Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.144 | Individual #3 was scheduled for an appointment with the psychiatrist on 12/17/12 but was not seen until 2/4/13. | 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.
| 1. All scheduled psychiatric appointments will be identified on the individual's psychiatric appointment summary at the conclusion of each session.
2. LSS Medical Coordinator, Assistant Medical Coordinator, Behavioral Specialist and/or Executive Program Director will communicate with outpatient psychiatrist when an appointment occurs eithger at the physician office and/or via teleconference to ensure follow-up dates are confirmed. When an appointment needs to be re-scheduled for a particular reason, the medical department, Behavioral Specialist and/or Executive Program Director will ensure an appointment summary is completed indicating with the appointment was re-scheduled.
[Partially Implemented] |
04/02/2013
| Implemented |
6400.163(b) | Individual #3 is prescribed medication to treat symptoms of a diagnosed psychiatric illness but there is no SEEN plan written to address the individual's needs. | (b) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness.
| LSS Program Case Coordinators are responsible in ensuring a SEEN plan is completed for all individuals being served in order to assure no individuals are missed when a Behavior Support Plan is discontinued. (Attachement 11).
[Fully Implemented] |
04/02/2013
| Implemented |
6400.167(b) | The prescription from the psychiatrist on 2/14/13 prescribes the medication Effexor XR, 225 milligrams, two times a day. The medication log indicates that Individual #3 is receiving Effexor 225 milligrams, only once a day. | (b) Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.
| To ensure medications administered are matching directions specified by the physician, certified nurse and or LPN, the Residential Service Workers and/or House Supervisors will attach a current copy of the individual's physician's order sheet or medication administration record to the appointment summary so that an accurate and current up to date list of medications are available for the physician to review.
LSS's medical department (Medical Coordinator & Assistant Medical Coordinator) will be responsible for ensuring medications administered are matching the individual's MAR. (Attachment 12).
[Partially Implemented] |
04/02/2013
| Implemented |
6400.181(e)(13)(vii) | The assessment for Individual #3 does not include progress and growth in the area of financial independence. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (vii) Financial independence.
| LSS revised the Assessment Summary to include check boxes identifying either progress or no progress for each specific domain (see attachment 9).
LSS Program Case Coordinators are responsible to identify whether the individual has either progressed or not progressed in the area of financial independence (see attachment 9).
[Partially Implemented] |
04/02/2013
| Implemented |
6400.181(e)(14) | The assessment for Individual #3 does not include information regarding his ability to temper water. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim.
| LSS Program Case Coordinator revised Individual #3's Assessment Summary to specify his ability to temper water (see attachment 9).
[Partially Implemented] |
04/02/2013
| Implemented |
6400.183(7)(iii) | The ISP for Individual #3 does not include the potential to advance in vocational programming. | (7) Assessment of the individual's potential to advance in the following: (iii) Vocational programming.
| LSS program Case Coordinator revised Individual #3's ISP to specify his potential to advance in vocational programming (see attachment 10).
[Partially Implemented] |
04/02/2013
| Implemented |
6400.183(7)(iv) | The ISP for Individual #3 does not include the potential to advance in competitive community-integrated employment. | (7) Assessment of the individual's potential to advance in the following: (iv) Competitive community-integrated employment.
| LSS Program Case Coordinator revised Individual #3's ISP to specify his potential to advance in competitive employment (see attachment 10).
[Partially Implemented] |
04/02/2013
| Implemented |
6400.187 | Copies of the ISP were not sent to all plan team members within 30 calendar days after the ISP meeting. The meeting was held on 8/10/12 and the ISP was sent out on 10/14/12. | A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings.
| LSS Program Case Coordinators are responsible to ensure all plan team members receive copies of the individual's ISP within 30 days after the ISP meeting.
LSS Program Case Coordinators will create a 30 day calendar alert as to when the new ISP should be available from the Support Coordinator. If the ISP is not available, email reminders will be sent to the Support Coordinator and copies of the emails will be filed in the individuals' Program Books as proof that the ISP have not been made available.
[Partially implemented] |
04/02/2013
| Implemented |