| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #6 has a letter from a doctor on 8/17/17 stating to have a gynecological exam including a pap smear every 3-5 years. Individual #6 had an appointment on 2/23/21 where it was documented that the pap smear was attempted but it was unsuccessful. On 9/28/22, there is a letter from a doctor stating "per mother's wishes, pap smear for this year was deferred as she was asymptomatic". This exceeds the requirement. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | This provider reached out to individual #6's supports coordinator and medical power of attorney to review her medical needs. This provider's program specialist was able to provide education on the 6400 regulations, as well as the importance of the annual GYN appointment for individual #6. Upon completion of the discussion, the medical POA for individual #6 has agreed to allow her to have an appointment scheduled for an annual exam. This discussion took place on 10/24/22, and the program specialist called the doctor on 10/25/22 to schedule, taking the first appointment available, in early January 2023. Individual #6 will be seeing Reading OBGYN in Exeter. |
10/26/2022
| Implemented |
| 6400.181(e)(13)(iii) | Individual #6's assessment dated 4/19/22 did not address their progress over the last 365 calendar days in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | 1. On 10/18/22, Individual #6's program specialist completed an addendum to her assessment to include the missing information. The addendum covered the progress noted during the past 365 days for financial independence, managing personal property, as well as activities of residential living. |
10/18/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual #6's assessment dated 4/19/22 did not address their progress over the last 365 calendar days in the area of 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.
| 1. On 10/18/22, Individual #6's program specialist completed an addendum to her assessment to include the missing information. The addendum covered the progress noted during the past 365 days for financial independence, managing personal property, as well as activities of residential living. |
10/18/2022
| Implemented |
| 6400.181(e)(13)(viii) | Individual #6's assessment dated 4/19/22 did not address their progress over the last 365 calendar days in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | 1. On 10/18/22, Individual #6's program specialist completed an addendum to her assessment to include the missing information. The addendum covered the progress noted during the past 365 days for financial independence, managing personal property, as well as activities of residential living. |
10/18/2022
| Implemented |
| 6400.166(a)(2) | Individual #6's October 2022 Medication Administration Record (MAR) did not include the name of the prescribers for the following medications: Triamcinolone Cre, Hydrocort Cre, and Ketoconazole Sha. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Director of Nursing contacted PDC pharmacy and obtained copies of all MARs/TARs to be printed for November 2022 and reviewed for accuracy and completion. Between 10/17/2022 and 10/27/2022, DON reviewed all MAR/TARs against medical exam forms for each consumer and provided PDC's Medical Records Coordinator and Data Entry/EHR Lead with diagnoses and prescriber names for any entries where they were missing. DON provided these via email and forwarded the changes to the Regional Director so that program can confirm that the changes are made when the printed MAR/TARs are received. |
11/02/2022
| Implemented |