| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(e) | Individual #1's follow up dental exam for October 2018 was not scheduled. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | 1. What was done immediately to correct the specific issue cited?
Due to the closure of the dental practice identified prior to individual #1's move to Horizon House, it was necessary to obtain a new dental practice. Staff researched alternative dental providers and found two possibilities within the local area, one which accepted Medicare and one which did not but was affordable. An appointment was set with the practice accepting Medicare for 1/29/19. Upon subsequent conversation with the dental practice, it became apparent that they would not suit the participant's needs due to their inability to provide dentistry under sedation. The team was able to identify a practice which could. Several medical clearances were required to enable sedation. Presently, cardiology clearance is being sought as well as consent from the medical power of attorney.
2. What specific change will be made?
For new participants, beginning 1/1/2019 we will contact medical providers 30 days prior to an upcoming appointment to verify the appointment and ascertain that the provider is open. In addition, all new participant admissions will be required to identify a secondary dental provider prior to admission. For existing participants, all teams will be required to identify a secondary dental provider at ISP meetings from 1/1/2019 moving forward.
3. Who (by title) will make the change?
In terms of individual participants, the Program Director will oversee and ensure dental appointments are scheduled by the house manager within 30 days of moving in. House managers will continue to make follow up appointments and ensure that all recommendations are followed. House Managers will be responsible for making the call 30 days prior to the first dental visit to ensure the appointment is intact.
4. When will the change be made?
The initial appointment was be made by 1/1/19 and staff did ensure that CD attended the appointment and all necessary paperwork was filled out. From 1/1/2019 forward, Program Specialist will ensure that new participant admissions have a secondary dentist identified by the team at the ISP meeting. In addition, Program Specialists will ensure all existing participants and their teams identify a secondary dentist at their annual ISP meeting.
5. What system has been implemented to make sure the same violation does not occur again?
From 1/1/2019 forward, Program Specialist will ensure that new participant admissions have a secondary dentist identified by the team at the ISP meeting. In addition, Program Specialists will ensure all existing participants and their teams identify a secondary dentist at their annual ISP meeting.
6. What education and training has been provided to staff?
All Program Specialists have been trained on this expectation by 4/22/2019.
7. How will we monitor to prevent reoccurrence?
The identification of a secondary dentist will be added to the back up documentation sheet as well as the lifetime medical history. Program Specialists will be required to monitor new participants while they are completing monthly documentation that the house manager made the 30 day call to verify the initial dental visit. |
01/01/2019
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. What was done immediately to correct the specific issue cited?
The recommendations were shared face to face at the ISP meeting in this particular case and the absence of them from the assessment document was an oversight. The Program Specialist completed the recommendations portion of the assessment in the subsequent ISP meeting.
2. What specific change will be made?
The Program Specialist was counseled on the absence of recommendations.
3. Who (by title) will make the change?
The Program Specialist will make the change.
4. When will the change be made?
The Program Specialist will complete all portions of the assessment before sharing it with the team.
5. What system has been implemented to make sure the same violation does not occur again?
The particular Program Specialist received counseling on the missing item. In the subsequent assessment and ISP cycle, the Program Specialist did complete the recommendations before sending the assessment to the team.
6. What education and training has been provided to staff?
All licensing citation items were reviewed with Program Specialist team as a reminder of the importance of attention to detail.
7. How will we monitor to prevent reoccurrence?
The ISP tracker includes this item. |
01/19/2019
| Implemented |
| 6400.186(e) | Individual #1's record did not give the team the option to decline receiving the ISP reviews. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | 1. What was done immediately to correct the specific issue cited?
An internal meeting was held to review current documentation used in conjunction with sending out the assessment to the Supports Coordinator and by Program Specialist at the ISP meeting on 4/22/19 to determine if we currently have a statement indicating to team members that they may receive or decline to receive quarterly updates. It was determined that we did not. A form was created that will be utilized at all upcoming ISP meetings occurring after 4/22/2019 which allows team members to sign indicating if they would like to receive quarterly updates or if they wish to decline.
2. What specific change will be made?
A form was created that will be utilized at all upcoming ISP meetings occurring after 4/22/2019 which allows team members to sign indicating if they would like to receive quarterly updates or if they wish to decline. A copy of the form is attached.
3. Who (by title) will make the change?
The Director of Service Coordination and Program Specialists developed a document to accompany all forms Program Specialists use at ISP meetings.
4. When will the change be made?
The change was made 4/22/19.
5. What system has been implemented to make sure the same violation does not occur again?
The documentation change has been made internally by Horizon House as of 4/22/19. All Program Specialists will be trained on the documentation change within 30 days of 4/22/19.
6. What education and training has been provided to staff?
All Program Specialists will be trained on the documentation changes within 30 days of 4/22/19. A column has been added to the ISP tracker to ensure this additional form is completed.
7. How will we monitor to prevent reoccurrence?
Program specialist will review the tracker weekly, meet monthly or quarterly with supervisor to monitor progress and prevent reoccurrence. |
04/22/2019
| Implemented |