| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | Individual #1 received unspecified amount of money in February 20022 but this was not recorded on their ledger. Individual #1's ISP states she does not understand the value of money. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Individual # 1s money was not completed for accuracy of compliance, due to lack of oversight of program. Program Specialist and Associate Director will review all individuals ability to manage money and ensure this is noted correctly in Assessments and ISP. If individual is unable to manage money, any money received will be added to their financial ledger and kept in locked area of home with staff oversight. Email will be sent to Supports Coordinator if information needs added or changed in ISP by April 30, 2022. All staff will be trained on financials and individual ability to manage financials by April 30, 2022. See attached for financial forms that will be implemented by April 30, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(7) | Individual #1's physical dated 12/1/2021 did not contain the gynecological examination. | 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 was scheduled a physical examination on April 11, 2022. 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 new completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(8) | Individual #1's physical dated 12/1/2021 did not contain the mammogram. | 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. 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 new completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.141(c)(10) | Individual #1's physical dated 12/01/2021 did not contain communicable disease. | 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 is scheduled for an appointment on April 27, 2022. 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 new completed physical dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.142(b) | Individual #1's dental exam dated 12/26/2021 did not include dental problems if applicable. | An individual who is using medication known to cause dental problems shall have a dental examination by a licensed dentist at intervals recommended in writing by the dentist. | Individual # 1s dental examination was not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 next dental appointment is scheduled for July 5, 2022. New dental form was implemented that include dental examination and recommendations. Staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on new dental form and how to correctly complete all prepopulated information by April 30, 2022. See Individual new dental form completed April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.142(c) | Individual #1's dental exam dated 12/26/2021 did not include a written record of the examination. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | Individual # 1s dental examination was not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 is scheduled for dental appointment on July 5, 2022. New dental form was implemented that include dental examination and recommendations. Staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on new dental form and how to correctly complete all prepopulated information by April 30, 2022. See Individual completed dental examination dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.142(d) | Individual #1's dental exam dated 12/26/2021 did not include a record of teeth cleaning. | The dental examination shall include teeth cleaning or checking gums and dentures. | Individual # 1s dental examination was not completed for accuracy of compliance, due to lack of oversight of program. Individual scheduled for dental appointment on July 5, 2022. New dental form was implemented that include dental examination and recommendations. Staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on new dental form and how to correctly complete all prepopulated information by April 30, 2022. See Individual completed dental exam dated April 11, 2022. |
04/30/2022
| Not Implemented |
| 6400.142(f) | Individual #1's dental exam dated 12/26/2021 did not include a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual # 1s dental hygiene plan was not completed for accuracy of compliance, due to lack of oversight of program. All individual dental hygiene plans were implemented, added to Assessment, and sent to Supports Coordinator to add to ISP. All staff will be trained on dental plans and how to correctly document dental information by April 30, 2022. See Individual #1 completed dental hygiene plan dated April 18. 2022. |
04/30/2022
| Not Implemented |
| 6400.165(g) | Individual #1 last psychiatric review was completed on 5/27/2021 and did not have once every three months since. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual # 1s psychiatric reviews and appointments were not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 is scheduled for an appointment with her psychiatrist for May 2, 2022. New prepopulated psychiatric/psychotropic quarterly review was implemented. Once review is completed by Psychiatrist, staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on quarterly psychiatric form and how to correctly complete all prepopulated information by April 30, 2022. See completed prepopulated quarterly psychiatric/psychotropic review dated April 13, 2022. |
04/30/2022
| Not Implemented |
| 6400.169(a) | Individual #1 was given medication in the months of March and April 2022 and staff #1, staff #2, staff #3 and staff #4 were not trained on the department approved medications administration course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff Medication Administration medication and Mar reviews were not completed, due to lack of oversight of program. Staff #1, #2, #3 and #4 were trained by Medication trainer who did oversight of medication administration passes on April 7, 2022, and April 11, 2022. Mar reviews were completed on April 13, 2022, and April 17, 2022. All reviews are sent to Human Resource Department where all training is placed in database with oversight of Human Resource Department. Staff trainer reminders are sent prior to due date to Program Specialist, Associate Director, and Executive Director. Medication trainer is in the process of getting all staff medication trained by May 20, 2022. See Medication reviews for all staff trained in Medication Administration dated April 7, 2022 April 17, 2022. |
05/20/2022
| Not Implemented |