| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's signed copy of rights were late -- the current were signed 4/26/18 and the previous were signed 1/13/17. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Due dates for Review of Resident Rights is on an Excel Spreadsheet and sent to Program Directors and Program Managers monthly to ensure timely review of rights. See attached form. Review for this individual is in my calendar for April 1, 2019 see attached |
05/21/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's current annual physical examination dated 1/12/18 did not document information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physician has updated the Annual Physical Assessment form - see attached and the Assistant Vice President of Intellectual Disabilities Department is reviewing all physicals to ensure they are thoroughly completed. |
05/14/2018
| Implemented |
| 6400.163(c) | Reviews of psychiatric medications prescribed for Individual #1 only occurred on 6/07/17 and 12/19/17. | 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. | A form has been created to assist Program Directors and Program Managers will ensuring psychiatric medications are reviewed a minimum of every 3 months by a licensed physician |
05/09/2018
| Implemented |