Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.68(b) | The hot water temperature in the shower was 123.5 degrees Fahrenheit on 01/29/2015. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The hot water temperature was lowered to below 120°F on 2/19/15. (see highlighted section of Attachment ¿E¿)
A new hot water heater was installed on 3/12/15, and temperature set to below 120°F. (see Attachment ¿D¿)
Lifesharing specialist will verify the water temperature in bathtubs and showers do not exceed 120°F at monthly monitoring.
If the water temperatures exceed 120°F the Lifesharing specialist will lower the temperature.
On-going follow up will be documented on the monthly note completed by the Lifesharing specialist. (see highlighted section of Attachment ¿B¿) |
02/19/2015
| Implemented |
6500.108(a) | There was no fire extinguisher in the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | An operable fire extinguisher with a minimum 2-A rating was placed in the attic on 2/19/15 (see highlighted section of Attachment ¿E¿)
Lifesharing specialist will verify that the fire extinguishers have a minimum 2-A rating and are located on each floor including basement and attic at monthly monitoring.
If the extinguishers are not with a minimum 2-A rating or are not located on each floor including the attic and basement, the specialist will replace the extinguisher.
On-going follow up will be documented on the monthly note completed by the Lifesharing specialist. (see highlighted section of Attachment ¿B¿) |
02/19/2015
| Implemented |
6500.121(c)(9) | Individual #1's physical examinatin dated 05/05/2014 did not include a prostate examination | The physical examination shall include: A prostate examination for men 40 years of age or older. | A prostate exam will be performed annually for men over aged 40.
The Lifesharing Specialist will assist the provider in monitoring, scheduling and completing the prostate exam for Individual #1. This individual has a prostate exam scheduled to be completed on 3/23/2015 at 4:45pm.
In order to prevent reoccurrence, the Clinical Specialist will complete quarterly audits, beginning in April of 2015, to review compliance with the regulations. The results of the audit will be reviewed by the Residential Director who will monitor the process.
The Lifesharing Specialist will be responsible for facilitating any medical or dental appointment that is in danger of being missed. |
03/23/2015
| Implemented |
6500.125(c)(1) | Staff # 1's physical examination dated 05/13/2014 did not include a general physical examination.
Staff # 1's physical examination dated 05/13/2014 did not include a signed statement regarding being free of communicable diseases
Staff # 1's physical exam dated 05/13/2014 did not include information regarding any medical problems which might interfere with the health of the individuals. | The physical examination shall include: (1) A general physical examination.(2.) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. (3.)A signed statement that the person is free of communicable diseases or specific precautions to be taken if the person has a communicable disease. (4.)Information of medical problems which might interfere with the health of the individuals. | Staff # 1's physical exam was resubmitted to the PCP to be completed to include: a general physical examination, a signed statement regarding being free of communicable diseases, information regarding any medical problems which might interfere with the health of the individuals. Documentation of the updated examination will be available for review on or before 4/20/2015
On- going audit of provider physicals will be completed by the Program Coordinator to ensure that the physical exam includes a general physical examination, a signed statement regarding being free of communicable diseases, and information regarding any medical problems which might interfere with the health of the individuals.
Audits of all staff records will be conducted, exams will be completed if the records show that the exam is missing (1) A general physical examination.(2.) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. (3.)A signed statement that the person is free of communicable diseases or specific precautions to be taken if the person has a communicable disease. (4.) Information of medical problems which might interfere with the health of the individuals. |
04/20/2015
| Implemented |
6500.137(a) | The Medication Administration Record for January, 2015, listed an ear drop solution to be administered at bedtime for Individual # 1 but the medication was not available in the individual's medication box. | Prescription medications and insulin injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The prescription medications were obtained and delivered to the site on 2/2/15 by the Lifesharing Specialist.
Lifesharing Specialist will check the prescription medications at the monthly monitoring. The Lifesharing Specialist will document their review of medications on the Monthly Note (see highlighted section of Attachment ¿B¿)
If the Lifesharing specialist finds medications are not available in the home but are prescribed, the specialist will immediately re-order or re-fill the prescription so that the medications are available in the individual¿s medication box.
The Lifesharing Specialist will document retraining of the provider on the importance of careful and consistent monitoring and reordering of prescribed medications. (see Attachment ¿C¿) |
02/15/2015
| Implemented |
6500.182(c)(1)(ii) | Individual #1's record did not include identifying marks. | Each individual's record must include the following information: Personal information, including: The race, height, weight, color of hair, color of eyes and identifying marks. | Each individual's record will include personal information including race, height, weight, color of hair, color of eyes and identifying marks.
Individual #1's record was revised on 3/11/2015 to include an entry under identifying marks. (see Attachment ¿A¿)
In order to prevent reoccurrence, the Clinical Specialist will complete quarterly audits, beginning in April of 2015, to review compliance with the regulations. The audits will also review thorough completion of all forms and documentation. The results of the audit will be reviewed by the Residential Director who will monitor the process.
The Lifesharing Specialist will be responsible for facilitating completion of any missing documentation in the individual¿s record. |
03/11/2015
| Implemented |