| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(14) | Individual # 1's physical examination dated 2/15/17 did not document information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Regulation: Individual physical examination must include medical information pertinent to diagnosis and treatment in case of an emergency.
Why is the regulation important? This regulation is important so that care providers are aware of medication information pertinent to the individual¿s diagnosis that would helpful for health care professionals and care givers to know during an emergency situation.
How was the regulation violated? Individual #1 annual physical dated 2/15/2017 did not document medical information pertinent to diagnosis; this section was left blank on the physical form.
What Caused the Violation? During annual physical examination on 2/15/2017, doctor did not fill out section for ¿information pertinent to diagnosis during emergencies¿ section. Life sharing provider whom accompanied individual #1 did not review physical examination form prior to leaving appointment to ensure that all sections of the form was completed.
What can be done right away to fix the violation? Physical form from 2/15/17 for individual #1 was updated to include information pertinent to diagnosis in case of an emergency. It was noted that individual #1 needs assistance during an emergency due to diagnosis of mild IDD and does not self administer medications. See attached document #1.
What can be done to prevent future violations? Life sharing provider, Deb Logan was retrained on completion of all sections of annual physical form need to be completed by doctor. Life sharing provider will ensure that all sections of the physical form are completely filled out prior to leaving appointment in the future. Program Specialist, Luz Fragoso will review annual physical forms prior to submitting to agency medical department and follow up with life sharing provider if necessary.
Who will be responsible for preventing future violations? Life Sharing Provider, Deb Logan and Program Specialist Luz Fragoso. |
07/17/2017
| Implemented |
| 6500.134(b) | Individual # 1 was administered Divalproex 25 mg and 50mg, Fenobiberate 54mg and Latuda as prescribed from 07/01/17 throug | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Regulation: 134 (b) Information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.
Why is the regulation important? This Regulation is important because the initials on the medication log tracks each medication administration. Accurate documentation is a key step in the process of safe medication administration and records that each medication was given as prescribed.
How was the regulation violated? The medication log for individual #1 was not initialed for on the front of the medication log for each medication administered from 7/1/17 through 7/12/17 for the following medications, Divaprolex 25 and 50mg, Fenoboberate 54mg and Latuda.
What Caused the Violation? Life Sharing provider, Deb Logan did not initial individual #1 medication log after each medication administration on 7/1/17 through 7/12/17.
What can be done right away to fix the violation? Life Sharing Provider and Program Specialist went back to blank entries on July MAR 7/1/17 through 7/12/17 and provided appropriate documentation recording on the back of MAR to indicate that medications were given on those dates but not signed for.
What can be done to prevent future violations? Life Sharing Provider, Deb Logan was retrained on documentation needed on MAR after each medication administration for individual #1 who is not self medicated. Life sharing provider will initial after all medications administered on the MAR going forward. Program Specialist, Luz Fragoso will check medication log during each monthly house visit to ensure MAR documentation is being done correctly after each dose.
Who will be responsible for preventing future violations? Life Sharing Provider, Deb Logan and Program Specialist, Luz Fragoso. |
07/12/2017
| Implemented |
| 6500.156(b) | Individual # 1's 3 month ISP review ending date 08/24/16 and 11/24/16 were not signed by the program specialist or the individual. | The family living specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Regulation: 156 (b): The Family Living Specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.
Why is the regulation important? This regulation is important because it allows the team members and the individual to evaluate the progress being made towards individual goals and to update plan accordingly if necessary in order to provide the best care for the individual.
How was the regulation violated? The quarterly ISP reviews 8/24/16 and 11/24/16 for individual #1 were not signed by the program specialist or the individual.
What Caused the Violation? Program Specialist did not review quarterly ISP reviews with individual when completed on 8/24/16 and 11/24/16. Individual did not live in life sharing program during the time of the 8/24/16 ISP review and was under a different program specialist at the time.
What can be done right away to fix the violation? Program Specialist reviewed 8/24/16 and 11/24/16 ISP reviews with individual and both signed signature page on 7/11/2017. See attached documents #4 and #5.
What can be done to prevent future violations? Program Specialist will review each quarterly ISP review upon completion with the individual during monthly home monitoring and sign and date signature page for each individual in the future.
Who will be responsible for preventing future violations? Program Specialist, Luz Fragoso. |
07/11/2017
| Implemented |