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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | Individual #1 had Tuberculin skin testing completed 5/13/13 and then again on 6/5/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Every attempt will be made to get the individual her TB test. In the event that she refuses we will put in place a counseling for refusing appointments. This individual will continue to receive counseling regarding refusal of appointments. [Immediately, the Residential Director shall develop and implement a tracking system to ensure individuals' physical examination including Tuberculin skin testing is completed timely. Within 30 days of receipt of the plan of correction, all individuals' physical examination shall be reviewed by a designated management staff person to ensure timely completion. At least quarterly, for 1 year a designated management staff person shall review the tracking system and a 25% sample of individuals' physical examinations including Tuberculin skin testing to ensure timely completion. (AS 4/15/17)]
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04/22/2017
| Implemented |
| 6400.164(a) | Individual #1 is prescribed Vitamin D3 1000 Units one time daily. Individual #1's March 2017 Medication Administration Record lists Vitamin D3 1000 Unit to be administered at 8:00AM and 8:00PM. Throughout March 2017, Direct Service Workers #1, #2, #3, #4, #5, #6, #7, #8, and #9 initialed as having given Vitamin D3 1000 Unit at 8:00AM and 8:00PM. March 2017 medication counts indicate Vitamin D3 1000 was given one time daily as prescribed. Direct Service Worker #1, Direct Service Worker #2, and Direct Service Worker #3 did not sign the March 2017 Medication Administration Record for Individual #1 to indicate the name of the person who administered the prescription medications. [Repeat Violation 2/3/16 et al.] | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | All medications will be checked to ensure that the medications are documented according to the prescription as order by he physician. For the next 90 days a review of the mar will be completed daily by the Team Leader and the RPW. [Within 30 days of receipt of the plan of correction, Direct Service Workers #1, #2, #3, #4, #5, #6, #7, #8, and #9 shall be retrained by a certified medication train the trainer in medication administration. Immediately and at least weekly for 1 month and continuing at least monthly, a designated nursing or management staff person shall review all individuals' medication administration record, medication and prescribers orders to ensure all individuals' are being administered medications as prescribed and documented as required. If documentation errors are found, staff shall be retrained to ensure all individual are being administered medications as prescribed and accurately documenting. Documentation of reviews shall be kept. (AS 4/25/17)] |
04/22/2017
| Implemented |
| 6400.181(d) | Individual #1's assessement, dated 7/3/16, was not signed by a program specialist. | The program specialist shall sign and date the assessment. | The Program Specialist will be retrained on signing and dating the individuals assessment. The Assistant Director will complete audits to ensure this is completed. [Immediately, the program specialist(s) shall review all individuals' current assessments to ensure the program specialist has signed and dated the assessment as required. At least quarterly, for 1 year the assistant director shall review a 25% sample of individuals' current assessments to ensure the program specialist signed and dated the assessment as required. Documentation of all reviews shall be kept. (AS 4/24/17)] |
04/22/2017
| Implemented |
| 6400.181(e)(12) | Individual #1's assessement, dated 7/3/16, did not include any recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist will be retained on making recommendation for specific areas of training. A review will be completed every 90 days by the Assistant Director. [Immediately, the program specialist shall complete Individual #1's assessment to include any recommendations for specific areas of training, programming and services. Immediately, the program specialist(s) shall review all individuals' current assessments to ensure the program specialist has completed all individuals' assessments in their entirety including recommendations for specific areas of training, programming and services. At least quarterly for 1 year, the assistant director shall review a 25% sample of individuals' current assessments to ensure the program specialist has completed the assessments with all required information. Documentation of all reviews shall be kept. (AS 4/24/17)] |
04/22/2017
| Implemented |
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