Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(a) | The physical exam for individual #1 was dated 9/26/18 and the previous one was dated 8/31/17. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Nurse Manager on 3/5/19 about the importance of timely medical appointments and documentation. The nursing manager will be responsible to assure that all individuals in the future have a physical exam completed according to regulatory timeframes by tracking the appointments in the new AVATAR electronic record keeping system.This citation was resolved on 3/28/19 when an individual in residential had their physical completed within regulatory timeframes. |
03/08/2019
| Implemented |
6400.141(c)(9) | The last prostate exam for individual #1 was dated 12/28/17. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Nurse Manager on 3/5/19 about the importance of timely medical appointments and documentation. The nursing manager will be responsible to assure that all individuals in the future have a prostate exam completed according to regulatory timeframes by tracking the appointments in the new AVATAR electronic record keeping system. This citation was resolved on 3/26/19 when an individual in residential had their prostate exam completed within regulatory timeframes. |
03/26/2019
| Implemented |
6400.163(c) | The 3 month psychiatric medication review for individual #1 between 9/27/18 and 1/14/19, exceeded 90 days. | 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. | Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Nurse Manager on 3/5/19 about the importance of timely medical appointments/documentation. The nursing manager will be responsible to assure that all individuals in the future have a psychiatric exam completed according to regulatory timeframes by tracking the appointments in the new AVATAR electronic record keeping system. This citation was resolved on 3/28/19 when an individual had their psychiatric exam completed within regulatory timeframes. |
03/28/2019
| Implemented |
6400.181(e)(3)(iv) | The assessment dated 6/19/18 for individual #1 did not record their needs with or without assistance. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Based on the licensing review of February 26-27, 2019, the Program Specialist Manager retrained All Program Specialists on 3/7/19 about the importance of ensuring that the Annual Assessment indicates what an individual can do with or without assistance. The Program Specialist Manager will be responsible to review and assure that all Annual Assessments are completed according to regulatory requirements. This citation was resolved on 4/8/19 when the Annual Assessment for an individual included information about personal needs with or without assistance. |
04/08/2019
| Implemented |