| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1's February 26 entry on Individual Financial Ledger states "Change from workshop lunch" in the amount of $1.73. However, there is no entry showing money was withdrawn and given to individual and her ISP indicates that she is unable to manage money. Further, ledger entries on 3/3/22, 3/10/22, 3/24/22, and 3/31/22 all show withdrawals of the exact amount on the receipts. Staff indicated that she is given money, but it is not entered on ledger until she returns with change. A withdrawal entry should be made each time she is given money and then a deposit entry should be made when she returns her change and provides the receipt. | (2) Disbursements made to or for the individual.
| Executive Director recognizes that this area of compliance is not able to be corrected for the individual #1 record. New financial log was established to include withdrawals (deductions) from individual¿s financials. Vouchers were also produced to ensure that the money being deducted for purposes without a receipt are accounted for. Vouchers will be signed by individual and person money released to. All vouchers will be kept with the financial record. Staff will be trained on new financial ledgers and vouchers and on how to correctly document on form when withdrawals of any kind are made on behalf of the individual by April 30, 2022. See attached for new financial records and staff training. See new financial ledger and voucher that will be implemented by April 30, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(a) | Repeat 1/4/2022: Individual #1 had a physical 2/1/21 and not again until 3/4/22 which was greater than 1 year. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual # 1s physical was not completed in time frame, due to lack of oversight of program. All physical examinations of all individuals were reviewed and scheduled by Program Specialist and added to shared outlook calendar. Alerts were added for each physical date to remind Program Specialist, Associate Director, and Executive Director one month prior to physical examination date due. Program Specialist will ensure that staff are called to add appointment to house calendar. All staff will be trained on the importance of individual physical dates and keeping in compliance with regulations by April 30, 2022.See Individual # 1 physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(b) | The 3/4/22 physical for individual #1 was signed by physician but was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual # 1 physical was scheduled and done on 4/11/22. New prepopulated physical was implemented to ensure all information are in compliance per regulations. Physical for individual #1 was prepopulated by Program Specialist. Physician signed and dated after completion of physical examination. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(3) | Nothing was noted for immunizations on the 3/11/22 physical for individual #1. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual # 1 physical was scheduled and done on 4/11/22. New prepopulated physical was implemented that include all up to date immunizations that can be added to prepopulated portion of physical by staff. Prepopulated portions of physical will be reviewed by Program Specialist and/or Associate Director prior to physical date, which will be signed and dated that it was reviewed and correct. If any information is incorrect, the Program Specialist or Associate Director will correct immediately. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(4) | Nothing was noted for vision and hearing on the 3/11/22 physical for individual #1. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual # 1s vision and hearing were not noted on the physical, due to lack of oversight of program. Individual # 1 physical was scheduled and done on 4/11/22. New prepopulated physical was implemented that include vision and hearing. Staff were trained on the new prepopulated physicals and to correctly check the physical prior to leaving physician office for accuracy of documentation per regulations. Program Specialist or Associate Director will review the physical to also check for all areas of compliance when completed. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(6) | Repeat 1/4/2022: The last TB for individual #1 was 2/11/19. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual # 1 received her TB test on 4/11/22 and it was read on 4/13/22 (negative), however it was administered and read by MA (medical assistant). TB is rescheduled for April 26, 2022, and to be read April 28, 2022, at Medwell. Program Specialist and Associate Director reviewed other physicals for absence of compliant TB testing. All individuals that needed TB testing were scheduled to ensure compliance. All appointments were entered into the shared Outlook calendar and will alert Program Supervisor, Associate Director, and Executive Director one month prior to scheduling appointment. New prepopulated physical form was implemented to include TB test is required prior to annual physical. Prepopulated physical will be filled out by staff and reviewed by Program Specialist or Associate Director prior to annual physical to ensure TB testing is in compliance. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. New TB test can be sent when completed on April 28, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(7) | Nothing was noted for a gynecological examination on the 3/11/22 physical for individual #1. | 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. | Individual # 1s gynecological exam was not noted on the physical, due to lack of oversight of program. Individual # 1 physical was scheduled and done on 4/11/22. All gynecological exams of all female individuals of age of regulations or per physician were reviewed and scheduled by Program Specialist and added to shared outlook calendar. Alerts were added for each mammogram date to remind Program Specialist, Associate Director, and Executive Director one month prior to appointment date due. Program Specialist will ensure that staff are called to update on appointment date, and to add to house calendar. All staff will be trained on the importance of individual physical dates and keeping in compliance with regulations by April 30, 2022. See Individual # 1 physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(8) | Nothing was noted for a mammogram on the 3/11/22 physical for individual #1. Also, the last mammogram was 10/29/20 and individual #1 is older than 50 and should have an annual mammogram unless recommended by doctor. There is no documentation from a doctor indicating individual only needs mammogram every 2 years. