| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(g) | Staff # 1's fire safety training dated 10/14/2015 was not conducted by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | To correct this going forward, a fire safety expert was brought in on 4/7/16 to provide training to staff who will be conducting future fire safety trainings (see attached). This ensures future fire safety trainings will be done by an expert. (a record review of all staff will be completed within 30 days of receipt of this plan in order to identify any other staff out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08/01/2016 |
04/07/2016
| Implemented |
| 6400.62(a) | Windshield Washing liquid, Old English furniture polish, Pine Sol, Petroleum Jelly and Purell cleaning wipes which indicated to contact poison control if ingested, was found unlocked in the staff office. Staff reported the individuals in the home go to the office for medication administration. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials were subsequently locked up. Going forward, Fire Drill forms were amended to include checks for any non secured poisonous materials (See attached). (All staff will be retrained on how to identify a poisonous substance. Staff will complete daily physical site checks to ensure poisonous substance are locked. The site check will be documented in the daily logs DS 08.02.16) |
04/06/2016
| Implemented |
| 6400.163(c) | Individual #1's psychological evaluations occurred on 04/06/2015, 07/27/2015 and 12/01/2015. | 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. | The gap in psychiatric services occurred due to a documented absence of the existing psychiatrist and the inability to secure the services of a replacement psychiatrist (see attached). As of licensing, a new psychiatrist had been secured and psychiatric appointments were being scheduled within the 90 day time frame.(a record review will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.02.16) |
12/01/2015
| Implemented |
| 6400.181(d) | Individual # 1's annual assessment dated 12/04/2015 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | A cover page has been added to the existing Assessment which provides a line for signature (see attached). NHS is in the process of altering the electronic form to include a line for signature. (All program specialist will be retrained in their job duties. a record review will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.02.16) |
04/06/2016
| Implemented |
| 6400.185(a) | Individual #1's 3 month ISP review documentation covering the period from 02/20/2015-05/26/2015 was not implemented by the ISP start date of 02/26/2015. | The ISP shall be implemented by the ISP's start date. | The previous system of counting 90 days in between Quarterly Reviews has been abandoned in favor of a new system of counting 3 months (i.e. 1/15/16 ¿ 4/15/16) therefore ensuring that all 3 month review documentation is implemented by the ISP start date. All 365 days of the year are covered. (All program specialists will be retrained in their job duties and a record review of all individuals served will be completed within 30 days of receipt of this plan. Any individual three months ISP review documentation found out of compliance with be correct within 15 days. A tracking system will be developed to ensure the three month ISP reviews follow the individual's ISP annual review update date. DS 08/02/2016) |
04/06/2016
| Implemented |