| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(c) | Staff #1 did not meet the qualifications for Program Specialist at the time of hire. The staff member had a Bachelor's Degree and one year of experience working with individuals with intellectual disabilities. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability. | Currently the staff has the proper experience and education for the position to date. Moving forward the regional director and the human resources personnel will ensure all program specialists meet the education and experience requirements before being hired or promoted to such a position. |
08/01/2018
| Implemented |
| 6400.82(f) | Hand soap was not accessible in the bathroom. It was locked separately in the house. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Hand soap was placed by all sinks in house. Hand soap has been purchased by the residential supervisor and placed in all bathrooms next to the sink so it is accessible to all individuals including staff. |
08/01/2018
| Implemented |
| 6400.141(c)(4) | There was no vision screening performed for Individual #1 on her physical exam dated 11/20/2017. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | An appointment with the PCP is scheduled for 9/27/18 at which the vision screening will be addressed. The program specialist will schedule and attend physical exam appointments on an at least annual basis and make sure vision and hearing are requested to be checked by the PCP. The regional director will follow up with program specialist post visit and review physical form. |
09/27/2018
| Implemented |
| 6400.141(c)(10) | This section was blank on Individual #1's physical exam dated 11/20/2017. | 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. | Program specialist has scheduled an appointment with the PCP for 9/27/18 to determine if the individual has a communicable disease, and will be so noted on the physical form. The program specialist will schedule and attend physical exam appointment and make sure the individual is checked and cleared of any communicable diseases on an at least annual basis. The regional director will follow up with program specialist post visit and review physical form to make sure this is done. |
09/27/2018
| Implemented |
| 6400.141(c)(11) | The Health Maintenance Needs section was blank on Individual #1's physical exam dated 11/20/2017. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Program specialist has scheduled an appointment with the PCP for 9/27/18 at which time the individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals will be assessed and documented by the PCP. The program specialist will schedule and attend physical exam appointment and make sure the individual¿s health maintenance needs, medication regimen and need for blood work are documented and met, and instructions are written on the physical form. The regional director will follow up with program specialist post visit and review physical form to make sure this is done. |
09/27/2018
| Implemented |
| 6400.163(c) | Individual #1 is prescribed Sertraline & Buspar. She does not have 3 month medication reviews by a licensed physician. | 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. | PCP as of 9/7/18 conducted med reviews and will continue doing so on a quarterly basis. PCP doctor will be doing three month med reviews, beginning with the 9/17/18 appointment with the individual. |
09/07/2018
| Implemented |
| 6400.183(5) | Individual #1 is prescribed Sertraline and Buspar. She does not have a SEE Plan to address any behaviors. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | SEE plan was completed 9/7/18. SEE plan and protocol has been developed and put into place by the program specialist. It has also been reviewed by the regional director and staff have been trained. |
09/07/2018
| Implemented |
| 6400.186(b) | Neither Individual #1 nor her Program Specialist signed and dated any 3 month ISP Reviews this past year. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The current ISP reviews have been signed up to date. The program specialist and client will physically sign 3 month ISP reviews instead of using electronic signature. The Regional director will review quarterlies to ensure they are physically signed. |
08/31/2018
| Implemented |