Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.164(a) | All of Individual #1's medication administration records listed "HS" for the time the medication was administered. There was no specific time to administer the medications. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | This regulation has been reviewed by agency nurse who measures compliance through monthly reviews of MARs. 164(a) was addressed with the applicable, non-compliant site supervisors. 164(a) will be reviewed with all site supervisors via their scheduled staff meeting on 7/15/14. A copy of the meeting agenda and attendance sheet will be sent as addendum. A copy of July¿s MAR for this location will be sent as addendum reflecting compliance. |
07/15/2014
| Implemented |
6400.186(b) | Individual #1 did not sign off indicating they reviewed their ISP reviews on October 3, 2013 and July 14, 2014. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | This regulation was included in a post-licensing training for Residential Specialists. A copy of the training records will be sent as addendum to the POC. A compliant, signed review will be sent as addendum. Additionally, a new PS has been assigned to this home. |
07/10/2014
| Implemented |
6400.187 | Individual #1's October 3, 2013 ISP review was not sent to the Plan Team within 30days after the review. | A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings.
| Program Specialists have been trained on 6400.187 and clarification was provided regarding the role of the Support Coordinator versus the Program Specialist with respect to the distribution of review materials. A copy of the training records will be sent as addendum. A compliant enclosure letter since the licensing inspection will be sent as addendum. |
07/10/2014
| Implemented |
6400.195(d) | The Program Specialist did not sign off on the October 7, 2013 Restrictive Procedure Review Committee meeting minutes. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| Restrictive Review Committee Minutes form has been updated to clarify required signatures with respect to 6400.195(d) and having the required minimum ratio of members who do not provide direct services. The next Restrictive Review will be held on 7/17/14. A compliant review will be sent as an addendum. |
07/17/2014
| Implemented |