Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.163(c) | The medication reviews for Individual #1 completed on 3/16/15 and 4/10/15 did not review the medications and dosages. | 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. | added policy for medical review psychiatric. which states that a copy of all physicians orders will be attached to the psychiatric appointment sheet for medical personal review. |
05/01/2015
| Implemented |
6400.181(e)(1) | The assessment for Individual #1 did not include functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | added the functional strengths, needs, and preferences to the assessment. |
04/28/2015
| Implemented |
6400.181(e)(2) | The assessment for Individual #1 did not include likes, dislikes, and interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | added likes, dislikes and interests to the assessment.Program specialist will review all records and will review records in the future to assure compliance. |
04/28/2015
| Implemented |
6400.181(e)(10) | The assessment for Individual #1 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | added lifetime medical history to assessment.Program specialist will review all records and will review records in the future to assure compliance. |
04/28/2015
| Implemented |
6400.181(e)(12) | The assessment for Individual #1 did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | added recommendations to the assessment.Program specialist will review all records and will review records in the future to assure compliance. |
04/28/2015
| Implemented |
6400.181(e)(13)(viii) | The assessment for Individual #1 did not include progress in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | added managing personal property to the assessment. Program specialist will review all records and will review records in the future to assure compliance. |
04/28/2015
| Implemented |
6400.183(5) | The Individual Support Plan (ISP) for Individual #1 did not include a protocol to address the social, emotional, and enviornmental needs of the individual. Individual #1 was prescribed Risperdal, Seroquel, and Neuontin for Mood Disorder and Fluoxetine for Depression. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | emailed support coordinator on 5/11/15 to have social, emotional, and environmental needs added to ISP. Have documentation that the email was sent. Program specialist will review all records and will review records in the future to assure compliance. |
05/11/2015
| Implemented |
6400.183(7)(iii) | The Individual Support Plan (ISP) for Individual #1 did not include an assessment of their potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | emailed support coordinator on 5/11/15 to have vocational added to ISP. Have documentation that the email was sent.Program specialist will review all records and will review records in the future to assure compliance. |
05/11/2015
| Implemented |
6400.186(b) | Individual #1 did not sign and date their quarterly. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Had individual sign and date quarterly review on 5/1/15 and had a received and sent signature page added to the quarterly review.Program specialist will review all records and will review records in the future to assure compliance. |
05/01/2015
| Implemented |
6400.213(11) | The 3/1715 physical for Individual #1 had that they were allergic to mushrooms. The Individual Support Plan (ISP) and identification sheet for Individual #1 had that they were only allergic to Penecillin, ivory soap, wool, and bee stings. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | went to pcp and had documentation stating that individual was not allergic to mushrooms.Program specialist will review all records and will review records in the future to assure compliance. |
04/30/2015
| Implemented |