Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.44(b)(1) | The assessment dated 10/4/16 for Individual #1 was completed by a direct service worker. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | Signature page of assessment corrected. Assessment to be done by the program specialist and reviewed by the program director. Program specialist was trained on this regulation as well as Ch. 6400 regulations and Laurel House policies. Review of the LII to be done quarterly. Any issues of concern will be brought to the program director for immediate attention and to be corrected. Annual training to be given to the program specialist. Supporting documentation attached. [On 1/12/17, the Program Director trained the program specialist and 5 staff, "assessments shall be completed by the program specialist." At least quarterly, the program specialist shall review the Q & As available on the Department web site and apply. (AS 1/25/17)] |
01/28/2017
| Implemented |
6400.81(k)(6) | Individual #1, Individual #2, Individual #3 and Individual #4 did not have mirrors in their bedrooms. | In bedrooms, each individual shall have the following: A mirror. | Mirrors were added to the bedrooms of individuals #1, #2, #3, and #4. Program specialist will complete the LII on a quarterly basis to review any issues with the physical site of the home. They will then report this information to the program director and corrections will be made immediately. Program specialist and staff trained on this regulation as well as Laurel House policies. Ongoing and annual training to be given. Supporting documentation attached. [Immediately and at least quarterly thereafter the program specialist shall complete an onsite check of all individual bedrooms to ensure all required items are present including mirrors. (AS 1/25/17)] |
01/28/2017
| Implemented |
6400.141(c)(9) | The two most recent prostate examinations for Individual #1 were completed on 7/27/15 and 11/18/16. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Prostate exam for individual #1 was completed on 11/18/16. The next scheduled appointment for a prostate exam for Individual #1 is 5/17/17. The staff will be responsible for accompanying the individual to the appointment. The program specialist will follow up with a review of the physical to ensure that all timeframes are within regulation and that all sections of the physical have been completed by the physician. The program director will review the physical as well. Staff and program specialists trained on this regulation. Annual and ongoing training to be given. Supporting documentation attached.Correction Date: 1/15/17[Immediately, the program director shall develop and implement a tracking system to ensure all individuals have physical examination including prostate examinations completed, timely. Documentation of reviews of physical examinations shall be kept. (AS 1/25/17]
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01/28/2017
| Implemented |
6400.141(c)(12) | The physical examination completed 6/8/16 for Individual #1 did not include the physical limitations of the the Individual. This section was left blank. | The physical examination shall include: Physical limitations of the individual. | A new physical exam was completed on 11/18/16 with this section being completed by the physician. The staff will be responsible for accompanying the individual to the appointment. The program specialist will follow up with a review of the physical to ensure that all timeframes are within regulation and that all sections of the physical have been completed by the physician. The program director will review the physical as well. Staff and program specialists trained on this regulation. Annual and ongoing training to be given. Supporting documentation attached.[On 1/12/17, Program Director trained 3 staff and the program specialist, "a physical exam shall include physical limitations. Documentation of reviews of physical examinations shall be kept. (AS 1/25/17] |
01/28/2017
| Implemented |
6400.141(c)(15) | The physical examination completed 6/8/16 for Individual #1 did not include special instructions for the individual's diet. This section was left blank. | The physical examination shall include:Special instructions for the individual's diet. | A new physical exam was completed on 11/18/16 with this section being completed by the physician. The staff will be responsible for accompanying the individual to the appointment. The program specialist will follow up with a review of the physical to ensure that all timeframes are within regulation and that all sections of the physical have been completed by the physician. The program director will review the physical as well. Staff and program specialists trained on this regulation. Annual and ongoing training to be given. Supporting documentation attached.[On 1/12/17, Program Director trained 3 staff and the program specialist, "a physical exam shall include special instructions for the individual's diet." Documentation of reviews of physical examinations shall be kept. (AS 1/25/17)] |
01/28/2017
| Implemented |
6400.143(a) | Individual #1 refused a dental examination on 3/2/16. Individual #1 was not trained about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual and staff trained on importance of dental care. Individual was seen by a dentist on 4/1/16 with no issues. Form developed for training and will be completed by the staff. Staff and program specialist will be responsible for counseling and completion of form. Program director will review the form. Ongoing and annual training on this regulation as well as Laurel House policies will be conducted. Supporting documentation attached. |
01/28/2017
| Implemented |