| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1 did not have a signed copy of rights in the record for 2018. | 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. | Our 6400.31(b) protocol has been updated and the following procedures have been instituted;
Rights package was reviewed and signed on 1/12/2019 by both the individual.
See attachment Q
All Program specialists will be trained to ensure Rights package are presented, reviewed and signed by the individual and their guardians annually to coincide with the Annual Individual Support Plan meeting and not to exceed 365 days from the previous signature date.
Target date 2/28/2019.
Person Responsible: Program Specialist. |
02/28/2019
| Implemented |
| 6400.72(b) | The closet door in individual #2's bedroom would not close. | Screens, windows and doors shall be in good repair. | Our 6400.72 (b) protocol has been updated and the following procedures have been instituted;
Work order was completed and closet door has been fixed. See attachment J.
A check for all closet doors to close properly will be added to our monthly environmental checklist completed by managers/program specialists by 3/31/19
All Program Specialists/Managers will be trained on how to utilize the environmental check list by 4/30/19.
The environmental check list will be completed monthly and any concerns noted will be reported to facilities within 24 hours.
Target Date 4/30/2019.
Person Responsible: Program Specialist. |
03/30/2019
| Implemented |
| 6400.113(a) | Individual #1 had fire safety on 11/10/16 and then again on 1/22/18 which was more than one year. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Our 6400.113(a) protocol has been updated and the following procedures have been instituted; Fire safety training for individual # 1 completed See attachment R and S All Program specialist will be trained on the Regulation 6400. 113 (a) All fired drill trainings will be completed in the month of November of each year and not to exceed 365 days from the previous training year date. Target date 2/28/2019. Person Responsible: Program Specialist. |
02/28/2019
| Implemented |
| 6400.165 | MAR for individual #1 indicates that Omeprazole 40mg was administered on 1/15/19, however the medication for that date was still in the blister pack. MAR for individual #1 indicates that vitamin D3 softgel was administered on 1/15/19, however, the medication for that date was still in the blister pack. | Documentation of medication errors and follow-up action taken shall be kept.
| The doctor was notified and a late administration was approved and given for the morning dose. Feedback was provided to both staff per Melmark's medication administration policy (see attachment G). Both staff were re-trained on the 15 steps of medication administration (see attachment H). Our 6400.165 & 167 (b) protocol has been updated and the following procedures have been instituted;
Documentation of medication error was completed and follow up action and review of the 15 steps of medication administration completed. See attachment G and H
The 15 steps of medication administration have been posted in the medication area to be followed and referenced verbatim during all medication administration times. See attachment I .
Target date 2/28 /2019.
Training to be completed by Program Specialist
Person Responsible: Program Specialist |
02/28/2019
| Implemented |
| 6400.167(b) | MAR for individual #1 indicates that Omeprazole 40mg was administered on 1/15/19, however the medication for that date was still in the blister pack. MAR for individual #1 indicates that vitamin D3 softgel was administered on 1/15/19, however, the medication for that date was still in the blister pack. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The doctor was notified and a late administration was approved and given for the morning dose. Feedback was provided to both staff per Melmark's medication administration policy (see attachment G). Both staff were re-trained on the 15 steps of medication administration (see attachment H). Our 6400.165 & 167 (b) protocol has been updated and the following procedures have been instituted;
Documentation of medication error was completed and follow up action and review of the 15 steps of medication administration completed. See attachment G and H
The 15 steps of medication administration have been posted in the medication area to be followed and referenced verbatim during all medication administration times. See attachment I .
Target date 2/28 /2019.
Training to be completed by Program Specialist
Person Responsible: Program Specialist |
02/28/2019
| Implemented |