6400.143(a) | Individual #1 refused his prostate exam on 8/8/14, and there was no documentation regarding continued attempts to train the individual on 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. | All residential supervisors and managers were retrained on Documenting Medical Procedures Refusals and Retraining on 3/13/15. Copies included for your review.
Individual in question was retrained on prostate exam process and desensitization. Copy included for your review.Residential managers, program specialists and supervisors are responsible for regular internal chart reviews with corrections being completed within 48 hours. Copy included for your review. [CEO or designee will continue to educate at least monthly Individual #1 and other individuals being served by the agency about the need for health care when an individual refuses medical examinations or treatment and document the attempts in the individual's records. (AS 4/20/15)] |
03/13/2015
| Implemented |
6400.213(1)(i) | The personal information in Individual #1's record did not include religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | All residential supervisors and managers were retrained on documentation completion dated 3/13/15. Copies included for your review.
Record in question was updated with the appropriate information. Copy included for your review. Residential managers, program specialists and supervisors are responsible for regular internal chart reviews with corrections being completed within 48 hours. Copy included for your review. |
03/13/2015
| Implemented |