| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment of the home on 4/22/16. The expiration date of the certificate of compliance is 7/21/16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Acme completed two self-assessments during this licensing year in attempt to be within the 3 to 6 months prior timeframe. Since the inspection instrument says "DATE(S) Inspected" ours was completed 4/18 through the 22nd, 2016. We also completed a second self inspection in July 2016, in order to attempt being in compliance to the "within" interpretation. The discrepancy is in interpretation of the word within. A previous inspector interpreted it oppositely as this current 2016 inspector. Thus, we followed the previous inspector's advice on date ranges.
The self assessment was started within the 3-6 month time frame. However, the last day finalizing the self-assessment was less than 3 months before the inspection certificate expires. That was the date ascertained as out of compliance by the 2016 inspector.
Acme tries to remain in compliance with this regulation and chapter by completing the self assessment during the expected periods of time. In the future Acme will complete the self inspection prior to three months before the certificate expiration date.[Upon receipt the CEO will review the Certificate of Compliance for the expiration date and then determine 3 to 6 month prior to the expiration date. CEO or designee will complete the self assessments for each home in this timeframe and another management staff will review prior to 3 months of expiration date to ensure timely completion. Documentation of all reviews shall be kept. (AS 10/7/16)] |
09/01/2016
| Implemented |
| 6400.68(c) | Colifom tests were completed on 11/2/15 and then again on 3/11/16. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Teaco Laboratories, the company that performs the coliform test for Acme, has been contacted and we have contracted with them to test every two months instead of quarterly. A water sample was collected on 8/11/16 with acceptable results, and samples will continue to be collected every two months thereafter. The more frequent testing will ensure that the tests are completed within the timeframes in the future, even if unforeseen circumstances occur. [Documentation of testing shall be kept and reviewed and tracked by the CEO to ensure timely completion. (AS 10/7/16)] |
08/11/2016
| Implemented |
| 6400.141(c)(3) | Individual #2's physical examination completed on 2/6/16 did not include immunizations; this section was marked "unknown." | 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. | Consumer 2 did not have his immunization for TDAP prior to his physical on 2/6/16. His prior immunization record was unattainable due to his age, disability and death of his caregiving parent. However, he did have his TDAP immunization administered on 2/27/2016. This was prior to his admission on 3/11/2016. Thus he received immunizations prior to admission since the history was unknown.
The physical form has been updated for future use to make the immunization section more user friendly for doctors to document all necessary information.[Immediately and at least quarterly for 1 year, the CEO or designee shall review completed physical examinations to ensure all required information is present and there are not any required areas left blank and will obtain missing information. Documentation of reviews shall be kept. (AS 10/7/16)] |
08/05/2016
| Implemented |
| 6400.143(a) | Individual #2 refused a prostate examination on 2/6/16. There was no documentation of the continued attempts to train the Individual #2 about the need for this healthcare. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Consumer 2 was not a resident of Acme Providers during his annual physical on 2/6/16. He was admitted on 3/11/16. Consumer 2 was educated by his BSC on the importance of attending health appointments and screenings prior to inspection on 5/17/16. He has also been reeducated after inspection, on the need for this healthcare on 8/27/16 by the program specialist.
All consumers who refuse recommended health appointments, screenings or procedures will have continued attempts to be educated by the program specialist or BSC regarding the need to follow health care recommendations. [Documentation of the continued attempts to educated Individual #2 and other individual as needed on the need for health care by the program specialist and/or BSC shall be kept as required and reviewed by the CEO to ensure completion as required. (AS 10/7/16)] |
09/05/2016
| Implemented |
| 6400.163(c) | The three month psychiatric medication reviews dated 3/3/16, 12/3/16 and 9/10/15 for Individual #1 did not include the need to continue the Citalopram (Celexa) for depression and Clomipramine for obsessive compulsive behavior. The three month medication review 9/10/15 did not include the need to continue for Citalopram HBR. | 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. | Consumer 1 has consistently been seen by the psychiatrist to review the need for psychotropic medications. The doctor filled out the paperwork for each visit, however, the doctor failed to complete our form in entirety by not marking the need to continue line. Consumer 1 has since visited the psychiatrist 9/1/16 and the doctor documented the need to continue all above mentioned psychotropic medications.
The form documenting the psychiatric medication review has been updated 9/1/16 to help make it more obvious for the doctor to document the need to continue the medication. The form also includes the other required documentation.
The house managers who accompany consumers on doctor appointments were also educated on 8/9/16 on the need to ensure the doctor completely fills out all necessary paperwork.[At least quarterly for one year, the CEO or program specialist shall review documentation by the licensed physician to ensure all required information is present. Documentation of reviews shall be kept. (AS 10/7/16)] |
09/01/2016
| Implemented |