| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.31(b) | Individual #1's rights were signed late. They were signed on 01-13-16 then not again until 02-14-17. | 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. | In the future the Program Specialist will ensure that each individual signs the rights statement up on admission and annually thereafter. Rights due dates will be electronically tracked and reminders sent to both the LSP and the Program Specialist 45 days prior to the annual due date. |
12/01/2017
| Implemented |
| 6500.66 | The interior stairs that lead to a basement area commonly used by the individual had no lighting. It was pitch black and the steps were not visible. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents. | At the time of the inspection the stairway leading from the main floor of the home to the basement was dimly lit. There was not a light shining directly over the stairs. A light has been installed in the stairway itself to provide more light over the steps. |
11/17/2017
| Implemented |
| 6500.110(c) | Individual #1's annual safety training was almost a month late. She had it on 01-13-16, then not again until 02-14-17. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). All training is being tracked by Extended Reach and reminders of training that is due will be sent to the Program Specialist and LS provider 45 prior to the training being due. |
12/01/2017
| Implemented |
| 6500.121(a) | Individual #1's physical was late. She had one 05-26-16 and not again until 07-31-17. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | In the future all individuals will have physicals completed within an annual time frame. Annual physical dates will be tracked on Extended Reach and reminders will be sent to both the LSP and Program Specialists 45 days prior to annual physical date to ensure compliance. |
12/01/2017
| Implemented |
| 6500.121(c)(6) | Individual #1's TB test was late. She had one on 02-11-14 then not again until 06-08-16. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | In the future (individual #1) will have Tuberculin skin testing done by Mantoux method every two years. The electronic record keeping system will send a reminder to both the LSP and the Program Specialist 45 days prior to the annual due date to help ensure future compliance for all individuals. |
12/01/2017
| Implemented |
| 6500.121(c)(7) | Individual #1 did not have a annual breast exam. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | A separate gyn form has been developed with specific blanks for the doctor to indicate clearly whether or not a breast exam, pelvic exam and PAP test have been completed and at what intervals they are recommending the exams be completed for each individual. Individuals who refuse any part of the gyn exam will be counseled as to the importance of the exam by the Program Specialist and if they continue to refuse, the refusal will be documented. The breast exam was performed on 3/22/2017. Documentation of the exam was not present in the file during inspection. |
11/17/2017
| Implemented |
| 6500.121(c)(10) | There was no section pertaining to communicable diseases on Individual #1's physical form. | 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. | During the licensing inspection it became apparent that the annual physical for JS was missing the 2nd page and that page of the form contains the section pertaining to communicable diseases. In the future the Program Specialist will ensure that all the pages of the annual physical exam are present and completed prior to filing the form in the individual¿s record. Additionally, we are working with the physician''s office to get a statement that individual is free from communicable diseases. |
12/29/2017
| Implemented |
| 6500.121(c)(11) | Assessment of health maintenance needs was left blank on Individual #1's physical form. | 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. | The section pertaining to health maintenance needs on Individual #1 has now been completed as n/a. The Program Specialist will develop a letter to physicians to be presented to the physician along with the physical form at the time of the physical instructing them not to leave anything blank on the physical. The Program Specialist will review all incoming physical forms to ensure compliance. Any physicals found to have blanks will be returned to the physician for completion. Documentation will be kept for physicals that were returned |
12/01/2017
| Implemented |
| 6500.121(c)(12) | The section pertaining to physical limitations was left blank on Individual #1's physical form. | The physical examination shall include: Physical limitations of the individual. | The section pertaining to physical limitations on Individual #1 has now been completed as n/a. The Program Specialist will develop a letter to physicians to be presented to the physician along with the physical form at the time of the physical instructing them not to leave anything blank on the physical. The Program Specialist will review all incoming physical forms to ensure compliance. Any physicals found to have blanks will be returned to the physician for completion. Documentation will be kept for physicals that were returned |
11/17/2017
| Implemented |
| 6500.121(c)(15) | A section pertaining to diet was not on Individual #1's physical form. | The physical examination shall include: Special instructions for the individual's diet. | The section pertaining to dietary needs on Individual #1 has now been completed as n/a. The Program Specialist will develop a letter to physicians to be presented to the physician along with the physical form at the time of the physical instructing them not to leave anything blank on the physical. The Program Specialist will review all incoming physical forms to ensure compliance. Any physicals found to have blanks will be returned to the physician for completion. Documentation will be kept for physicals that were returned |
11/17/2017
| Implemented |