14 on_7.18.2026
· Family Living Provider will be trained by Family Living Program Specialist on reg 6500.121c14 by 8.15.2026.
· Family Living Provider will ensure all sections of the physical examination are completed including medical information pertinent to diagnosis and treatment in case of an emergency.
· Life Sharing Program Specialist will provide a list of all medical appointments and vaccinations due dates to each Life Sharing Provider with for the year by January 31. |
07/20/2026
| Implemented |