| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1's last annual physical was dated 1/31/19, which was more than one year from the previous physical dated 1/2/18. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Why is the regulation important?
Annual physical exams are essential to your ongoing health. Visiting your primary care provider for regular preventive care is one of the best ways to identify and treat health issues before they get worse. These visits also help you track your progress toward your health goals.
How was the regulation violated?
The individual did not have an annual physical completed within 1 year.
What caused the violation?
The resident manager and program director overlooked this appointment and therefore failed to schedule it within the allotted time frame.
What can be done right away to fix the violation?
There is nothing that can be done to remedy this specific situation as the appointment was completed late. An attempt to schedule this appointment for the upcoming year was made with the PCP on 9/16/19, however the PCP is not currently booking appointments for 2020 and informed the resident manager that they only books appointments 3 months out.
What can be done to prevent future violations?
Information regarding appointment will be added to the medical appointment planner (attachment #5) which will allow for the tracking and timely scheduling of medical appointments. Training of this chart will occur by 9/27/19
Who will be responsible for preventing future violations?
Resident Manager and Program Director. |
09/16/2019
| Implemented |
| 6400.141(c)(7) | Individual #1's last Gynecological exam was held on 2/13/19 more than one year from the last appointment on 9/18/17. | 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. | Why is the regulation important?
Visiting the appropriate specialists regularly as prescribed is one of the best ways to identify and treat health issues before they get worse. These visits also help track progress toward health goals.
How was the regulation violated?
Individual did not have appointment with this specialist in the time frame suggested by their doctor.
What caused the violation?
The resident manager and program director overlooked this specialist and therefore failed to schedule this appointment.
What can be done right away to fix the violation?
There is nothing that can be done to remedy this specific situation as the appointment was completed late. On 9/16/19 resident manager attempted to scheduled next gynecology exam for February 2020 in order to ensure that the next exam is performed within the 1 year window however they were not able as this doctor is not scheduling appointments into 2020 yet.
What can be done to prevent future violations?
Information regarding appointment will be added to the medical appointment planner (attachment #5) which will allow for the tracking and timely scheduling of medical appointments. Training of this chart will occur with all managers by 9/27/19
Who will be responsible for preventing future violations?
Resident Manager and Program Director. |
09/16/2019
| Implemented |
| 6400.181(e)(5) | Individual #1's last assessment dated 6/12/19 did not indicate whether or not they could self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Why is the regulation important?
The regulation is important to ensure that the ISP is reflective of the individual¿s current status regarding self-administration of medications so that appropriate supports and supervision can be directed and therefore implemented properly.
How was the regulation violated?
In the individuals 2019 assessment the section on the individual¿s ability to self-administer medication and medication needs in general was left blank.
What caused the violation?
The current template for assessments is not a locked and completed in Microsoft Word. Due to the template not being locked as information is being inputted the document shifted resulting in that section being split among two pages and therefore missed.
What can be done right away to fix the violation?
Program Director Cal Dietz added information to this section on 8/22/19.
What can be done to prevent future violations?
The template that the assessment is currently being edited so that the textboxes are locked preventing the shifting of categories. This will be completed by 9/30/19 and then immediately implement.
Who will be responsible for preventing future violations?
Director of Services and Director of Residential Services. |
09/30/2019
| Implemented |