| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | A bill from the Genesis Health Care, dated 05/14/2014, for the amount of $225.00 was paid from Individual #3's personal account. The bill did not indicate the reason for the charge. | Individual funds and property shall be used for the individual's benefit. | Documentation was obtained from Genesis Health Care. Amount paid for individual #3 was for $25 daily co-pays while he was using services at rehabilitation facility for nine days. All such information will be attached to payment register by administrative fiscal technician so that it is readily available each time such bills are incurred. The Program Specialist will conduct monthly reviews of the all financial transactions conducted for the Individuals of the home. |
04/30/2015
| Implemented |
| 6400.76(a) | The dresser drawers in the bedrooms of Individuals # 1, # 2 and # 3 were missing knobs and handles | Furniture and equipment shall be nonhazardous, clean and sturdy. | All knobs and handles were restored and tightened by maintenance department. Assistant Site Manager will monitor quarterly. |
02/05/2015
| Implemented |
| 6400.141(c)(4) | Individual #3's annual physical examination, dated 10/15/14, recommended further evaluation by a specialist in regard to a hearing screening and there was no documentation the hearing screening was completed. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #3 had ENT appointment on 1/28/2015. However, due to cerumen buildup, hearing evaluation could not be completed at that time. Debrox drops were prescribed. Follow up was completed later due to medical insurance issue on 4/14/2015. TM's appeared normal and tympanometry was obtained during this follow up visit. Follow up is scheduled for 6 months. Nursing department will review recommendations for additional testing and flag as needed for follow up for annual physicals. The nursing department staff will review all physical examinations to ensure that all follow-up testing is scheduled timely. |
04/14/2015
| Implemented |
| 6400.181(e)(13)(vii) | Individual # 3's annual assessment, dated 12/09/2014, did not include progress and growth in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Progress and growth in the area of financial independence was added to individual #3's annual assessment. Revised Annual Assessment was diseminated to team members on 1/8/2015. Training on this topic for Program Specialist and all CLA Program Specialists was held on 1/30/15. Assistant Residential Director will review plan for completeness during chart audits which occur once to twice per year. |
01/30/2015
| Implemented |
| 6400.183(5) | Individual # 3 is prescribed Haldol, Seroquel and Remeron and does not have a SEEP or behavioral support plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | SEEP for individual #3 was completed. SEEP was diseminated to team members on 1/08/15 Training on this topic for Program Specialist and all CLA Program Specialists was held on 1/30/15.Assistant Residential Director will review all plans for completeness during chart audits which occur once to twice per year |
01/30/2015
| Implemented |