Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.74 | The interior basement stairs and the back porch outside steps did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Nonskid surfaces / strips will be added to the interior basement stairs and the exterior deck steps. All Program Specialists will be trained in the regulation to ensure future compliance. All other surfaces have been inspected and are in compliance. [CEO or designee will complete on site visits of each home at least quarterly to ensure steps and/or stairs have non skid surfaces. (AS 12/8/15) |
11/25/2015
| Implemented |
6400.141(c)(7) | The physical examination completed on 10/13/14 for Individual #1, date of birth 3/15/54 did not include a gynecological examination. | 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. | Records for other female consumers have been checked and are in compliance regarding this regulation. Upon admission this individual's next of kin did not feel the examination was appropriate. At a meeting in spring 2015, the next of kin understood the need for the examination and options in the future. The individual did have a gynecological examination in June 2015. To prevent this citation from occurring in the future, the Program Specialists have all been trained in this regulation. Further, a process has been established that utilizes a shared calendar with the Program Director. The Program Director will monitor appointments with the Program Specialists to ensure appointments are occurring as regulated / in a timely manner. |
11/20/2015
| Implemented |
6400.141(c)(8) | Individual #1, date of birth 3/15/54, had a mammogram completed on 4/17/14 and then again on 6/11/15. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Records for other female consumers have been checked and are in compliance regarding this regulation. To prevent this citation from occurring in the future, the Program Specialists have all been trained in this regulation. Further, a process has been established that utilizes a shared calendar with the Program Director. The Program Director will monitor appointments with the Program Specialists to ensure appointments are occurring as regulated / in a timely manner. |
11/20/2015
| Implemented |
6400.186(d) | Individual #1's 3 month ISP reviews completed on 11/14/14, 2/14/15, 5/12/15 and 8/12/15, were not sent to all plan team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | To immediately correct this citation, the 3-month ISP Reviews will be sent to the day program for the individual. Records for other individuals have been checked and are in compliance. To ensure future compliance: All Program Specialists will be trained in the regulation. The ISP Review Document has been updated to add a list of team members for the individual. All activities listed will be completed by 11/20/2016.[Immediately, Program directors and program specialists will review each individuals' ISPs, invitation letters and other documentation to ensure the entire team is included in receiving ISP reviews as required. (AS 12/8/15) |
11/20/2015
| Implemented |
6400.213(1)(i) | The record for Individual #1, date of admission 11/3/14, did not include identifying marks. | 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. | Records for other individuals have been checked and are in compliance. To ensure future compliance: All Program Specialists will be trained in the regulation. The Pertinent Information Form is used to document ¿identifying marks¿. The Program Specialist erroneously left the area blank. The Program Specialist has updated the form. [CEO or designee will review a 25% sample of all individual records at least quarterly for the next 6 months to ensure all required personal information including identifying marks is present. (AS 12/8/15) |
11/20/2015
| Implemented |