Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.104 | The 8/18/16 fire notification letter indicated both individuals residing in the home are ambulatory however, Individual #1 required verbal and physical assistance to evacuate the home. Individual #2 required verbal prompts to evacuate. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The fire drill letter has been updated to include the following for both individuals ¿This individual is ambulatory, but at any given time may require verbal or physical assistance to evacuate.¿ The fire drill letter was sent to the appropriate fire company. See attachment 104 Prospect. Moving forward all Fire drill letters will include the following ¿ at any given time an individual may require verbal and/or physical assistance to evacuate.¿ The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all Fire Drill Letters include ¿ at any given time an individual may require verbal and/or physical assistance to evacuate.¿ The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. |
11/13/2017
| Implemented |
6400.144 | REPEATED VIOLATION - 10/26/16. Individual #1's 7/8/16 dental exam had a 6 month recall. Individual #1 did not return to the dentist until 1/30/17. | 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.
| The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all medical and dental appointments are completed on time. The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. The PM assumed that the appointment met state regulation as it was within the 6th month. This PM is no longer employed with TLC. However, the PM overseeing the home currently is aware that appointments must be scheduled based on date, not month. |
11/13/2017
| Implemented |
6400.163(c) | REPEATED VIOLATION - 10/26/16. Individual #1's 3/22/17 psychiatric medication review was completed late. The previous review was completed on 12/5/16. The 3/22/17 medication review did not include the reason for prescribing the medications. | 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. | Moving forward, it is the responsibility of the Clinical ADOS/PS to ensure all medication review forms are completed accurately and entirely prior to a psychiatric medication review appointment. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all psychiatric medication review are completed on time. The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. |
11/20/2017
| Implemented |
6400.167(b) | REPEATED VIOLATION - 10/26/16. Individual #1 was prescribed L-Methylfolate,15mg to be administered by mouth at 8am. Wellspan indicated to discontinue the medication of the current psychiatrist feels it is no longer necessary. Typical Life Corporation did not follow up with the psychiatrist. The medication was discontinued on 3/17/17 without a physician's order to discontinue. The medication was restarted on 4/27/17 without a physician's order to restart the medication. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | An order was obtained from the PCP stating ¿Patient was discontinued from Methylfolate on 3/17/17 and restarted on 4/21/17.¿ See attachment 167(b). Moving forward, it is the responsibility of the Clinical ADOS/PS to follow-up with the psychiatrist in regards to medication management. |
11/20/2017
| Implemented |
6400.181(e)(13)(ii) | Individual #1's 1/31/17 assessment did not include progress over the past year in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). |
11/09/2017
| Implemented |
6400.181(e)(13)(v) | Individual #1's 1/31/17 assessment did not include progress over the past year in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). |
11/09/2017
| Implemented |
6400.181(e)(13)(vii) | Individual #1's 1/31/17 assessment did not include progress over the past year in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). |
11/09/2017
| Implemented |
6400.186(c)(1) | REPEATED VIOLATION - 10/26/16. Individual #1's 12/29/16, 3/17/17, 6/28/17, and 9/22/17 Individual Support Plan (ISP) reviews did not include progress on the ISP outcomes of activities and outings and independence. | The ISP review must include the following: 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. | The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). |
11/09/2017
| Implemented |