| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The assessment for Individual #1, dated 2/14/15, was not completed by the program specialist. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | A training was held on 12-21-15 to review the requirements for completing the assessment for each individual. All 6400 regulations referring to the assessment were reviewed including the completion by the Program Specialist and their signature.[CEO or designee will review a 25% sample of completed assessments at least quarterly for the next year to ensure the program specialist is completing assessments accurately and within required time frames. Documentation of the assessment reviews will be maintained. AS 1/13/16)] |
12/21/2015
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination on 3/4/14 and then again on 5/1/15. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Twin Trees, Inc. was aware of this missed physical and in an attempt to minimize missed dates a new position was created. One of the new Program Assistant's responsibilities is to track the annual requirement dates which include annual physicals to prevent future physicals from being out of compliance.[CEO or designee will review a 25% sample of completed physical examinations at least quarterly for the next year to ensure the physical examinations are completed thoroughly and within required time frames. Documentation of the physical examination reviews will be maintained. AS 1/13/16)] |
10/19/2015
| Implemented |
| 6400.141(c)(6) | Individual #1 had a Tuberculin skin test completed on 3/7/13 and then again on 5/4/15. | 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. | Twin Trees, Inc. was aware of this missed Tuberculin skin test and in an attempt to minimize missed dates a new position was created. One of the new Program Assistant's responsibilities is to track the annual requirements dates which include Tuberculin skin tests dates to prevent missing dates and being out of compliance..[CEO or designee will review a 25% sample of completed physical examinations at least quarterly for the next year to ensure the physical examinations are completed thoroughly and within required time frames. Documentation of the physical examination reviews will be maintained. AS 1/13/16)] |
10/19/2015
| Implemented |
| 6400.163(c) | The most recent psychiatric medication review for Individual #1 was completed on 9/2/15. | 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. | A medication review was completed on 10-5-15. No change was noted at that time.[Within 1 month of receiving the Inspection Summary the CEO or designee will develop a tracking system of when required reviews for all individuals are due and ensure appointments are scheduled so that reviews are completed within required time frames. CEO or designee will review a 25% sample of psychiatric medication reviews at least quarterly for the next year to ensure the psychiatric medication reviews are completed thoroughly and within required time frames. Documentation of the psychiatric medication reviews will be maintained. AS 1/13/16)] |
10/05/2015
| Implemented |
| 6400.181(f) | Individual #1's assessment, dated 2/14/15, was not provided to all plan team members at least 30 days prior to the ISP meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| A training was held on 12-21-15 to review the requirements for completing the assessment for each individual. All 6400 regulations referring to the assessment were reviewed including all team members receiving a copy 30 days prior to the ISP meeting.[Immediately the Program Specialist will review all individuals' ISPs, invitation letters and other documentation to ensure all individuals plan team members are provided required documentation. Documentation of correspondence to team members will be maintained. CEO or designee will review a 25% sample at least quarterly of correspondence documentation to ensure all plan team members are provided the assessments as required. (AS 1/13/15)] |
12/21/2015
| Implemented |