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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.80(a) | The two walkways from the rear exits on Navajo were completely snow and ice covered. A maintenance crew was called and the problem was corrected at the time of inspection. . | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The walkways were cleared of snow and ice at the Navajo location while the Inspector was on site. The COO went to each house in operation at the agency immediately, (2-21-19) and inspected each egress pathway from the homes.
On 2-21-19, the COO, Mr. Colville Brown trained the maintenance team to clear all means of egress walkways, from every home, on an on going basis, as snow and ice present themselves. On 2-25-19, The agency Supervisors and the Administrative Team were educated in the practice of visually checking each means of egress, from each home in operation, when snow and ice present themselves. If clearance is needed the staff in the homes; or the maintenance team will clear the walkways immediately. This training and observation practice will continue for the upcoming year and be incorporated into daily operations permanently. |
02/25/2019
| Implemented |
6400.163(c) | Individual #1's initial med review was on 07-02-18, then not again until 12-20-18. | 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. | Individual #1's medication was discontinued by the Psychiatrist on 12-20-18. The agency has implemented an Administrative Review Team process starting on 2-26-19. The AR Team will meet bi-weekly, for a time frame of no less than one year, to review the medication categories, reasons for prescribing, ISP documentation content, and daily progress notes for each individual. The Admin Review Team will measure the presenting documentation for compliance with regulation 6400.163(c). On 2-26-19, the Administrative Staff were trained to review the adherence to Psychotropic Medication reviews for each applicable individual. |
02/26/2019
| Implemented |
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