Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.103 | Repeat 10/5/16: The written emergency evacuation plan does not include individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| As a result of this citation an audit of all homes written evacuation procedure plan was completed and any evacuation procedure plan that did not include the individual¿s responsibilities was updated to include this information. Attached you will find the new written evacuation procedure plan for the Walter Road home. See Attachment #13
Program Managers have reviewed and understand the requirements of this document. (Attachment # 2).In addition, all Supervisors will be trained on this regulation on 12/13/17. See attachment #3 |
12/13/2017
| Implemented |
6400.106 | Repeat 10/5/16: The furance cleaning was completed on 10/14/16 and not again. It was due on 10/14/17. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnace at the Walter Road home has been cleaned on 11/7/17. See attachment # 12. As a result of this task not being completed within the required timeframe, we have assigned the monitoring of this task to the Community Living Manager, whom we feel has the skills to ensure furnace cleanings are completed on time in the future. Program Managers were trained on this requirement. See attachment #2. Supervisors will be trained on this requirement on 12/13/17. see attachment #3. |
12/13/2017
| Implemented |
6400.141(a) | Individual #1s physical was completed on 10/17/16 and not again. A physical was due on 10/17/17. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 had an annual physical due 10/17/17. Staff called the PCP office to schedule the physical appointment on 8/1/17 (attachment # 7 ). However, the first available appointment was 11/15/17, which is when she obtained the physical ( attachment # 8 ).
The Supervisor of this program has been trained on the importance of scheduling appointments within the appropriate time frame according to state regulations. See attachment # 6, which shows the calendar reminder for the Supervisor to schedule the physical 4 months prior to the due date next year.
Program Managers have reviewed and understand the need for appointments to be followed-up within the timeframe outlined by physicians.
See attachment # 2
In addition, all Supervisors will be trained to schedule appointments as early as six months in advance when appropriate (ie. 6-month follow-up, annual follow-up, 2 year follow-up, etc.)
See attachment # 3
Attachment # 9 shows a physical completed within one year of the previous physical. |
12/13/2017
| Implemented |
6400.141(c)(6) | According to Individual #1's physical dated 10/17/16 he/she had a tuberculin (TB) skin test read on 9/3/15 and not again. A TB test was due 9/3/17. | 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. | Individual # 1 did not have a TB test completed within two years as required by state regulations. She did have her TB test completed at her annual physical on 10/15/17. (attachment #8)
The Supervisor of this program has been trained on the importance of scheduling appointments within the appropriate time frame according to state regulations. See attachment # 6, which shows the calendar reminder for the Supervisor to schedule her physical 4 months prior to the due date next year.
Program Managers have reviewed and understand the need for appointments to be followed-up within the timeframe outlined by physicians.
See attachment # 2
In addition, all Supervisors will be trained to schedule appointments as early as six months in advance when appropriate (ie. 6-month follow-up, annual follow-up, 2 year follow-up, etc.)
See attachment # 3
Attachment # 9 shows a TB completed within two years of the previous TB test. |
12/13/2017
| Implemented |
6400.141(c)(7) | Individual #1 had a gynecological examination on 10/13/14 and not again. According to Individual #1's primary care physician this service is to be completed every three years. One was due 10/13/17. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual # 1 was due to have a gynecological exam on 10/13/17. Although it was late, she did have this exam completed annually during her physical exam with her PCP. See attachment # 8
Staff called the PCP office to schedule the physical appointment/GYN exam on 8/1/17 (attachment # 7). However, the first available appointment was 11/15/17, which is when she obtained her physical/GYN exam
The Supervisor of this program has been trained on the importance of scheduling appointments within the appropriate time frame according to state regulations. See attachment # 6, which shows the calendar reminder for the Supervisor to schedule Individual#1's physical 4 months prior to the due date next year.
Program Managers have reviewed and understand the need for appointments to be followed-up within the timeframe outlined by physicians. See attachment # 2
In addition, all Supervisors will be trained to schedule appointments as early as six months in advance when appropriate (i.e. 6-month follow-up, annual follow-up, 2-year follow-up, etc.) See attachment # 3
Attachment # 11 shows a GYN exam completed within the time frame recommended by the physician. |
12/13/2017
| Implemented |
6400.164(b) | Repeat 3/6/17: Individual #1's medication administration record (MAR) showed that staff did not sign off after administering his/her dose of Ofloxacin on 7/22/17. Individual #1's MAR shows that on 9/4/17 staff did not inital for administering his/her Calcium D medication. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Medications were administered. However, due to the blank space on the electronic MAR where staff initials should appear to indicate that medication was administered, it is assumed that the electronic system was not operating properly. To eliminate any future incidents of this nature, the Supervisor will print and review the electronic MAR to ensure there are no blanks on the MAR. If for some reason there is a blank space, the Supervisor will ensure staff have initialed the paper medication log, as they currently do if they are unable to access the electronic MAR.
Program Managers and Nurses have reviewed and understand the regulation.
See attachment # 2
This will be discussed further at the Residential Supervisor meeting on 12/13.
See attachment # 3 |
12/13/2017
| Implemented |
6400.183(1) | Individual #1's individual support plan (ISP) updated 8/30/17 stated he/she is working on an outcome of increasing his/her domestic skills. However Individual #1's ISP reviews dated 11/1/17, 7/28/17, 4/27/17 and 1/24/17 document that he/she is working on an outcome to increase his/her physical activity. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual's plan team. | The Program Specialist has emailed the Support Coordinator regarding the need for the ISP to be updated with the current outcome. See attachment # 1
All Program Specialists were re-trained on the need to ensure they notify the Support Coordinator any time there is a change to an outcome, requesting this information to be updated in the ISP. This email will include information regarding the new outcome, a start date for the new outcome, and an end date for the current outcome. In addition, the Program Manager will work with the house Supervisors to complete an audit of the ISP for each individual to ensure the outcome in the ISP matches the outcome they are currently working toward. This Audit will be completed by 12/15/17.
See attachment # 2 & 3 |
12/13/2017
| Implemented |
6400.213(11) | Individual #1's individual support plan (ISP) updated 8/30/17 states that Individual #1 returns every two years for a dexa scan however there is a letter from the doctor dated 5/8/17 stating that Individual #1 is to have a dexa scan completed every three years. Individual #1's ISP states under the health promotion section for oral hygiene that Individual #1 is to see the dentist every year. A letter written from Individual #1's dentist indicates that he/she is to see the dentist every two years. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The DEXA scan was completed on 11/16/17.
See Attachment # 5
The Program Specialist emailed the Support Coordinator requesting an update to the ISP reflecting the doctor's recommendations (attachment # 4) for Individual # 1 to have a Bone Density scan every two years. See attachment # 1.
The dental recommendations stated on the dental exam states the dental exam should be completed every two years. The Program Specialist emailed the Support Coordinator asking for this to be updated in the ISP. See attachment #1
The Supervisor of this home has been counseled on the importance of following recommendations from the physician and schedule appointments well in advance of the due date.
See attachment # 6
All Program Managers have reviewed and understand the need for follow-up appointments to occur per physician¿s recommendations.
See Attachment # 2
All Supervisors will be trained at the next Supervisory meeting on December 13, 2017 on the need to adhere to doctors¿ recommendations and submit changes to the Support Coordinators to ensure the changes in physician¿s recommendations are updated in the ISP. See Attachment # 3 |
12/13/2017
| Implemented |