| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual # 1 received a physical examination on 06/24/22 and not again as of 07/11/23. An appointment is scheduled in future. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | We recently implemented an Appointment Tracking form (Attachment 2), which was to be used on a voluntary basis, and is now mandatory. On 7/20/23, Supervisors, Program Specialists, Compliance Specialist and Associate Directors were trained on the form and how to use it. (Attachment 3-Training Signature Sheet). The programs must have it completed and in use no later than 7/27/23. The Program Specialist, Associate Director, Compliance Specialist and/or Director will review/sign off on the Appointment Tracking form in their respective programs by no later than 8/5/23. |
08/05/2023
| Implemented |
| 6400.144 | Repeat 10/24/22- Individual # 1 had an appointment scheduled for 08/15/22 with the GastroEnterologist. The medical summary reads "Staff arrived late to appointment. Rescheduled appointment 08/17/22". | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| We acknowledge it is not acceptable to miss an appointment. The individual can be challenging to leave for appointments and he was that morning, then the staff got lost on the way to the appointment resulting in them being late and the doctors office had to reschedule the appointment. The appointment was rescheduled and completed on 8/17/22. |
08/05/2023
| Implemented |
| 6400.151(a) | Staff # 5 was hired on 05/25/22. Her physical was not completed prior to her hire date. The TB results were received on 05/27/22 and her first day with individuals was 05/26/22 | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | HR Director, sent an email with the Physical and TB Screening Policy to HR staff, as they process the paperwork for all new hires. We had not had it written in a Policy previously. Attachment 4. |
07/18/2023
| Implemented |
| 6400.50(a) | Staff # 3's Orientation Training (Stage Two document) does not include the length of training for Individual Rights, Abuse or Person-Centered Practices. The day total hours is listed as 8 hours, but the individual training lengths are not specified. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The Stage Two form of new hire orientation has been modified to show the amount of time spent on each area covered, versus a total number for the day. The updated Stage Two form was implemented on 7/17/23 with the new hires that started on that date. |
07/17/2023
| Implemented |
| 6400.165(g) | Individual # 1 had a psychiatric medication appointment on 04/07/22 and not again until 09/12/22. Psychiatric medication appointments are required at least every 3 months. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The gap occurred in 2022. The individual had an appointment at the correct time but the doctors office called to cancel as the doctor was out of town. The earliest appointment they could see the individual on was 9/12/22. Staff did not obtain documentation from the doctors office stating that they canceled and the date was the soonest appointment they could do. There is a note on our `pink¿ pages noting the doctors office called to cancel and reschedule. We have been attempting to obtain a note from the doctors office explaining as such, but no luck to date. While we weren't the cause no 3-month appointment, the Appointment Tracking form we have initiated will help that kind of situation also.
We recently implemented an Appointment Tracking form (Attachment 2), which was to be used on a voluntary basis, and is now mandatory. On 7/20/23, Supervisors, Program Specialists, Compliance Specialist and Associate Directors were trained on the form and how to use it. (Attachment 3-Training Signature Sheet). The programs must have it completed and in use no later than 7/27/23. The Program Specialist, Associate Director, Compliance Specialist and/or Director will review/sign off on the Appointment Tracking form in their respective programs by no later than 8/5/23. |
08/05/2023
| Implemented |