| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The written emergency evacuation plan did not include the means of transportation. The plan indicated staff were going to transport the individual but did not explain how; i.e. staff vehicle, personal vehicle, company vehicle, etc. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| November 8, 2018- All Program Specialists were trained on their responsibilities that there shall be written emergency evacuation procedures that include individual and staff responsibilities, mean of transportation, and an emergency shelter location. A training record was signed indicating their attendance and understanding. The agency Emergency and Removal Transfer Plan template has been revised to include means of transportation. This new form is a template and is prepopulated to ensure compliance when referencing means of transportation.
November 12, 2018- In all agency homes the Program Specialist updated all Emergency and Removal Transfer plans. They have been verified by the ID Director to be correct and in compliance. |
11/12/2018
| Implemented |
| 6400.144 | Individual #1's prescribed Fluticasone Prop Spray 50mcg was never administered on 10/8/18 and 6/18/18 at 8am due to the medication not being available in the home. On 10/7/18 and 7/19/18 at 8pm, the individual's Montelukast Sod 10mg was not administered. On 2/13/18, the individual's 100% Psyllium Husk Daily Fiber was not administered at 9AM. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| November 8, 2018- All Program Specialists were trained on their responsibilities that health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. A training record was signed indicating their attendance and understanding.
November 18, 2018- A ¿Medication Away/Return¿ form has been developed and will be consistently used when Individual #1 goes home. The Medication Away/Return form documents the medications that are sent home with Individual #1 and their verification that all the medications were returned back with Individual #1 when he returns to the program. Individual #1 went home on 11/16/18 and then returned back to the program on 11/18/18. The agency form indicates that Individual #1 left with all his medications and then verified he returned back to the program will all medications listed. A review of all individuals in the agency who currently go home and take prescription medications with them that need to be administered while they were gone was reviewed by the Program Specialist for the release and return of the medications and all were in compliance. Program Specialists will review medications monthly to ensure compliance. |
11/18/2011
| Implemented |
| 6400.162(a) | Individual #1 is prescribed by a doctor, but not listed on his/her over the counter (OTC) medication approval form, Stool Softner, Vitamin D, Mucinex and Diphenhydramine 25mg. These medications do not have a pharmaceutical label.
--Individual #1 is prescribed Montelukast Sod 10mg. The medication label indicated this medication is to be taken at 5pm. The medication log indicated the medication is being administered at 8pm. According to staff, the medication time was changed from 5pm to 8pm. A new label was not obtained.
--The individual is prescribed Mucinex 1 tab as needed. The original label on the medication indicated a dosage of 1200mg per tablet. The medication log listed the dosage at 600mg. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | November 8, 2018- All Program Specialists were trained on their responsibilities that the original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. A training record was signed indicating their attendance and understanding.
November 5, 2018- Individual #1¿s stool softner, Vitamin D, and Diphenhydramine 25mg were changed from an OTC bottle to a prescription medication with a pharmaceutical label.
November 19, 2018- A doctor¿s note was faxed approving the medication, Mucinex be taken as an OTC.
November 9, 2018- The time frame for Montelukast to be given for Individual #1 was clarified by the doctor at an appointment to be administered at 5 pm as stated on an agency medical visits record form.
November 19, 2018- Individual #1¿s Mucinex dosage was corrected to be 600mg instead of 1200mg by his physician. A new bottle of Mucinex 600mg was purchased for Individual #1. All prescription medications have been reviewed by the Program Specialists to ensure correct labeling. The Program Specialists will review medications monthly to ensure the original container for prescription medications have a pharmaceutical label and over the counter medications are approved by a doctor. |
11/19/2018
| Implemented |
| 6400.163(b) | Individual #1 is diagnosed with depression and his/her Individual Support Plan (ISP) does not include a written protocol that addresses his/her social, emotional and environmental needs related to the symptoms of the diagnosed psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. | November 8, 2018- All Program Specialists were trained on their responsibilities that if a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. A training record was signed indicating their attendance and understanding.
