| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.103 | The furnace was cleaned on 9/10/19 and not again until 10/18/20. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | Providers Plan of Correction:
1. Immediate fix: 6500 Gehr Rd will complete a furnace cleaning on or before 10/18/2021.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. Team Supervisors will create a chart with furnace cleaning due dates in all homes that have a furnace no later than 8/27/21.
6. A program check will be conducted in all homes not inspected no later than 8/27/21.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A copy of the furnace cleaning due date chart (Attachment #19) will be sent to ODP no later 9/30/21.
6. Program check log sheet (Attachment #20) will be completed and sent to verify compliance in all homes not inspected no later than 9/30/21.
7. If we find violations in any other homes, they will be corrected by 9/30/21. |
09/30/2021
| Implemented |
| 6500.121(c)(14) | Individual #1's 4/2/19 and 9/8/20 annual physical examinations only state "dial 911" for "medical information pertinent to diagnosis and treatment in the event of an emergency." | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Providers Plan of Correction:
1. Immediate fix: The life sharing specialist will correct the physical and request that the corrections be approved by the PCP no later than 8/27/21.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The copy of corrected physical will be requested no later than 8/27/21.
6. A program check will be conducted for all physicals to measure compliance. The program check findings will be completed by 8/27/21.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A copy of the corrected physical for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #38).
6. Program check log sheet (Attachment #39) will be completed for all individuals and sent to ODP no later than 9/30/21. |
09/30/2021
| Implemented |
| 6500.122(c) | Individual #1's 8/18/20 dental examination did not include the procedures completed or information regarding follow up treatment. | A written record of the dental examination, including the date of the examination, dentist's name, procedures completed and follow-up treatment recommended shall be kept. | Providers Plan of Correction:
1. Immediate fix: The client in question is due for another dental by 8/18/21. The Life Sharing Specialist will make sure the caregiver uses the correct dental form. The 8/18/20 appointment form will also be corrected during the upcoming dental exam and cleaning.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The copy of corrected dental form will be requested no later than 8/27/21.
6. A program check will be conducted for all dental exams to make sure the correct forms were used. The program check findings will be completed by 8/27/21.
7. A copy of the next dental exam for any client in the program will be provided to show that program corrections have been made.
8. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A copy of the corrected appointment form showing follow-up treatment for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #43).
6. A copy of the next client dental exam for someone in the program showing that the corrections have been made will be sent to ODP no later than 9/30/21 (Attachment #44).
7. A copy of the upcoming dental exam for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #47).
8. A program check will be conducted for all dental exams to measure compliance. The program check findings will be sent by 9/30/21 (Attachment 47). |
09/30/2021
| Implemented |
| 6500.186 | There is no documentation provided indicating that individual #1 has completed a release of information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | Providers Plan of Correction:
1. Immediate fix: Complete a release of information for all team members and services providers that are not authorized to share information by 8/27/21.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The release of information for anyone not authorized to share information will be completed no later than 8/27/21.
6. A program check will be conducted to verify that all individuals in the entire have a release of information based on the ODP clarification of who is an authorized party. The program check findings will be completed by 8/27/21.
7. This violation is a program violation and it is expected that all individuals in the program need a release of information based on the ODP clarification. The corrections will be made for all individuals no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A completed release of information for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #56).
6. A program check for the release of information for all individuals will be completed with findings sent to ODP no later than 9/30/21 (Attachment #57). |
09/30/2021
| Implemented |
| 6500.124 | Individual #1's 4/2/19 annual physical examination indicated that there should be a follow-up appointment for hyperlipidemia in 6 months. This examination was never completed. | 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. | Providers Plan of Correction:
1. Immediate fix: The PCP will be contacted asap to make sure the individual is current with all follow-up recommendations and appointments.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The copy of the PCP check regarding needed follow-up appointments will be requested no later than 8/27/21.
6. A program check will be conducted to verify that all follow-up appointments were completed for all clients. The program check findings will be completed by 8/27/21.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A copy of the PCP check showing follow-up treatment for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #46).
6. A program check that follow-up appointments were completed for all clients will be sent to ODP no later than 9/30/21 (Attachment #49). |
09/30/2021
| Implemented |
| 6500.135(g) | Individual #1 had a psychiatric medication review on 9/22/20 and 2/24/21. There are no reviews in between those dates, and there has not been a review since 2/24/21. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Providers Plan of Correction:
1. Immediate fix: The client in question will complete a medication review as soon as the doctor is willing to schedule the review.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. A medication review will be requested as a first available appointment. A copy of that review will be collected no later than 8/27/21 unless an extension is requested.
6. A program check will be conducted to verify that medication checks are being completed every 3 months for all individuals prescribed a medication to treat a mental health diagnosis. The program check findings will be completed by 8/27/21 and it is expected that we will find other violations that need corrected.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested. We predict some delays with this correction due to the volume of corrections anticipated, shortage of MH care in the area, and challenges to influence the physicians to see clients based on frequencies in the 6500 regulations.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A copy of the medication check for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #50).
6. A program check to see who needs to visit the physician more often will be completed for all clients with a MH diagnosis and sent to ODP no later than 9/30/21 (Attachment #51). |
09/30/2021
| Implemented |
| 6500.136(a)(11) | Individual #1's medication administration record does not include the diagnosis or purpose for the following medications: Pravastatin, Travatan, Alendronate Sodium, Multivitamin, Fluoxetine, and Famotidine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Providers Plan of Correction:
1. Immediate fix: The diagnosis or purpose for each medication will be added to the MAR no later than 8/27/21.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The copy of revised MAR showing the diagnosis or purpose for all medications will be completed no later than 8/27/21.
6. A program check will be conducted to verify that all medications for all individuals in the entire program have a MAR with diagnosis or purpose for each medication. The program check findings will be completed by 8/27/21.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A copy of the revised MAR with at least one administration for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #52).
6. A program check of all MARs will be completed with findings sent to ODP no later than 9/30/21 (Attachment #54). |
09/30/2021
| Implemented |