Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(5) | Upon admission the diphtheria/ tetanus was dated 1/15/2003; The most recent diptheria/tetanus shot was recieved on 9/20/13. | (5) Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204.
| This individual was admitted on 3/27/2013 as an emergency placement due to the death of his caregiver. Medical were not readily available upon admission. When medical records were obtained and indicated the diphtheria/tetanus was out of date it was completed. New admissions will not be accepted in the future without complete medical records. The health care coordination will be responsible to ensure all new admission medical records are complete. |
02/01/2014
| Implemented |
6400.141(c)(6) | Individual #1 was admitted to the program on 3/27/13; but did not have a TB screening until 6/7/13. | (6) Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.
| This individual was admitted on 3/27/2013 as an emergency placement due to the death of his caregiver. Medical were not readily available upon admission. When medical records were obtained and indicated the diphtheria/tetanus was out of date it was completed. New admissions will not be accepted in the future withoutcomplete medical records. The health care coordination will be responsible to ensure all new admission medical records are complete. |
02/01/2014
| Implemented |
6400.186(c)(1) | There was no progress documented on Individual #2's monthly summaries from July 2013 to December 2013. | (c) The ISP review must include the following:
(1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter.
| Program Coordinators, who complete the monthly reports were retrained regarding the content of these reports on 2/20/2014. Quality Assurance reviews of these reports will include an increased focus on content regarding progress. The Quality Assurance Training Coordinator will ensure all monthly reports contain the required information. A auditing tool will be developed and implemented to ensure that monthly reports are completed timely and contain the necessary information. A 10% sample of monthly reports will be pulled quarterly to ensure compliance. |
02/20/2014
| Implemented |