| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | The annual physical exam for individual#1 was completed late. One physical was completed on 7/6/22, and the follow up annual exam was completed on 7/31/23. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The physical was scheduled for 7/5/2023 however the doctor's office had a flood.. The physical was rescheduled as soon as possible and completed on 7/31/2023. [Attachment J] |
07/31/2023
| Implemented |
| 6400.141(c)(7) | The was no indication noted on the annual physical that a gynecological exam was completed for individual#1. | 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. | Prior to moving into our program Individual #1 lived at home with her family. The family was initially not able to provide a full and complete medical history and continues to assist the individual on medical appointments so ensuring that we have all of the completed paperwork is a work in progress. . Upon further review with the PCP (8/15/2023) it is now noted the the individual had a hysterectomy [Attachment L and Q]. |
08/15/2023
| Implemented |
| 6400.141(c)(11) | There was no bloodwork completed for individual#1in the record. | 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. | Blood work was completed on 8/10/2023 [Attachment N]. This individual has very involved family who attend all medical appointments so at times getting accurate and thoroughly completed forms has been a challenge, one that we continue to work on. The family maintains the medical portals so we will continue to request documentation from them. |
08/10/2023
| Implemented |
| 6400.141(c)(13) | The allergy section on the current physical was left blank. Individual#1 does have allergies and is taking medication for the diagnosis. | The physical examination shall include: Allergies or contraindicated medications. | Upon further review with the PCP (8/15/2023) Individual #1's allergies were noted on the physical [Attachment J]. |
08/15/2023
| Implemented |
| 6400.141(c)(14) | Information pertinent to diagnosis in case an emergency was not completed by the physician for individual#1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Upon further review with the PCP (8/15/2023) Individual #1's information pertinent to diagnosis and treatment was noted on the physical [Attachment J]. |
08/15/2023
| Implemented |
| 6400.163(h) | Medication ROBITUSSIN DM was located in individual#1's med box but not listed on the (MAR). | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This individual has family involved who are in the medical field and at times will drop off OTC medications that are not prescribed by a physician. Staff were trained to store any medications that are provided by the family in with the poisonous materials at the home and to notify the Program Coordinator. Robitussin DM was removed from the medication box. |
08/11/2023
| Implemented |
| 6400.165(b) | Medication ATIVAN 1MG is listed on individual#1's MAR but not located in the medication box. | A prescription order shall be kept current. | Ativan 1 mg. was obtained from the pharmacy and placed in the medication box. |
08/10/2023
| Implemented |
| 6400.167(a)(4) | Individual#2 was not administered medication at the prescribed time, individual #2 was administered the medication at 10:27am which exceeded the 8am dose time. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | The medication administration was reviewed with the staff involved. Medication observations will be completed as required. |
08/10/2023
| Implemented |