| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1's January 2016 log indicated a balance of $28.85 however, the balance should have been $22.67. The June 2016 indicated a balance of $120.88 however, the balance should have been $120.93. The 1/15/16 receipt totaling $2.64 was not documented on the financial ledger until 1/20/16. The 1/4/16 receipt totaling $1.50 was not documented on the financial ledger until 1/20/16. | (2) Disbursements made to or for the individual.
| Team Member who made errors within Individual # 1¿s financial documents was removed immediately from financial oversight of Individual # 1 when the errors were found on 6/22/2016. Team Member was also retrained and documentation of that retraining occurred. Program Manager currently has direct oversight of Individual # 1's finances.
An excel self-calculating ledger resource is currently being created to be utilized across all 6400 Waiver Homes for financial oversight. This excel resource will allow the program to minimize errors that will assist with 6400 regulatory compliance.
Care Tracker documentation will verify that all Program Managers, Program Coordinators, and Friendship Community¿s Resident Financial Coordinator are trained on the use and long term use of the excel self- calculating ledger resource. |
10/31/2016
| Implemented |
| 6400.141(c)(9) | Individual #1 had a prostate exam completed on 9/2/14 and not again. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual # 1 received an annual physical examination on 9/3/2015 where the Individual did not receive a prostate examination. Individual # 1 has a prostate examination scheduled for 7/27/2016 with their PCP.
Each Program Manager and Program Coordinator will be trained on 6400 regulations regarding male Individuals, 40 years or older, receiving annual prostate examinations.
Using Care Tracker documentation, each Program Manager, Program Coordinator, and Nurses will be trained on 6400 regulations regarding male Individuals, 40 years or older, receiving annual prostate examinations or as deemed appropriate by a physician. |
10/31/2016
| Implemented |
| 6400.144 | On 3/30/16, Individual #1 did not receive Fosamax because the medication was not available at the home. On 2/15/16, Individual #1 did not receive Biotene mouthwash because it was not available at the home. | 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.
| Since the late medication administration without specified time from the Physician already occurred and it is a timely citation, no immediate corrective action can occur.
All Program Managers, Program Coordinators, Nurses, and Medical Support Professionals will be retrained to ensure all written orders to non-medical professionals and all written/or verbal orders to medical professionals have a specified time that late administration of a medication for an Individual should occur.
Utilizing Care Tracker documentation, all Program Managers, Program Coordinators, Nurses, and Medical Support Professionals will be retrained to ensure all written orders to non-medical professionals and all written/or verbal orders to medical professionals have a specified time that late administration of a medication for an Individual should occur. |
10/31/2016
| Implemented |
| 6400.181(f) | Individual #1's 7/15/15 assessment was sent to plan team members on 7/15/15 for an 8/13/15 Individual Support Plan meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Program Coordinator (or designee) of each Program Specialist will verify through supervision and monitoring that each Individual's assessments are completed at least 30 calendar days prior to the Individual Support Plan meeting.
Care Tracker documentation will verify that all Program Specialist are retrained on Individual's assessment regulatory expectation and documentation. |
10/31/2016
| Implemented |
| 6400.195(d) | Individual #1's restrictive plan was not signed or dated by the program specialist. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| Restrictive Plan was updated to include the review and signature of the Program Specialist. All Program Managers, Behavior Support Consultants, and the Program Specialists will be trained on the necessity of a Program Specialist participating in the review and signed approval of an Individual¿s Restrictive Plan.
Documentation will verify that all Program Managers, Behavior Support Consultants, and Program Specialists are trained on the necessity of a Program Specialist participating in the review and signed approval of an Individual¿s Restrictive Plan.
Care Tracker documentation will verify that each Behavior Support Consultant has audited all Restrictive Plans for compliance. |
10/31/2016
| Implemented |
| 6400.195(e)(5) | Individual #1's restrictive plan did not include an outcome target date. | The restrictive procedure plan shall include: A target date for achieving the outcome.
| Restrictive Plan was updated on 7/6/2016 to include target outcomes and target dates.
All Behavior Support Consultants will be trained on the necessity of target outcomes and/or target dates being included in an Individual¿s Restrictive Plan.
Care Tracker documentation will verify that all Behavior Support Consultants are trained
on the necessity of target outcomes and/or target dates being included in an Individual¿s Restrictive Plan.
Care Tracker documentation will verify that each Behavior Support Consultant has audited all Restrictive Plans for compliance. |
10/31/2016
| Implemented |