| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | The egress to garage has key deadbolt from interior. No key is permanently affixed. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Deadbolt removed/cover installed over location. Attachment #2 |
04/30/2018
| Implemented |
| 6400.165 | On 2/2/18 individual #1's MAR was blank for carbamazepine 200mg 8pm dose. | Documentation of medication errors and follow-up action taken shall be kept.
| Upon being informed of the MAR error, the Incident was entered into EIM. A copy was given to the licensor at that time (it is in Attachment #10). A policy is being created, by the Dir Res Svs, that will address: the House Supervisor will review the MARs at least once weekly ¿ should they find an error, they will address it at that time; at the end of the month, the Supervisors will deliver the MARs to their Program Specialist, who in turn, will review the MARs for that month ¿ should they find an error, it will be addressed at that time. Both the Supervisor and Program Specialist will initial and date the MAR reflecting when they reviewed it. The Program Specialists will be trained on the policy on 5/31/18 and the Supervisors will be trained at their next meeting on 6/7/18. A copy of the policy and training signature sheets will be submitted no later than 6/8/18.
CPARC, historically, has not officially tracked medication errors; the Director of Services is in the process of creating a Med Error Tracking spreadsheet that the Residential Services Administrative Secretary will maintain and update, daily, as med errors are faxed into the main office. Her Supervisor, the Residential Admin Mgr will be responsible for ensuring the spreadsheet is kept up to date. The spreadsheet will be implemented no later than 5/22/18. A copy of the spreadsheet (completed) will be submitted no later than 6/15/18, reflecting med errors up till then. This will lead to the creation of a Medication Administration Error Policy; Supervisors to be trained on 6/7/18; Program Supervisors to be trained on 6/14/18. Training signature sheets and the policy will be submitted no later than 6/18/18. The Dir Res Svs is responsible for the creation and training re: the policy. |
06/18/2018
| Implemented |
| 6400.181(e)(7) | Individual #1's assessment dated 2/2/18 does not include her ability to sense and move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | An Addendum was written for the individual's Assessment and the SC was requested to input the correct information into the ISP; which has been done. In order to ensure areas of the Assessment are not overlooked in the future, an Assessment Check List is being prepared by the Director, Residential Services. The Program Specialists will be responsible for the completion of the check list. When an Assessment is completed, the Associate Director will retain the completed check list and use it as a measurement for the Program Specialists' annual performance evaluation (thoroughness and timeliness). The Program Specialists will be trained on the use of the check List on 5/31/18 at their next regularly scheduled meeting, the Check List will go into effect 6/1/18 and a completed Check List will be submitted no later than 7/1/18. |
07/01/2018
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP reviews dated 8/11/17, 11/3/17, and 2/2/18 did not review the dental and seizure protocol. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The Individual's dental plan has been reviewed; staff trained on it. A seizure protocol was implemented upon speaking with the individual's doctor; staff have been trained on the protocol. The Program Specialist is responsible for these areas. Attachment 9b.
To ensure plans are not overlooked in the future, an ISP Review (Quarterly) Check List was implemented on 3/16/18 for all quarterlies. The Program Specialist is responsible for completing a Check List for each Review, and upon completion, the Associate Director retains the Check List, reviewing it to see it is completed. They use this tool as one measurement to review during the Program Specialists' Annual Performance Evaluation (timeliness and thoroughness). A completed Check List for an individual is attached. Attachment 9a. |
05/13/2018
| Implemented |