| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | The telephone number of the nearest ambulance was not on or by the telephones in the living room, kitchen, and upstairs foyer. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| All telephones located in the residential homes will have new phone numbers applied with telephone numbers of the nearest hospital, police department, ambulance service and fire department. Poison control center phone number will also be listed on the phones.
Residential Supervisors will replace old stickers with new numbers by October 12, 2015. Residential Directors will validate that each home has been completed and report back to the CEO.
Residential Directors will notify all staff of the above change by an education event. |
10/10/2015
| Implemented |
| 6400.163(c) | The psychiatric medication review for Individual #1 completed on 6/29/15 did not include the reason for prescribing the medications and the need to continue the medications. The psychiatric medication review for Individual #1 completed 4/7/15 did not include the need to continue the medications. | 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. | All psychiatric medication reviews will always include the reason for prescribing the medications and the need to continue the medications. These reviews will occur every three months.
An in-service was held with all residential supervisors and directors on September 16, 2015. All physicians have been notified that the medication review is not complete without all of the above requirements being completed.
At the end of each psychiatric medication review, a quality review will be done by the residential directors. |
10/10/2015
| Implemented |
| 6400.186(b) | Individual #1 did not sign the three month ISP reviews completed in April 2015 and July 2015. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | All 3 month ISP reviews will be signed by individuals involved and program specialist.
CEO met with all residential supervisors and directors and reviewed the above requirement on September 16, 2015.
CEO educated all supervisors and directors on the importance. Program Directors will do a quality review each month for compliance. |
10/10/2015
| Implemented |