| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(7) | Individual #1 had a gynecological exam on 6/4/19 and not again until 6/8/21. No deferment letter was provided documenting why Individual #1 had the gynecological exam deferred for two years. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Providers Plan of Correction:
1. Immediate fix: The life sharing specialist in this home will request a deferment letter from 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 the deferment letter will be collected no later than 8/27/21.
6. A program check will be conducted for female individuals to verify we have a deferment letter for anyone not receiving an annual gyn exam. The program check 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 deferment letter for the individual in question will be sent to ODP no later than 9/30/21 (Attachment #36).
6. Program check log sheet (Attachment #37) will be completed for all female individuals and sent to ODP no later than 9/30/21.
7. A copy of the next program gyn exam with a deferment letter will be sent by 9/30/21 to show that program corrections have been made (Attachment #42). |
09/30/2021
| Implemented |
| 6500.121(c)(14) | On Individual #1's annual physical examination dated 8/21/20, the section for information pertinent to treat/diagnose in the event of an emergency simply stated to call 911 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 #40).
6. A copy of the next client physical for someone in the program showing that the corrections have been made will be sent to ODP no later than 9/30/21 (Attachment #41).
7. A program check will be conducted for all physicals to measure compliance. The program check findings will be sent to ODP by 9/30/21 (Attachment #48). |
09/30/2021
| Implemented |
| 6500.186 | No documentation was provided for Individual #1 documenting that a release of information was signed. | 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. Complete a release of information for anyone not authorized to share information no later than 8/27/21.
6. A program check will be conducted to verify that all individuals in the entire program 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 #58).
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 |
| 6500.136(a)(2) | The Medication Administration Records for Individual #1 did not have all their prescribing physicians listed. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Providers Plan of Correction:
1. Immediate fix: The prescriber 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 prescriber 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 a prescriber 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 #53). |
09/30/2021
| Implemented |
| 6500.136(a)(11) | The Medication Administration Records for Individual #1 do not include the diagnosis/purpose for the following medications: Fluticasone, Neo-poly Dox Eye Drop, Clorazepate, Alendronate Sodium, or Calcium 600 Vitamin D3. | 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 #55).
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 |