Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(3) | The physical exam for Individual #1 last Tentus immunization was given 9/7/07 and was due 9/7/17. Individual #1 did not receive the tentus immunization, making it late. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | All Program Specialists were trained on their responsibilities concerning regulation 141(c)(3). The physical examination shall include immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta , Georgia.( See Attachment # 1 )
Individual #1 received a Tetanus immunization on 9/29/2017. (See Attachment #2 )
All Program Specialists reviewed individual records and a Tetanus immunization was given to an individual that had an immunization due on 10/31/2017. The Tetanus immunization was given on 10/11/2017. (See Attachment #3)
All Program Specialists conducted a review of immunizations to ensure that all immunizations are current . |
10/25/2017
| Implemented |
6400.141(c)(6) | Individual #1 date of admission was 11/17/15, the TB was not admisinstered until 12/9/15. This is to be completed prior to the admission date | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | All Program Specialists were trained in their responsibilities concerning regulation 141(c)(6). The physical examination shall include Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.( See Attachment # 1 )
Individual #1 received a TB skin test by Mantoux method on and again on .(See Attachment #2)
All Program Specialists conducted a review of individuals TB test due dates to ensure that all are current. |
10/25/2017
| Implemented |
6400.163(c) | REPEAT from the 2016 inspection- Individual #1 is prescribed a medication to treat symptoms of a diagnosed psychiatric illness, there was only 1 medication review held on 12/7/16, this is to be completed at least every 3 months. | 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. | All Program Specialists were trained on their responsibilities concerning regulation 163(c). 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.( See Attachment # 1 )
This specific prescription for individual #1 was a PRN and has been discontinued as of 10/3/2017 (See Attachment #2)
All Program Specialists will ensure that medications prescribed to treat symptoms of a diagnosed psychiatric illness will be reviewed with documentation by a licensed physician at least every 3 months with all regulatory information.(See Attachment #3)
All Program Specialists reviewed individuals records to verify that medication reviews for all individuals taking psychiatric medications were reviewed by a licensed physician at least every 3 months. |
10/25/2017
| Implemented |
6400.181(e)(13)(vi) | REPEAT from 2016 inspection- Individual #1¿s 6/8/17 annual assessment did not include press and growth in recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | All Program Specialists were trained on their responsibilities concerning regulation 181(13)(vi). The assessment must include the individuals progress over the last 365 calendar days and current level in the area of recreation.( See Attachment # 1 )
Individual #1 assessment has been updated to include progress and growth over the last 365 calendar days and current level in the area of recreation. (See Attachment #2 )
SFI Annual Assessment was revised to reflect each specific regulation and the information to be reviewed. All future assessments will have this information included.(See Attachment #3)
A review of all individual assessments was completed to ensure they all included progress and growth over the last 365 calendar days and current level in the area of recreation. |
10/25/2017
| Implemented |
6400.181(e)(13)(vii) | REPEAT from the 2016 inspection- The 6/8/17 annual assessment for Individual #1 did not include progress and growth in financial independence | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| All Program Specialists were trained on their responsibilities concerning regulation 181(13)(vii). The assessment must include the individuals progress over the last 365 calendar days and current level in the area of financial independence. (See Attachment # 1 )
Individual #1 assessment has been updated to include progress and growth over the last 365 calendar days and current level in the area of financial independence. (See Attachment #2)
SFI Annual Assessment was revised to reflect each specific regulation and the information to be reviewed. All future assessments will have this information included. (See Attachment #3)
A review of all individual assessments was completed to ensure they all included progress and growth over the last 365 calendar days and current level in the area of financial independence. |
10/25/2017
| Implemented |
6400.186(a) | Individual #1's ISP reviews where not completed within the 3 month time frame according to the dates of the program specialist and Individual #1. The 12/19/16 ISP review not signed until 3/13/17, the 3/19/17 ISP review not signed by PS until 6/16/17, the 6/19/17 ISP review not signed by the PS until 9/18/17. | 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. | All Program Specialists were trained on their responsibilities concerning regulation 186(a). 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 individuals every 3 months or more frequently if the individuals needs change which impacts the services as specified in the current ISP.(See Attachment # 1)
The ISP review for Individual #1 ended on 9/19/2017.The report was reviewed and signed by individual
#1 and the Program Specialist on 10/4/2017. (See Attachment #2 ).
All Program Specialists will ensure that ISP reviews will be completed ,reviewed and signed by the individuals and Program Specialists within the 30 day time frame.
All ISP reviews were checked to ensure that they were completed, reviewed and signed by all individuals and Program Specialists within the 30 day time frame .. |
10/25/2017
| Implemented |
6400.186(d) | Individual #1's ISP reviews where not sent to the team members within the 30 days after the ISP review meeting according to the dates of the program specialist and Individual #1. The 6/19/17 ISP review sent to team on 9/18/17, the 12/20/17 ISP review sent out to team on 6/16/17, the 9/20/16 ISP review sent out on 3/8/16, but this review was not signed by the program specialist until 3/13/16 as being completed. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | All Program Specialists were trained on their responsibilities concerning regulation 186(d). The Program Specialist shall provide the ISP review documentation, including recommendations,if applicable,to the SC,as applicable, and plan team members within 30 calendar days after the ISP review meeting. (See Attachment # 1 )
The ISP review for individual #1 ended on 9/19/2017 , the report was sent out to all team members on 10/4/2017. (See Attachment #2)
All Program Specialists will ensure that all ISP reviews will be sent out to all team members within the 30 day time frame.
All ISP reviews were checked to ensure that they were sent out to all team members within the 30 day time frame. |
10/25/2017
| Implemented |