| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The fire notification letter dated 7/3/14 states that one individual in the home needs verbal prompts to evacuate. The fire drill logs indicate that individual needs verbal prompts and physical assistance to evacuate. The fire notification letter needs to be updated to reflect her needs. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An updated letter was sent to the fire company specifying the needs of the individuals living in the home on 1/15/2015. (See document #12).A memo was issued to Associate Directors and Program Specialists to remind them of the need to send notification to the local fire company in the event of an individual's needs changing during fire evacuation. All current letters were checked by the Administrative Assistant by comparing the letters to recent fire drills to assure that all information is up to date. This was completed during the month of April. (See document #13) |
04/17/2015
| Implemented |
| 6400.141(c)(6) | Individual #1did not receive a TB test in the regulatory timeframe. She had a TB test completed on 6/30/2012 and not again until 7/17/2014. | The physical examination shall include: 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. | A memo was sent to the Program Specialist and staff to remind them that each individual must have a TB test done every two years. (See document #10). Another individual had their TB screening done since the inspection and was completed in the proper time frame - 3/26/2013 and again on 3/24/2015. (See document #11). |
04/17/2015
| Implemented |
| 6400.163(c) | Individual #1 moved into this home on 6/24/14 and did not have a medication review with a licensed physician until 10/20/2014. She takes medication for anxiety. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 had an annual physical on 7/14/2014. (See document #5) At this appointment, her PCP did review her use of the psychotropic medication but did not specifically document the need to continue use of the med. The PCP did provide a document stating that the medication was reviewed and the need to continue the medication.(See document #6 dated January 28, 2015).
Individual #1 was then seen on 10/20/2014, and 12/30/2014 for subsequent medication reviews. (See documents #7 and #8). A memo was sent to Program Specialist and staff to remind them that if medications are prescribed to treat psychiatric illness, then there shall be a review with documentation by a licensed physician at least every three months that includes all of the necessary information. (See document #9) |
04/17/2015
| Implemented |
| 6400.183(5) | The ISP for Indivdiual #1 does not include a SEEN plan for her diagnosis of anxiety. | 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. | The Program Specialist sent n ISP update to the SC on 2/23/2015 to add a SEEN plan to address anxiety (See document #2 Request 18 and Request 21). A memo was sent to the Program Specialist and staff to clarify this requirement. (See document #4. |
04/17/2015
| Implemented |
| 6400.213(11) | The record for Indivdiual #1 contains discrepancies with her supervision level. Her assessment indicates she is only to have unsupervised time while in the shower however, her ISP indicates she can be in other rooms and the yard as long as staff are on the premises.
Individual #1's ISP indicates that she is not taking psychotropic medications however, she is. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Individual #1's assessment was updated on 2/2/2015 to clarify her level of supervision to be consistent with her ISP. (See document #1). The Program Specialist sent ISP updates to the SC on 2/23/2015 including information regarding use of psychotropic medication for anxiety. (See document #2 Request #6 and Request #9).
A memo was sent to the Program Specialist and Program Staff to remind them of the need for all information to be consistent in the individuals records. (See document #3) |
04/17/2015
| Implemented |