| 6400.15(a) | A self-assessment was completed on 6-6-2016, and the certificate of compliance expired on 2-5-2017. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Residential Program Coordinators were all re-trained on the Plan of Correction for the 6400 audit. The Program Director will generate a reminder for all Self-Assessments to be completed when we are six months from the expiration of our current license, which is due to expire on 02/05/2018. The reminder will be sent by email.[Prior to 3 months of the expiration date of the agency's certificate of compliance, the Program Director shall review all self-assessments to ensure timely completion. Documentation of the review shall be kept.(AS 3/10/17)] |
03/06/2017
| Implemented |
| 6400.163(c) | Individual #1's psychiatric review, on 8-8-2016, did not address the need to continue the medication. | 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. | The Residential Program Coordinators were all re-trained on the Plan of Correction for the 6400 audit. The Program Director has instructed all of the Program Coordinators to be vigilant when reviewing the three month medication reviews. If there is an issue the Program Coordinator will be responsible to contact the physician to make the changes needed. [At least quarterly for 1 year, the program director shall review a 25% sample of completed psychiatric medication reviews to ensure all required information is included. Documentation of reviews shall be kept. (AS 3/10/17)] |
03/06/2017
| Implemented |