| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(e) | Individual # 1 had a dental exam in Jan. 2013 which recommended follow-up on 7/22/13 which did not occur. | (e) Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Individual's dental exam was completed on 8/26/13.
A review of all CLA individual's medical charts was completed October 2013 by the Nurses and CLA Nurse Manager to review completed appointments, exam due dates, and follow up due dates.
To assure compliance in this area, the Nurse Manager has developed and will maintain a written log of all CLA individuals medical appts.- due date, type of medical appt., date scheduled, and date completed. The Nurse Manager will facilitate bi-weekly meetings with each healthcare assistant and Nurse team for the primary purpose of reviewing medical appointments for each individual per caseload. For all medical follow up needed, the healthcare assistant who facilitates the appointment will inform the Nurse or Nurse Manager within (1) business day and a follow up appt. will be immediately scheduled. The healthcare assistants and Nurses will maintain all medical appts. per caseload on their Microsoft Outlook calendars, which are shared.
|
08/26/2013
| Implemented |
| 6400.183(4) | Individual # 1 requires 10 hrs of unsupervised time in the home and 10 hrs of unsupervised time in the community. The supervision plan does not address the outcome for this individual to achieve a higher level of independence | (4) A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.
| The individual's assessment was updated on 9/27/13 and further revised on 11/6/13 to address unsupervised time.
To assure compliance in this area, the CLA Assessment document was revised and implemented in October 2013 with revisions to the Independence section (IV.). The program specialists were trained on revisions to this document on October 30, 2013. All Assessments are reviewed by the CLA Assistant Director.
|
11/06/2013
| Implemented |
| 6400.188(c) | The following outcomes did not have protocals developed to measure outcomes in individual #1 ISP dated 11/ 1/ 12: Independence, Vacation, Healthy life styles, Safety in Community, and Meal preparation. | (c) The residential home shall provide services to the individual as specified in the individual's ISP.
| The individual's assessment was updated on 9/27/13 and further revised on 11/6/13 to address protocol for the individual's independence, vacationing, healthy lifestyle, safety in community, and meal preparation.
To assure compliance in this area, the CLA Assessment document was revised and implemented in October 2013 with revisions to section XXIII. B. and C. The program specialists were trained on revisions to this document on October 30, 2013. All Assessments are reviewed by the CLA Assistant Director.
|
11/06/2013
| Implemented |