November 9, 2018- Individual #1 had their ISP updated to include a protocol to address the social, emotional, and environmental needs of the individual related to the symptoms of a diagnosed psychiatric illness. All ISP¿s have been reviewed and verified by the Program Specialists to be correct and in compliance. Program Specialists will review all sections of the ISP in each quarterly report which includes the protocol for social, emotional, and environmental needs of the individual related to the symptoms of the psychiatric illness. |
11/09/2018
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's 6/20/18 assessment did not include functional skills. This section was blank. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | November 8, 2018- All Program Specialists were trained on their responsibilities that the assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. A training record was signed indicating their attendance and understanding.
November 15, 2018- The agency assessment template was revised to allow a place to respond to ¿Acquisition of Functional Skills.¿ The revision and addition of this expanded space will help to make it more clear that it is a section to be addressed. Individual #1¿s assessment has been updated to include information on their current level of performance and progress in the area of ¿Acquisition of Functional Skills.¿ All assessments agency wide have been reviewed by the Program Specialists to ensure compliance. Program Specialists will review assessment content in the quarterly reports. |
11/15/2018
| Implemented |
| 6400.186(a) | REPEAT from 9/27/17 annual inspection: Individual #1's Individual Support Plan (ISP) reviews were late and not completed within the 15 day grace period after the end of the quarter: completed 10/11/18 but reviewed the quarter 6/14/18-9/13/18, completed 7/5/18 but reviewed the quarter 3/14/18- 6/13/18, and completed 1/4/18 but reviewed the quarter 9/14/17-12/13/17. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | November 8, 2018- All Program Specialists were trained on their responsibilities that an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A training record was signed indicating their attendance and understanding.
November 6, 2018- A three month review was completed on 11/6/18 for the review period ending 10/28/18. The three month review was signed/dated by the individual and Program Specialist on 11/6/18 and then sent out to the team on 11/6/18.
In addition, a new process has been instituted and all Program Specialists must send all quarterly reports to the Assistant Director of ID for verification of completion and distribution within 15 days after the three month review period ends, allowing time for a reminder notification to be sent to the Program Specialists. All agency quarterlies have be reviewed and verified by the Program Specialists to ensure current compliance. |
11/08/2018
| Implemented |
| 6400.213(11) | --Individual #1's Individual Support Plan (ISP) indicated Prednisone as a contraindicated medication with a reaction of hallucinations. This contraindicated medication was not listed on his/her physical exam.
--The individual's ISP indicated a diagnosis of Esophageal Dysmotility and as a result, the individual is at risk of choking and requires appropriate meal prep: Food (especially meats) need to cut into small pieces and encourage to drink fluids during meal. The individual's assessment indicated that he/she is able to eat meals on his/her own and does not need to have food cut up prior to serving. This specific eating precaution is not indicated anywhere on his/her physical examination.
--The individual's assessment listed that he/she required constant supervision in the community. The individual's ISP listed that he/she can be alone up to 10 minutes in a car, restaurants, sporting events if staff need to use restroom or help another peer. The individual's ISP reviews listed that he/she could have 5-10 minutes of unsupervised time in community. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | November 8, 2018- All Program Specialists were trained on their responsibilities that each individual¿s record should not include content discrepancy in the ISP, the annual update or revision. A training record was signed indicating their attendance and understanding.
November 14, 2018- Individual #1 had their physical updated to include the contraindicated medication of Prednisone per an allergy profile received from the doctor.
November 15, 2018- The assessment and physical were both updated to include the following, ¿He can eat meals on his own but does need to have food cut up for him prior to serving and is encouraged to drink fluids during meals to prevent choking.¿ Also, the assessment was revised to reflect the current supervision needs in the community which were correct in the ISP stating that ¿they can be alone up to 10 minutes unsupervised time when he is in the car and staff are picking up his housemates or getting gas/running into a convenience store. Staff will also take weather conditions and temperature into account when leaving him in the vehicle. He would be able to wait either close by or comfortably seated in a vehicle, restaurants or sporting events while staff went to get refreshments, used a restroom, or attended to the needs of a peer while in the community for up to 10 minutes.¿ All ISP¿s were reviewed by the Program Specialists to ensure there is no content discrepancy, and they are in compliance agency wide. Program Specialists will review all ISP¿s content in the quarterly reports for consistency. |
11/15/2018
| Implemented |