| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.122(a) | It is recommended by individual #1's dentist to be seen annually. He had a dental exam on 8/4/17 and not again until 10/31/18. | An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Family Living Provider will request annual dental exam for 9-12 months at the end of the annual appointment. This is to ensure that if the dentist cancels the appointment, there will be adequate time to ensure compliance with 6500.122(a). The Director of Quality Assurance & Training completed the training on October 28, 2019. The outline and sign in sheet are attached. To ensure no further infractions occur, the Family Living Specialist will ensure all follow ups are completed and document within the quarterly report. The Non-Residential Director will review quarterlies for one year, beginning October 28, 2019 and ending November 1, 2020. The Quality Assurance Associate will review the documentation randomly throughout the year, with at least two reviews. |
10/28/2019
| Implemented |
| 6500.124 | Individual #1's physician ordered bloodwork (CBC levels) to be completed in January 2019 (during his annual physical examination) on 1/8/19. Bloodwork (CBC levels) were not checked until 4/11/19. | 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. | Upon completion of all health services, the Family Living Provider will forward a copy of all medical appointment documentation to the Family Living Specialist for review. The Director of Quality Assurance & Training completed the training on October 28, 2019. The outline and sign in sheet are attached. To ensure no further infractions occur, the Family Living Specialist will ensure all follow ups are completed and document within the quarterly report. The Non-Residential Director will review quarterlies for one year, beginning October 28, 2019 and ending November 1, 2020. The Quality Assurance Associate will review the documentation randomly throughout the year, with at least two reviews. |
10/28/2019
| Implemented |
| 6500.20(c) | The 9/18/19 incident for individual #1 was not reported to his next of kin who is designated to be contacted. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | When an incident occurs, the Operations Director will ensure that persons designated by the individual is notified within 24 hours of discovery of an incident. The Director of Quality Assurance and Training completed the training on October 28, 2019. The outline and sign in sheet are attached. Once completed, the Operations Director must inform the On Call System, which will be added to the EIM report. The EIM reports will be utilized as verification. |
10/28/2019
| Implemented |