Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.110(c) | There was no documentation of annual fire safety training for Staff #2. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | Fire Safety Officer training will only be scheduled on days that the entire family and the individuals will be able to attend. |
02/28/2022
| Implemented |
6500.121(c)(3) | Current physical for Individual #1 is documented as being completed on 1/31/22. Diphtheria and Tetanus immunization is documented on this form as being completed on 1/4/22. Previous physical for Individual #1 completed on 1/26/21 indicates that the prior Diphtheria and Tetanus immunization was completed on 12/5/11. Diphtheria and Tetanus immunization is required every ten years. This exceeds the required time frame and 15-day grace period. | 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. | Staff will schedule the immunizations with the individual¿s physician at least every 10 y years. Staff will be retrained on the regulation¿s requirements regarding individuals¿ annual physicals. Ensuring that all individuals have up to date Immunizations |
02/28/2022
| Implemented |
6500.121(c)(6) | Current physical for Individual #1 is documented as being completed on 1/31/22. Corresponding Mantoux Screening form documents the Mantoux as given on 1/31/22. Previous Mantoux for Individual #1 is documented on the prior Mantoux Screening form as being given on 1/13/20. Mantoux is required every two years. This exceeds the required time frame and 15-day grace period. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | Staff will schedule the TB/Mantoux screening with the individual¿s physician at least every 2 years. Staff will be retrained on the regulation¿s requirements regarding individuals¿ annual physicals. Ensuring that all individuals have up to date TB screening. |
02/28/2022
| Implemented |
6500.121(c)(7) | Individual #1 had an annual GYN exam completed on 2/4/21. No PAP was completed. Physician noted "not performed, next pap Jan 2025." No additional documentation was present to indicate the reason why the annual requirement should be waived. Annual pap screenings are required unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Staff will be retrained on proper documentation for medical appointments. Training will include emphasis on areas that require explanation from the physician regarding their recommended screening intervals. The agency did seek further explanation from the physician but have not received a return on our requests. |
02/28/2022
| Implemented |