Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.31(b) | A statement acknowledging receipt of the information on individual rights was signed by Individual #1 on 3/17/16 and then again 4/13/17. | A statement signed and dated by the individual, or the individual's parent, guardian or advocate if appropriate, acknowledging receipt of the information on individual rights upon admission and annually thereafter, shall be kept. | FLS was trained on 7/20/17 on reg 6500.31(b). all consents will be reviewed and signed within 1 year of prior consents. Clinical coordinator will review files quarterly to ensure all documents including consents are signed off on annually. [Within 30 days of receipt of the plan of correction, the Program Manager shall develop and implement a tracking system to ensure individuals are informed of the individuals' rights, timely. Within 45 days of receipt of the plan of correction, the program specialist shall be trained on the tracking system. At least quarterly, for 1 year the Program Manager shall review the tracking system to ensure individuals are informed of the individuals' rights, timely. (AS 8/10/17)] |
08/03/2017
| Implemented |
6500.121(a) | Individual #1 had a physical examination completed on 5/18/16 and then again on 6/7/17. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | FLS was trained on 7/20/17 on reg 6500.121(a). all physicals will be completed within 1 year of prior exam. Clinical coordinator will review files quarterly to ensure all medical appointments occur annually[Within 30 days of receipt of the plan of correction, the Program Manager shall develop and implement a tracking system to ensure individuals have a physical examination, timely. Within 45 days of receipt of the plan of correction, the program specialist shall be trained on the tracking system. At least quarterly, for 1 year the Program Manager shall review the tracking system to ensure individuals have a physical examination, timely. (AS 8/10/17)] |
08/03/2017
| Implemented |
6500.156(a) | Individual #1's most recent ISP review was completed 4/1/16. | The family living specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the family living home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change, which impacts the services as specified in the current ISP. | Family living specialist held quarterly ISP reviews but did not file appropriate supporting documents, signature pages. FLS was trained on 6500.156(a) Clinical coordinator will review all files quarterly to ensure proper documentation is maintained for quarterly ISP reviews. [Documentation of reviews shall be kept. (AS 8/11/17)] |
08/03/2017
| Implemented |