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual # 1s mammogram was not completed in time frame, due to lack of oversight of program. Individual # 1 physical was scheduled and done on 4/11/22. All mammograms of all female individuals of age of regulations or per physician were reviewed and scheduled by Program Specialist and added to outlook calendar. Alerts were added for each mammogram date to remind Program Specialist, Associate Director, and Executive Director one month prior to appointment date due. Program Specialist will ensure that staff are called to update on appointment date, and staff to add to calendar. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(10) | There was no place on the 3/11/22 physical for individual #1 to indicate communicable disease status. | 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. | Individual # 1s physical was not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 physical was scheduled and completed on 4/11/22. New prepopulated physical was implemented that include communicable disease for each individual can be added to prepopulated portion of physical by staff. Prepopulated portions of physical will be reviewed by Program Specialist or Associate Director prior to physical date and will sign and date that it was reviewed and correct. If any information is incorrect, the Program Specialist or Associate Director will correct immediately. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(12) | Nothing was noted for physical limitations on the 3/11/22 physical for individual #1. | The physical examination shall include: Physical limitations of the individual. | Individual # 1s physical was not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 physical was scheduled and done on 4/11/22. New prepopulated physical was implemented that include physical limitations for each individual can be added to prepopulated portion of physical by staff. Prepopulated portions of physical will be reviewed by Program Specialist or Associate Director prior to physical date and will sign and date that it was reviewed and correct. If any information is incorrect, the Program Specialist or Associate Director will correct immediately. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(15) | Nothing was noted for special dietary needs on the 3/11/22 physical for individual #1. | The physical examination shall include:Special instructions for the individual's diet. | Individual # 1s physical was not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 physical was scheduled and done on 4/11/22. New prepopulated physical was implemented that include special dietary needs for each individual can be prepopulated on physical by staff. Prepopulated portions of physical will be reviewed by Program Specialist or Associate Director prior to physical date and will sign and date that it was reviewed and correct. If any information is incorrect, the Program Specialist or Associate Director will correct immediately. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See Individual #1 completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.144 | Repeat 1/4/2022: The 2/1/21 physical for individual #1 recommended an additional appointment to test hearing. No appointment was made to have hearing tested. Also, the ISP for individual #1 indicates she needs dental appointments every 6 months but this is not being followed. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual # 1s hearing test was not completed, nor dental appointments completed as per ISP for accuracy of compliance, due to lack of oversight of program. Individual #1 was seen for annual physical on 4/11/22, in which Program Specialist conversed with physician on hearing test. Hearing test is scheduled for May 20, 2022. New dental form was implemented to include dentist recommendations. Individual #1 is scheduled for dental appointment on May 9, 2002, in which staff will talk with dentist and document on dental form how often Individual is to be see for cleaning and examination. All staff will be trained on new physical form and how to correctly complete all prepopulated information by April 30, 2022. See new completed dental form dated April 11, 2022. |
05/20/2022
| Not Implemented |
| 6400.181(e)(13)(i) | The 3-27-22 assessment for individual #1 does not mention that individual is at risk for choking but the 3/31/22 ISP states she is at risk for choking. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| April 5, 2022, Executive Director immediately upon notification from licensee corrected Individual # 1 assessment to include risk for choking and Individuals Mealtime Support Plan, that includes choking concerns and procedures. Updated Assessment was sent to Supports Coordinator for update in Individual #1 ISP. Licensee reviewed Assessment information that was sent to Supports Coordinator. Program Specialist will be trained on ensuring all information and ISP are correct and follow regulatory compliance by April 18, 2022. See attached for Assessment and email to Supports Coordinator dated April 5, 2022. See attached for Program Specialist training sheet dated April 19, 2022. |
04/19/2022
| Not Implemented |
| 6400.166(a)(11) | The February and March MARs for individual #1 did not include a diagnose/reason or prescribing physician for some of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | February and March Mars were not completed for accuracy of compliance, due to lack of oversight of program. Program Specialist and Associate Director have reviewed all Mars for diagnosis/reason for prescribing and updated information on Mar for compliance. Pharmacy was emailed on April 13, 2022, to ensure that all Mars include diagnosis/reason for prescribing on all upcoming months. Mar Review Record was implemented with Program Specialist and Associate Director will use when monitoring Mars. ALCUP is working with Martella¿s Pharmacy and Quick Mars to implement electronic medication system, with tentative date of June 30, 2022. All staff will be trained on reviewing all information on the Mars per regulations by April 30, 2022. See Individual # 1 new Mar Review dated April 4, 2022. |
04/30/2022
| Not Implemented |