| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(c) | Individual #1, admitted 11/19/12, who is prescribed Fluoxetine (Prozac) 20 mg QD by mouth for depression, did not have reviews with documentation by a licensed physician. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1's medication was reviewed on 6/20/16 and again on 9/6/16 . All managers were reminded of the requirement at a meeting on 9/22/16. Agency medication guidelines were revised in September to include specifications regarding review of medications for maladaptive behaviors. Managers were trained on new guidelines on 9/27 and 10/4/16. Documentation to be submitted. [At least quarterly for 1 year the Program Coordinator shall review a 10% sample of documentation by a licensed physician to ensure timely completion of medication review for individual who are prescribed medication to treat symptoms of a diagnosed psychiatric illness. Documentation of reviews shall be kept. (AS 10/7/16)] |
09/22/2016
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment dated 3/29/16 to the entire plan team members including the behavioral services. | (f) 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, 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).
| Assessment was sent to omitted team member (behavior specialist) on 8/30/2016. The three month review document has been amended to include checkboxes to assure assessment is shared with appropriate team members within timeframes required. This was distributed throughout the agency on August 30 2016. Documentation to be submitted. [Within one month of receipt of the plan of correction, the CEO or designated management staff person shall develop and implement procedures to ensure all plan team members are provided the assessments by the program specialist as required. Program specialist shall review all Individuals' ISPs, invitation letters and other documentation prior to sending assessments to ensure all team members are included when providing assessments. Correspondence documentation showing that all team members were provided the assessments shall be kept. At least quarterly for one year, a 10% sample of correspondence documentation shall be reviewed by quality assurance coordinator staff person to ensure the program specialist provides the assessment to all plan team members as required. (AS 10/7/16)] |
08/30/2016
| Implemented |
| 6400.186(d) | The program specialist did not provide the ISP review documentation dated 5/31/16, 2/28/16, 11/30/15 and 8/31/15 for Individual #1 to the entire plan team members including the behavioral services. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Most recent three month review was sent to omitted team member (behavior specialist) September 19th. The three month review document has been amended to include checkboxes to assure document is shared with appropriate team members within timeframes required. This was distributed throughout the agency on August 30 2016. Documentation to be submitted.[Within one month of receipt of the plan of correction, the CEO or designated management staff person shall develop and implement procedures to ensure all plan team members are provided the ISP reviews by the program specialist as required. Program specialist shall review all Individuals' ISPs, invitation letters and other documentation prior to sending ISP reviews to ensure all team members are included when providing ISP reviews. Correspondence documentation showing that all team members were provided the ISP reviews shall be kept. At least quarterly for one year, a 10% sample of correspondence documentation shall be reviewed by quality assurance coordinator to ensure the program specialist provides the ISP reviews to all plan team members as required. (AS 10/7/16)] |
08/30/2016
| Implemented |