| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.162(a) | The label attached to a PRN medication, prescribed for Individual #1, does not indicate that the medication is to be used as needed. Label reads, "Bacitracin 500 unit 1 gm ointment-apply to affected areas as directed, twice daily topical use only, for use on sores." (Partially implemented-adequate progress-2/20/2013-CEM) | (a) The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician.
| The medication label was replaced before licensing staff departed. Program Specialists will check all med labels when they do their monthly monitoring. Staff was trained on 8/24/2012 in regards to ensuring all medications are labeled properly and checked during monitoring and staff shift changes. A monitoring summary form will be completed by DSPs on a daily basis. The program manager will be responsible for ensuring medication labels are accurately documented according to the doctor's prescription and for ensuring the monitoring summary is completed. |
08/24/2012
| Implemented |
| 6400.213(7)(ii) | Invitation for Individual #1's annual ISP review, held on 10/11/11, was not in the individual file. (Partially implemented-adequate progress-2/20/2013-CEM) | (ii) The annual update meeting.
| The Supports Coordinator brought over the invitation to the 10/11/11 meeting. The Program Specialist will make sure that they will also do their own invite letters and keep them in the file. Staff were trained on 8/24/2012 in regards to quarterly review paperwork requirements specific to the ISP invitation letter. The program specialist will request a copy of the invitation letter upon knowledge of the scheduled meeting date. If the letter is not provided, written proof of the request of the letter will be maintained in the individual file. The program manager will be responsible for ensuring all pertinent documentation is kept in each individual file. |
08/24/2012
| Implemented |
| 6400.213(8)(ii) | Signature sheet for Individual #1's annual ISP review, held on 10/11/11, was not in the individual file. (Partially implemented-adequate progress-2/20/2013-CEM) | (ii) The annual update meeting.
| Supports Coordinator brought the sign off sheet over for the 10/11/11 meeting before licensing staff departed. The program specialist will request a copy of the sign-in sheet during each ISP meeting. If the sign-in sheet is not provided, written proof of the request of the sheet will be maintained in the individual file. Program Specialists will do their own sign off sheets at meetings and keep them in the file. Training was provided to staff on 8/24/2012 in regards to ISP documentation requirements that must be kept in each individual file. The program manager will be responsible for ensuring all pertinent documentation is kept in each individual file. |
08/24/2012
| Implemented |