| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 was seen by the Primary Care Physician on 2/24/12; there was to be a follow-up appointment in 2 months. This appointment had not been completed at the time of the inspection 10/9/12. In addition, Individual # 1 is a person who has diabetes and according to the PCP notes of 2/24/12 should have blood work drawn every three months to determine HGAIC levels. The only time blood work was completed was on 8/31/12. | 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.
| This violation resulted from the inability of the Residential Director to follow through on the recommendations from this individual's PCP.
This individual has a new PCP where she was seen on 11/07/2012. This individual also had a follow up visit on 11/26/12 where she had the results of her blood work done on 11/16/12 reviewed.
All completed appointment forms will be submitted to the Assistant Residential Director, who will within 48 hrs from time of completion of appointment, review returned forms for accuracy and schedule follow up appointments. A tracking sheet will be used to monitor upcoming appointments and the Assistant Residential Director will be responsible for this. |
11/09/2012
| Implemented |
| 6400.163(c) | Individual # 1 had medication review appointments on 7/26/12, 8/12/12 and 9/13/12; however, the documentation does not list the medications being review, nor the reason for the medication. | (c) 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.
| This violation resulted from the inability of the Residential Director to check returned medical appointment documentation for completeness and accuracy.
This individual had a medication review on 11/06/2012 and the documentation from this visit includes the list of medications being reviewed, reason for the medication and the dosage.
All completed appointment forms will be submitted to the Assistant Residential Director, who will within 48 hrs from time of completion of appointment, review returned forms for accuracy and schedule follow up appointments. A tracking sheet will be used to monitor upcoming appointments and the Assistant Residential Director will be responsible for this. |
11/06/2012
| Implemented |
| 6400.181(a) | Individual #1's assessment dated 1/13/12, did not meet the regulatory requirements. The assessment did not list the individual's progress and growth over the past 365 days, nor were the individual's water safety skills listed. | (a) Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.
| This violation resulted from an oversight in following through with regulation as it relates to assessments.
A new assessment has been completed for this individual dated 10/17/2012 to include the individual's progress and growth over the last 365 days as well as the individual's water safety skills.
Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director. |
10/17/2012
| Implemented |
| 6400.181(e)(4) | Individual # 1 has eight hours of unsupervised time in the community; the assessment does not reflect that this individual has the skills to be left alone for up to eight hours, nor has a protocol been developed to address the unsupervised time. | (4) The individual's need for supervision.
(4) A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.
| This violation resulted from the inability of the Program Specialist to create a protocol to address her unsupervised time in the community, and also capture this individual skills to be left alone in the community in the assessment.
A protocol dated 12/1/2012, has been created to address this individual's independence time in the community. The staff working with this individual in the home shall be trained on this protocol.
Going forward, a protocol must be created to address any independence time as specified in the individual's assessment. The Program specialist shall review every ISP for independence time and ensure that a protocol exists for such. The Assistant Residential Director will ensure compliance to this. |
12/01/2012
| Implemented |
| 6400.183(5) | Individual #1 has a Behavioral Support Plan (BSP) dated 4/12/12. The BSP does not address all of the behaviors documented in the Individual¿s assessment or ISP; additionally, the BSP does not document who should be trained on the plans implementation prior to working with this individual. | (5) 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.
| This violation resulted from the program's oversight in ensuring that the BSP addresses all of the behaviors documented in the individual's assessment or ISP.
The Behavioral Specialist is working on the BSP to address all the target behaviors and staff training for these behaviors.
Going forward, the Program specialist as the plan lead will ensure that the BSP matches the assessment and ISP. If it doesn't, the PS will contact the Behavioral specialist to make required changes. The Assistant Residential Director will monitor to ensure compliance |
11/30/2012
| Implemented |
| 6400.185(b) | Individual #1¿s ISP dated 3/13/12 is not being implanted as written. The following outcomes are not being implemented:
- Insulin Management
- Behavioral Supports
| (b) The ISP shall be implemented as written.
| This violation resulted from the inability of the Program Specialist to ensure that the ISP is being implemented as written.
The Behavior specialist has formulated a new BSP dated 11/10/2012, for which staff will be trained on. An amended quarterly report has been created for this individual. Staff working with this individual will be trained on the ISP outcomes and the BSP.
Going forward, the Program Specialist will review the ISP and ensure that the goals written are implemented and also monitor for progress and growth.
|
11/30/2012
| Implemented |
| 6400.186(c)(1) | Individual #1's montly reviews from May 2012 thru September 2012 did not include the individual's progress toward outcomes. | (c) The ISP review must include the following:
(1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter.
| This violation resulted from the oversight of the Program Specialist in following through with the regulation as it relates to monthly reviews.
An amended quarterly report, dated 12/01/2012 has been created and it includes the individual's progress towards the ISP outcomes.
Going forward, the Program Specialist will monitor and review all monthly reports to ensure progress towards the outcomes. The Assistant Residential Director will also monitor to ensure content and accuracy.
|
11/01/2012
| Implemented |
| 6400.188(c) | The services listed in Individual's ISP were not developed into measurable outcomes. | (c) The residential home shall provide services to the individual as specified in the individual's ISP.
| This violation resulted from the inability of the Program Specialist to ensure that services listed in the Individual's ISP were developed into measurable outcomes.
Methodologies have been developed for the outcomes in this individual's ISP. Staff shall be trained on these methodologies.
Going forward, the Program Specialist will develop appropriate methodologies for all the outcomes listed in the individuals' ISPs. |
11/30/2012
| Implemented |