| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(c) | Individual #1 is prescribed medication for a diagnosed psychiatric illness. The psychiatric medication reviews completed 6/19/18, 3/20/18, 12/21/17 and 9/25/17 for Individual #1 do not include a need to continue the medications. | 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. | On 8/30/18, the Program Manager and the Program Coordinator have been retrained and counseled on the regulation regarding 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.
The psychiatric medication reviews completed on 6/19/18, 3/20/18, 12/21/17, and 9/25/17 were corrected on 8/29/18 by the physician prescribing the medication, to include the need to continue the medication.
Going forward all psychiatric appointments will be entered and monitored in Therap by the program manager and reviewed by the program coordinator to ensure that the need to continue the medication is documented by the physician on the consultation form. Supporting documentation of the retraining and the corrected consultation forms will be submitted. [Upon completion, a designated staff person educated in the requirements of psychiatric medication reviews shall audit all individuals' psychiatric medication review to ensure timely completion with all required information and all individual are administered medications as prescribed. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/6/18)] |
08/30/2018
| Implemented |
| 6400.169(a)(1) | Individual #1's assessment, dated 9/19/17, indicates that individual #1 cannot self-administer medications because s/he does not know the names of the medications or the current prescribed dose of medications; however, Individual #1 started self-administering medications on 9/20/16 and has continued to the present. | To be considered capable of self-administration of medications an individual shall: Be able to recognize and distinguish the individual's medication. | The assessment dated 9/17/17, indicates that the individual is not able to self-administer medications; effective 8/9/18, the individual is no longer self-medicating until a new assessment is completed by 9/17/18. The new assessment completed by the Program Manager for this individual will include an accurate assessment of his medication skills and abilities, and will also include the Medication Self-Administration Assessment Checklist from The Pennsylvania Department of Public Welfare Medication Administration Training Program. Going forward, any updates from the new assessment to revise a service or outcome will be requested by the program specialist to be documented in the ISP. Supporting documentation will include the current revised Medication Administration Record that shows the staff documentation of administering medications. Also included is the Medication Self-Administration Assessment Checklist from The Pennsylvania Department of Public Welfare Medication Administration Training Program that will be completed in addition to the assessment. [Within 30 days of receipt of the plan of correction, a designated management staff person shall educated all staff person responsible for assessing individuals in their ability to self administer medication in the requirements and the aforementioned procedures to ensure individuals are assessed accurately in their ability to self-administer medications. Documentation of trainings shall be kept. (DPOC by AES, HSLS on 9/6/18)] |
08/09/2018
| Implemented |
| 6400.181(b) | Individual #1's assessment, dated 9/17/17, indicates that the individual is not able to self-administer medications; however, the individual has been self-administering medications since 9/20/16. This information was not included in the assessment and there was no recommendation by the Program Specialist to include this information in the ISP. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | The assessment dated 9/17/17, indicates that the individual is not able to self-administer medications; effective 8/9/18, the individual is no longer self-medicating until a new assessment is completed by 9/17/18. The new assessment completed by the Program Manager for this individual will also include the Medication Self-Administration Assessment Checklist from The Pennsylvania Department of Public Welfare Medication Administration Training Program. Going forward, any updates from the new assessment to revise a service or outcome will be requested by the program specialist to be documented in the ISP.
Supporting documentation will include the current revised Medication Administration Record that shows the staff documentation of administering medications. Also included is the Medication Self-Administration Assessment Checklist from The Pennsylvania Department of Public Welfare Medication Administration Training Program that will be completed in addition to the assessment. [Within 30 days of receipt of the plan of correction, a designated management staff person shall educated the program specialist(s) in the responsibilities of the program specialist position as per 6400.44(b)1-19. Documentation of the training shall be kept. At least quarterly for 1 year, a designate management person shall audit a 10% sample of individual's assessments to ensure if a program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/6/18)] |
08/09/2018
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment, dated 9/17/17, indicates that the individual is not capable of self-administering medications; however, the individual has been self-administering medications since 9/20/16. | The assessment must include the following information: The individual's ability to self-administer medications. | The assessment dated 9/17/17, indicates that the individual is not able to self-administer medications; effective 8/9/18, the individual is no longer self-medicating until a new assessment is completed by 9/17/18. The new assessment completed by the Program Manager for this individual will also include the Medication Self-Administration Assessment Checklist from The Pennsylvania Department of Public Welfare Medication Administration Training Program. Going forward, any updates from the new assessment to revise a service or outcome will be requested by the program specialist to be documented in the ISP.
Supporting documentation will include the current revised Medication Administration Record that shows the staff documentation of administering medications. Also included is the Medication Self-Administration Assessment Checklist from The Pennsylvania Department of Public Welfare Medication Administration Training Program that will be completed in addition to the assessment. [Within 30 days of receipt of the plan of correction, a designated management staff person shall educated the program specialist(s) in the responsibilities of the program specialist position as per 6400.44(b)1-19. Documentation of the training shall be kept. At least quarterly for 1 year, a designate management person shall audit a 10% sample of individual's assessments accurately completed. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/6/18)] |
08/09/2018
| Implemented |