| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(7) | Individual #1's last gynecological exam was 11/14/13. There was no current gynecological exam in the record. | 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?
This regulation is important in order to maintain good gynecological health. A Pap test can detect early signs of cervical dysplasia and precancerous changes in the individual.
How was the regulation violated?
The individual¿s last gynecological exam with a Pap test was last completed on 11/14/2013 and should have been completed by November 2015 but was not completed.
What Caused the Violation?
The individual attended an OBGYN appointment in November 2014, however a gynecological exam/Pap test was not completed because Medicare only covers every two years. Appointment was not made for November 2015.
What can be done right away to fix the violation?
An OBGYN appointment was completed on February 4th 2015 at 1:30 pm
What can be done to prevent future violations?
New updated medical appointment planner was completed for the individual to better track upcoming due dates and scheduled appointments. The medical appointment planner will be reviewed at each monthly monitoring with Life Sharers. See Attachment #6
Who will be responsible for preventing future violations?
Life Sharing program specialist. |
02/04/2016
| Implemented |
| 6500.151(a) | Individual #1's previous assessment was dated 12/5/14. The most recent assessment was dated 1/6/16. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the family living home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the family living home. | Why is the regulation important?
This regulation is important because the assessment alerts the team of current needs of the individual and needed changes to the updated Individual Support Plan to better serve the individual.
How was the regulation violated?
The assessment for the individual was due on 11/15/2015 but was not completed until 1/6/2016.
What Caused the Violation?
Changes to administration for Life Sharing Program Spec during this time was unaware of assessment schedule.
What can be done right away to fix the violation?
Once aware of assessment being past due the assessment was completed on 1/6/2016 and sent to this Supports Coordinator prior to ISP meeting. See Attachment #4
What can be done to prevent future violations?
Life Sharing Program Spec was trained in assessment tracking and a new tracking system was created in order to avoid assessments being completed late in the future.
Who will be responsible for preventing future violations?
Life Sharing Program Spec. |
08/16/2016
| Implemented |
| 6500.151(f) | Individual #1's assessment dated 1/6/16 did not have documentation in the record that it was sent to the support coordinator and team members. | 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 of the ISP, the 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). | Why is the regulation important?
This regulation is important because the assessment needs to be sent to the individual¿s ISP team members 30days prior to the ISP meeting in order to review for updates and changes and to have documentation of assessment being sent to team members.
How was the regulation violated?
The assessment was not sent to the ISP team members 30 days prior to ISP meeting. The assessment was sent 1/11/16.
What Caused the Violation?
The assessment was not completed 30 days prior to the ISP meeting, therefore it was not sent to ISP team members by due date
What can be done right away to fix the violation?
The assessment was completed and sent to ISP team members on 1/11/16 via email. Email was printed for documentation that the assessment was sent prior to meeting, however not 30 days prior. See attachment #3
What can be done to prevent future violations?
Life Sharing Program Spec created a new assessment tracking form that includes date assessment needs to be completed, the date the assessment needs to be sent to ISP team members, date of the ISP meeting and the ISP annual update date. Life Sharing program Spec will print out documentation and it will filed in individuals book. See attachment #4
Who will be responsible for preventing future violations?
Life Sharing Program Spec. |
01/11/2016
| Implemented |