| 6400.141(c)(10) | Individual 1's annual physical dated 10/29/18 did not indicate whether or not they were free of communicable disease. The area on the physical was left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | 1. What was done immediately to correct the specific issue cited?
Supervisor returned to PCP on December 14, 2018 and received supporting documentation verifying individual was free from communicable disease. Annual physical was updated to reflect participant free from communicable disease.
2. What specific change will be made?
Annual physical exam documentation will be reviewed following completion of exam to ensure all areas of the form are completed as required.
3. Who (by title) will make the change?
Supervisors and Program Directors.
4. When will the change be made?
December 14, 2018 and Ongoing thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisor has been retrained supporting participants in the completion of medical appointments. Discussion points included reviewing the annual physical exam prior to leaving appointments and when picking forms up from physician to ensure all areas are completed. All medical appointment documentation is scanned to agency nurse for final review prior to filing in health record.
6. What education and training has been provided to staff?
Supervisor and Program Director met on Monday, January 7, 2019 and reviewed medical supports training documentation and procedures related to ensuring all documentation obtained on medical appoints is complete and thorough.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up. All medical appointment documentation will be scanned to agency nurses immediately following appointments to ensure final review of documentation before filing into the participant¿s health records. Program Directors will review medical appointment documentation for annual appointments at the time of the monthly supervision to ensure accuracy of documentation. |
12/14/2018
| Implemented |