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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.68(b) | On 4/5/18 at 11:52 AM, the hot water temperature at the bathtub in the bathroom by the front door of the home measured 125.6 degrees Fahrenheit. Individual # 1 is assessed to need assistance to temper bathwater. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The Director of Lifesharing Servcives believes the violation of this regulation to be incorrect. The basis for this is that the regulation states: Do hot water temperatures in bathtubs and showers that are accessible to individuals exceed 120 degrees F? The explanation says Hot water temperature in bathtubs and showers may exceed 120 degrees F if all individuals in the home understand the danger of hot water and have the ability to sense and move away from the hot water quickly. Documentation of each individual's understanding and ability must be in each individual's assessment. The assessments for the individuals living in the home, including individual #1's assessment, indicates that they are able to regulate the water temperature when bathing and washing hands and can sense and move quickly away from hot water. (Sections of the assessments for each individual liiving in the home will be provided to demonstrate this.)
The hot water in individual #1's home has been turned down by the lifesharing provider to below 120 degrees F.
To prevent this from occurring again:1) A change that will take place is that the thermometer utilized during self-assessments will be changed to the same type/model of thermometer used by the licensing inspectors. When the program specialist had completed the pre-licensing inspection, the thermometer used had a reading of under 120 degrees F. The information on the thermometer used was provided by the inspectors at the time of licensing. Extech instrucments-39240 waterproof digital thermometers will be purchased. The Director of Lifesharing Services will submit the request to purchase to the fiscal office by 4/20/18.
2) The lifesharing provider at individual #1's home will be required to check the water temperature and utilize a hot water temperature monitoring tool on a weekly basis. This change will be explained by the program specialist to the lifesharing provider through a training at her next home monitoring on 4/19/18 and implementation will begin immediately. This tool will be reviewed monthly.3) The program specialists will utilize a monthly monitoring tool at the homes of all of their individuals which includes a space to check physical site, including hot water temperature.4) Each program specialist will train each of their individuals' providers using the reminder tool at their next monthly monitoring on the importance of remaining in compliance of state regulations, including maintaining appropriate water temperature in the home.Training of the program specialists took place on 4/12/18 as a reminder of the regulations for lifesharing homes, including importance of maintaining a water temperature below 120 degrees F. The use of the monthly monitoring tool which includes a space for physical site/water temperature was explained, as well as, the training tool for lifesharers. Each program specialist will then train each of their individuals' providers using the reminder tool at their next monthly monitoring. [At least monthly, the program specialist or designee shall measure hot water temperature at all family living homes to ensure the hot water temperature in bathtubs and showers that are accessible to individuals does not exceed 120°F, as required for the health and safety of the individuals. (AS 5/3/18)] |
04/20/2018
| Implemented |
| 6500.133(c) | The most recent psychiatric medication review completed for Individual # 1 was 12/11/17. | 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 issue has been corrected by 4/4/18 when a conversation was held between the provider and Individual #1's doctor's office in which the regulation was explained and the doctor's office has agreed to change the scheduling of appointments to every 3 months. (Statement from doctor received). Lifesharing provider was also educated on the importance of being sure individual #1's appointments for psychiatric medication reviews be scheduled in a 3 month timeframe. to remain compliant. Individual #1 was seen for a psychiatric medication review on 4/10/18 and is scheduled again for 5/11/18.
To prevent this from occurring again:
1) Lifesharing provider of individual #1 was educated on 4/6/18 by the program specialist on the importance of being sure the individual's appointments for psychiatric medication reviews be scheduled within a 3 month timeframe in order to remain compliant with regulations. The doctor's office has also been made aware of state regulations for timeframe of appointments on 4/4/18 and has agreed to schedule psychiatric medication reviews within a 3 month timeframe.2) A tool was developed to use for training to remind the lifesharing provider of the timeframes when psychiatric/medical appointments are required.3) Training of the program specialists by the Director of Lifesharing Services took place on 4/12/18 as a reminder of the regulation regarding psychiatric medication reviews, as well as all medical appointments. The use of the monitoring tool was explained as well as the training tool for lifesharers.4) Each program specialist will train each of their individuals' providers using the reminder tool at their next monthly monitoring on the importance of remaining in compliance for appointments for the individual(s).5) A change that will take place is that the assumption will no longer e made that the lifesharers are scheduling appointments appropriately, but rather, the program specialists will review appointments schedule with all lifesharing providers at their monthly moinitorings to ensure that they are following the necessary timeframes and will instruct a change in appointment date if necessary. The program specialist will utilize a monitoring tool which includes a space to address reviewing upcoming appointments for compliance..Training of the program specialists took place on 4/12/18 as a reminder of the regulations for psychiatric medication reviews as well as all medical appointments. The use of the monitoring tool was explained as well as the training tool for lifesharers. Each program specialist will then train each of their individuals' providers using the reminder tool at their next monthly monitoring. A statement from the doctor's office that the appointments for individual #1 whose psych med review was found to be in violation will now be scheduled every 3 moths, the program monitoring tool, the lifsharing providers' training/reminder tool, and the staff verification forms for the training provided by the program specialists. [At least quarterly for 1 year, the CEO or designee shall review all psychiatric medication reviews to ensure timely completion with all required information and that medication is administered as prescribed. (AS 5/3/18)] |
04/12/2018
| Implemented |
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