| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Repeat 4/5/16: The bathroom sink is chipping and has a brown stain approx 6" long in sink. | Floors, walls, ceilings and other surfaces shall be in good repair. | Bathroom sink and counter top were replaced on 4/28/17 by maintenance staff. The Property Manager did site reviews at all homes to check for surfaces in good repair. Any needed repairs were scheduled and addressed by our maintenance staff. |
05/01/2017
| Implemented |
| 6400.141(c)(6) | Individual #1 had a tuberculin test completed on 2/12/15 and not again. | 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. | An appointment was made for a TB test for Individual #1 on 4/12/17 and the test was read on 4/14/17. (See submitted med appointment review). A memo was sent to Supervisors reminding them of this regulation, and all were required to complete a form verifying completion dates for TB tests. |
04/28/2017
| Implemented |
| 6400.141(c)(8) | Individual #1 had a mammogram completed on 3/17/15 and not again until 7/13/16. | 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. | A memo was sent to all Supervisors reminding them of the need to assure that mammograms are scheduled at least every two years for women age 40 to 49, and at least every year for women 50 years of age and older. All Supervisors were required to complete a form verifying completion dates for mammograms for women in their programs. |
04/28/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's physical dated 7/13/16 did not include info pertinent to diagnosis and treatment in case of emergency. It was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The medical information pertinent to diagnosis and treatment in case of an emergency was added to Individual #1¿s 7/13/17 physical. All current physicals were reviewed by Residential Supervisors to assure that this information is up to date on all individuals¿ physicals. A memo was sent to Supervisors reminding them of this regulation. |
04/26/2017
| Implemented |
| 6400.181(e)(8) | Individual #1's assessment completed 7/28/16 did not include his/her ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | The Program Specialist wrote an addendum to Individual #1¿s 7/28/16 Assessment to include her ability to evacuate in the event of a fire, and this was sent to all team member on 4/21/17. Also a training was held for all Program Specialists reviewing all information necessary to be covered in Assessments on 4/27/17. |
04/27/2017
| Implemented |
| 6400.183(5) | Individual #1's ISP updated 12/21/16 did not include a protocol to address social, emotional, nviromental, needs plan. Individual #1 takes Seroquel XR 100mg 1 tab QD and Paxil HCL 40mg 1 tab QD and Paxil HCL 10mg 1 tab QD. | 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 wrote an addendum to Individual #1¿s ISP to include protocol to address a SEEN plan. A general update was sent to the SC on 4/21/17. Also a training was held on 4/27/17 for all Program Specialists to review this regulation and the information necessary for the ISP. |
04/27/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP reviews dated 4/28/16, 7/28/16, 10/27/16, and 1/27/17 did not include a review of bowel protocol which is tracked daily on a chart. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Individual #1had an appointment with her PCP on 4/12/17 and obtained clarification regarding her bowel protocol. (See submitted medical appointment review form and scripts). The Program Specialist wrote an addendum for the lifetime medical history and ISP to clarify the bowel protocol. The quarterly review for Individual #1 on 4/29/17 includes a review of the bowel protocol. |
04/29/2017
| Implemented |
| 6400.186(c)(5) | Individual #1's assessment completed on 7/28/16 states that his/her can be at home unsupervised for 1 hour however ISP updated 12/21/16 states that he/she can be unsupervised at home up to 2 hours. The assessment should have an addendumm for when the suupervision needs changed. | If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment as required under § 6400.181(b) (relating to assessments). | The Program Specialist wrote an addendum to Individual #1¿s Assessment (Safety in the Home, and Home Supervision sections) on 4/21/17 (See submitted documentation).Also an addendum to the ISP Fire Safety Section, and Supervision section on 4/21/17. A general update was sent to the SC also on 4/21/17 was written. |
04/21/2017
| Implemented |
| 6400.186(d) | Individual #1's ISP review dated 4/28/16, 7/28/16, and 1/27/17 were not sent to all team members. They were not sent to his/her brother. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | All current Accept/Decline forms for all individuals have been copied and are kept in our main office so the Program Specialist has easy access to assure that all interested individuals are mailed copies of ISP information. A training was held on 4/27/17 for all Program Specialists to review their responsibilities regarding ISP review and revisions. (See submitted documentation). |
04/27/2017
| Implemented |
| 6400.186(e) | Individual #1's ISP reviews did not include option to decline to his/her brother. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist contacted Individual #1¿s brother to determine his interest in receiving ISP¿s and reviews on 4/21/17. He declined receiving them, and this has been noted in her records. A training was held for Program Specialists reviewing the regulations regarding ISP review and revisions on 4/27/17. |
04/27/2017
| Implemented |