| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | THERE WAS NO THERMOMETER IN THE FIRST AID KIT. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The thermometer was replaced in this first aid kit on 03/14/2017 by the Site Supervisor.
Every week, the Site Supervisor will check the contents of the first aid kit to ensure completeness during their Site visits. The Residential Director will monitor for compliance.
Please see attachment #4 for supporting documentation. |
03/14/2017
| Implemented |
| 6400.141(c)(3) | THE PHYSICAL EXAM FOR INDIVIDUAL #1 DATED 03/16/2016 LISTS HER MOST RECENT IMMUNIZATION AS 03/22/2006 WHICH IS LONGER THAN RECOMMENDED BY THE UNITED STATES PUBLIC HEALTH SERVICE, CDC WHICH IS ONCE EVERY 10 YEARS. | 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. | This individual received her TDAP Immunization on 03/16/2017. The Medical coordinator has reviewed the records of the rest of the Individuals to confirm that their immunization is current.
The medical coordinator will be monitoring the due dates of the immunization of all the individuals to ensure compliance to the CDC recommendation , using the database created for Medical appointments. The Residential Director will monitor this process to ensure compliance.
Please see attachment #3 for supporting documentation. |
03/16/2017
| Implemented |
| 6400.183(4) | INDIVIDUAL #1'S ISP DATED 06/23/2016 DOES NOT CONTAIN A FADING PLAN TO ADDRESS THE INDIVIDUAL'S 1:1 LEVEL OF SUPERVISION. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: 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. | A fading plan has been developed for this individual as of 03/30/2017 and the SC has updated this plan in the ISP which is pending approval.
Going forward the Program Specialist will monitor the ISP of each individual with intensive staffing to ensure that fading plans exists and that such plans will be updated as necessary. This will be monitored for compliance by the Residential Director.
Please see attachment #2 for supporting documentation. |
03/30/2017
| Implemented |
| 6400.213(1)(i) | THE PHOTO IN INDIVIDUAL #1'S RECORD IS NOT DATED. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual #1's record has been updated to reflect a current and dated photograph as of 03/15/2017. The Program Specialist updated this record as well as that of all the Individuals being served by Casmir Care Services.
Every quarter, the Program Specialist will review the records of all individuals served by Casmir Care Services to ensure that it contains a current and dated photograph.
Please see attachment #1 for supporting documentation. |
03/15/2017
| Implemented |