| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(e) | The annual dentist appointment for individual#1 dated 3/25/2021 stated follow up needed on 9/25/2021. Documentation of follow up appointment on the aforementioned date was not provided. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | -Dental Appointment for the individual is scheduled for 1.13.2022 at 9:30am.
-The was the first appointment available. |
12/22/2021
| Implemented |
| 6400.144 | It could not be determined if individual#1 medication, entecavir .5 mg tab, with instructions to take 1 tablet by mouth daily at 7 am for hepatitis, was administered during the month of November 2021, as the entire medication record for this month was blank where initials of the staff person who administered it should have been. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| -Provider Nurse investigated providing conclusion that medication had been given (reviewal of blister pack) but staff failed to document accordingly or as trained.
-Documentation in Comment Section of the MAR(November) was completed (by Community Home Manager to reflect documentation concerns
-Documentation since Citation Discovery has occurred (by DSP Staff administering medication)
-Incident Report Completed by Residential Director |
12/28/2021
| Implemented |
| 6400.181(a) | The assessment dated 9/17/2021 did not adequately discuss individual#1's progress and growth in functional skills, communication, personal adjustment, personal needs. The individual's progress in health, motor skills, activities of daily living , personal adjustment, socialization, recreation, financial independence, managing personal property, and communication was not measured on the current assessment. The fields discussing recommendations and progress were left blank on all areas of the assessment except work skills and supervision. The individual's ability to swim was also not discussed, only individuals general water safety. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. | -Assessment was revised and updated to reflect progress and growth, blank sections (in all areas), and the individuals ability to swim |
12/29/2021
| Implemented |