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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill conducted on 12/7/21 does not indicate the exit route utilized for evacuation. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Supervisors will train staff to ensure understanding of how to accurately and correctly complete fire drills documentation to avoid errors when documenting evacuation time. [Documentation of monthly fire drill reviews for October 2022, November 2022, December 2022, and January 2023 were received on 2/15/23 and reviewed 3/8/23. Documentation of staff training, related to fire drill documentation, dated 11/1/22, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/14/2022
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 3/15/22, did not address information pertinent to diagnosis and treatment in the event of an emergency. This section of the form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialists will review medical appointment paperwork weekly to ensure all supporting documentation is complete and attached/included on the physical. They will communicate with house supervisors and staff if they discover missing documentation so it can be added to the medical record. [Documentation of monthly medical appointment reviews for October 2022, November 2022, December 2022, and January 2023 were received on 2/15/23 and reviewed 3/8/23. Documentation of staff training, related to medical appointment documentation, dated 11/1/22, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness; however, the individual has not had a psychiatric medication review completed. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Program Specialists will review medical appointments on a monthly basis to ensure all required medical appointments are being scheduled and attended per regulations. Program Specialists will communicate required appointments with house supervisors and staff to ensure appointments are made and individuals receive the care they need. [Documentation of monthly medical appointment reviews for October 2022, November 2022, December 2022, and January 2023 were received on 2/15/23 and reviewed 3/8/23. Documentation of staff training, related to medical appointment documentation, dated 11/1/22, was received on 2/15/23 and reviewed 3/8/23. Documentation of a completed psychiatric medication review for Individual #1, dated 2/14/23, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not indicate religious affiliation. Individual #1's photograph is not dated, therefore compliance cannot be measured. | Each individual's record must include the following information: Personal information, including: (iv) religious affiliation and (vi) a current, dated photograph | The date the individual's photo was taken was added to the electronic individual record on 09/23/2022.
The individual's religious affiliation of Lutheran was entered into the electronic individual record on 09/23/2022. [Documentation that Individual #1's Demographic Form contains a current photograph, dated 10/27/22, and religious affiliation has been added to the individual's record was received on 2/15/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
09/23/2022
| Implemented |
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