Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.71 | During the 4/5/22 inspection, there were no emergency numbers listed on or near the telephone in the living room. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home. | Emergency numbers were posted on 4/12/22. |
04/12/2022
| Implemented |
6500.121(c)(4) | Individual #1's 10/13/21 annual physical examination did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Physical form was updated to include explicit instructions for completing the form. |
04/12/2022
| Implemented |
6500.121(c)(13) | The allergies and contraindicated medications of Individual #1's 10/13/21 annual physical examination was left blank. | The physical examination shall include: Allergies or contraindicated medications. | Physical form was updated to include explicit instructions for completing the form. Forms will be pre-filled (the sections that are possible) by the program specialist prior to physical appointments with this information. |
04/12/2022
| Implemented |
6500.121(d) | Individual #1's tuberculin test dated 9/17/20 was read by a Certified Medical Assistant. | Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. | A new form was created for TB tests, showing whom may place and read TB tests. |
04/12/2022
| Implemented |
6500.124 | Individual #1's physician, Dr. Malozzi, ordered monthly blood pressure checks on 8/21/20, with a note indicating "if greater than 140, let me know." Individual #1 had blood pressures greater than 140 on 10/29/21, 12/18/21, and 2/22/22. There is no record indicating that Dr. Malozzi was contacted regarding these readings. | 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 medical case note was updated to include a section for ongoing, updates, changes and the discontinuation of standing medical orders. |
04/12/2022
| Implemented |
6500.45(b) | Staff person #4 was certified for 2 years in CPR on 9/28/19 and not again until 11/9/21. | The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter. | Program Specialist uses an excel spreadsheet to track all reoccurring trainings and due dates. In addition, reminders will be sent to FLP about pending trainings and time frames. |
04/19/2022
| Implemented |
6500.136(a)(2) | Individual #1's Medication Administration Records do not include the prescriber's name. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | A new form was created for medication administration, including prescribers name. |
04/12/2022
| Implemented |
6500.136(a)(11) | Individual #1's Medication Administration Records does not include the diagnosis or purpose for their medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A new form was created for medication administration, including diagnosis/purpose. |
04/12/2022
| Implemented |