| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | Individual #1's physical examination, completed on 3/19/2021, did not address medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The lead supervisors will provide training on how to verify that physicians address the medical information pertinent to diagnosis and treatment in case of emergency during a physical examination when completing the form. Training will be provided to the house supervisors by 5/7/22 and monthly thereafter for any newly hired house supervisors. The house supervisors are the designated staff who accompany our clients to their annual physical examinations. |
05/07/2022
| Not Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed on 9/15/2021, does not address lifetime medical history. This section says, "N/A." | The assessment must include the following information: A lifetime medical history. | The Program Specialist will be responsible for ensuring provider¿s annual assessments include a lifetime medical history. If there is a vacancy with the Program Specialist position. The Sr. Director will assume responsibility for ensuring the annual assessment includes a lifetime medical history. [Immediately, the program specialist will complete the lifetime medical history for Individual #1 and all other individuals in the community homes. Over the next 2 weeks, the Sr. Director shall review all individuals' current assessment to ensure all required information is included in all individuals' current assessment. (DPOC by AES,HSLS on 5/4/2022)] |
04/11/2022
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, completed on 9/15/2021, does not include psychological evaluations. This section says, "N/A." | The assessment must include the following information: Psychological evaluations, if applicable. | The Program Specialist will be responsible for ensuring the annual assessments will include a psychological evaluation, when applicable. Beginning 5/1/22 and re-occurring for each annual assessment completed afterwards. If there is a vacancy with the Program Specialist position. The Sr. Director will assume responsibility for ensuring the annual assessment includes a psychological evaluation. [Immediately, the program specialist will obtain a psychological evaluation for Individual #1 and all other individuals in the community homes, as required. Over the next 2 weeks, the Sr. Director shall review all individuals' current assessment to ensure all required information is included in all individuals' current assessment. (DPOC by AES,HSLS on 5/4/2022)] |
05/01/2022
| Implemented |
| 6400.18(a)(3) | Individual #1 was admitted to the hospital on 3/18/2022 and it was not reported in the Enterprise Incident Management system until 3/24/2022. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital.
| The SR. Director will provide training to staff (Lead Supervisors and Program Specialist) who have access to the EIM incident management system. The training will include what is to be reported in the EIM system and the deadlines for submitting the reports. By 5/1/22 and monthly thereafter for any newly hired staff persons with access to the EIM incident management system. The Lead supervisors will provide training to all direct care staff on the requirement to report inpatient hospital admissions to their lead supervisor within 2 hrs. By 5/1/22 and thereafter data entry will be completed on all inpatient hospital admissions by staff (Sr. Director, Program Specialist, and Lead Supervisors) with EIM incident management system access. |
05/01/2022
| Not Implemented |
| 6400.166(a)(11) | Individual #1's March 2022 Medication Administration Record does not have the diagnosis or purpose for the following medications: Clonazepam, Desmopressin, Pantoprazole, Risperidone, Ketoconazole cream, Lactulose, Lamotrigine, Levothyroxine, Escitalopram, Fiber-Lax Tab, Atomoxetine, Carbamazepine and Trazodone. | 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. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the diagnosis or purpose of the medication. If a medication does not have the diagnosis or purpose of the medication, the LPN/RN will contact the pharmacy to provide the diagnosis or purpose of the medication. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |