| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | For Individual #1 the annual physical dated 8/28/18 the "medical information pertinent to diagnosis and treatment in case of emergency" was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical Coordinator will fill out all consult forms and physical forms prior to any appointments. There will be extra for each individuals located within the home in the individuals medical binder incase of a medical emergency. Also weekly desk audits will be completed to ensure Sunset is in compliance in all areas of support and services. |
10/16/2019
| Implemented |
| 6400.144 | For individual #1, per Hospital discharging instructions on 8/10/19 it was instructed to follow up with the orthopedic surgeon about restarting held Medications (Xarelto/Lorazepam) at the follow up appointment. Staff #3 attended follow up appointment with the orthopedic surgeon on 8/21/19 and 9/4/19 and held medications were not addressed/discussed. Individual #1 also had a PCP appointment on 9/4/19 and again, held medications were not addressed. Individual was nonverbal. | 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.
| Medical Coordinator will call the doctor and the pharmacy, whenever there is a medication change to ensure medication changes are accurate. This will ensure that the right decisions are being made. Medical Coordinator will be responsible to do a follow up phone call if medications are on hold and it will be the responsibility of the Medical Coordinator to go to all ER or Hospitalization follow up appointments. |
10/23/2019
| Implemented |
| 6400.181(e)(10) | For individual #1 the most recent lifetime medical history attached to the most recent assessment dated 4/19/19 did not include the updated diagnosis of Bilateral Deep Vein Thrombosis. | The assessment must include the following information: A lifetime medical history. | Director's assistant will ensure weekly desk audit are being completed to ensure all areas of Sunsets supports and services are in compliance. CEO and Director will oversee desk audits. |
10/16/2019
| Implemented |
| 6400.181(e)(13)(i) | For individual #1 the most recent assessment dated 4/19/19 did not contain the diagnosis of Bilateral Deep Vein Thrombosis. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Director's assistant will ensure weekly desk audit are being completed to ensure all areas of Sunsets supports and services are in compliance. CEO and Director will oversee desk audits. |
10/16/2019
| Implemented |
| 6400.166(d) | For individual #1 Medications Lorazepam and Xarelto were put on hold per Orthopedic surgeons orders on 8/10/2019. The September MAR did not list these 2 medications, they were completely removed from the MAR and discontinued when they should have just been put on hold. Additional evidence that the medications were discontinued is due to a phone consult where a staff was told by the pharmacy that Lorazepam would need a new order from the psychiatrist. Should the medication have just been put on hold, then there still would have been medications available for when the DR indicated it should be restarted and the mar should have indicated, by special symbol, that the medication was not given, and reason detailed in the appropriate MAR location. | The directions of the prescriber shall be followed. | Medical Coordinator will call the doctor and the pharmacy, whenever there is a medication change to ensure medication changes are accurate. This will ensure that the right decisions are being made. Medical Coordinator will be responsible to do a follow up phone call if medications are on hold and it will be the responsibility of the Medical Coordinator to go to all ER or Hospitalization follow up appointments. |
10/16/2019
| Implemented |