| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(c)-1 | Individual # 1's is diagnosed with PICA and there was no documentation of leading testing being completed. | If the home serves an individual 4 years of age or younger or an individual who ingests paint or paint substances, the home shall test all layers of paint at the home for lead content. | This citation was resolved on 9/14/15 when lead testing was conducted at the site: the report concluded that ¿Out of 75 readings that were conducted, none of the readings were at or above the regulatory limit.¿ The CLA Director shall check the Diagnostic Record of individuals entering the CLA and assure that when individuals are diagnosed with PICA or ingesting paint substances, the home shall be tested for lead paint before the individual is admitted to the residential program. |
09/14/2015
| Implemented |
| 6400.141(a) | Individual # 1's previous physical examination was completed on 01/08/2014 and the most recent physical examination was completed on 02/05/2015. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This citation was resolved on 10/5/15 when an individual at this site had their physical completed within regulatory timeframes. Based on the licensing review of September 9-11, 2015, the CLA Director retrained the Nurse Manager on 9/15/15 about the importance of timely medical documentation. The nursing manager will be responsible to assure that all individuals in the future have a physical exam completed per regulatory timeframes. |
10/05/2015
| Implemented |
| 6400.142(h) | Individual # 1 record did not contain a dental plan. | The dental hygiene plan shall be kept in the individual's record. | This citation was resolved on 9/17/15 when a dental plan was developed for this individual. Based on the licensing review of September 9-11, 2015, the CLA Director retrained the Nurse Manager on 9/15/15 about the importance of timely medical documentation. The Nurse Manager will be responsible to assure that all individuals in the future have a dental plan completed per regulatory timeframes. |
09/17/2015
| Implemented |
| 6400.181(c) | Individual #1's annual assessment dated 10/15/2014 did not include the basis of the assessment. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Based on the licensing review of September 9-11, 2015, the CLA Management staff revised the annual assessment to better assure that it includes the basis of the assessment. All Program Supervisor/Specialist were trained on this new assessment on 10/15/15. The next annual assessment for this individual dated 10/15/2015 was reviewed by the Assistant CLA Director and included the basis of the assessment. All future assessments will include this assessment component and be reviewed by the Assistant CLA Director to assure compliance. |
10/15/2015
| Implemented |