| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual # 1's record did not include a gynecological exam. | 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. | Although individual #1 goes to her a GYN office on a regular basis for her depo shot, the first available appointment for GYN Exam was scheduled for October 16th, 2019 . The appointments and there compliance will be reviewed for past and upcoming appointments ( for all individuals) via the Program specialist checklist that is completed/submitted monthly to the team. |
10/16/2019
| Implemented |
| 6400.144 | Individual #1's medication Econazole Nitrate was not found in the medication box but it was initialed on the medication log as being administered 2 times a day. | 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 prescribing doctor office was contacted and the econazole nitrate being on the MAR was an error and it was subsequently removed via the pharmacy. The medication was ordered based on priors visit, due to a rash and it was to be given for a certain time frame. Staff will check the medications daily basis for accuracy. The lead and program coordinator will check on the medications and availability within all homes assigned¿weekly/bi-weekly and document via the house oversight checklist. If follow up is required, they will report it /document /and follow up as needed. |
07/24/2019
| Implemented |
| 6400.168(d) | The staff #1 did not have an updated practicum. The last one on record was 11/06/16. Staff was found to administer meds as recent as 6/25/19. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | Staff #1 completed a med training class and took the test and was observed and is now in compliance with giving medications. The staff trainings hours including medication administration( testing/observations) will be tracked and reviewed monthly via the program specialist checklist , which will be submitted to the team for review, in order to check for compliance. |
07/25/2019
| Implemented |
| 6400.181(e)(14) | Lifetime medical record was not found in the record for individual #1. | A lifetime medical record shall be kept in the record. | The lifetime medical record for individual # 1 was updated . Lifetime medical records will be updated annual( all individuals) and the program specialist was retrained on this process. |
07/25/2019
| Implemented |
| 6400.195(e)(5) | Individual #1 restrictive plan did not include a target date for achieving the outcome. | The restrictive procedure plan shall include: A target date for achieving the outcome.
| The restrictive procedure was updated to include a target date for completion for a achieving the outcome . staff for individual #1 were retrained on this outcome. The plan will be reviewed during staff meeting as well , ongoing and any changes /updates will be highlighted |
07/24/2019
| Implemented |
| 6400.166(b) | Individual #1's medication log did not include initials of staff who administered Ibuprofen and Midol on 6/8/19. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The documentation error was reviewed with Elroy staff and the process for documenting giving medication was reviewed as well. The MAR/Kardex will be checked on a daily basis by staff on the shift and then weekly by either the lead staff and or the program coordinator . |
07/24/2019
| Implemented |
| 6400.166(d) | Individual #1's medication Loratadine 10mg was to be given once daily, but on the medication log it was noted that it was given 2 times a day. | The directions of the prescriber shall be followed. | The MAR /Kardex was updated to reflect the directions of the prescriber.
The staff will check the MAR daily for accuracy and the Lead staff and or the Program coordinator will check the MAR /Kardex weekly for accuracy |
07/01/2019
| Implemented |
| 6400.181(f) | The assessment for individual #1 dated 1/1/19 was not provided at least 30 days prior to the ISP meeting held on 1/14/19. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist was retrained on the time frame of the process of submitting an assessment as well as the back up procedure in case a supports coordinator is not responsive within the appropriate time frame. Part of the plan is to send a follow up email as proof of documentation that the assessment was sent 30 days prior. Due date for the assessments will be reviewed monthly via Program specialist checklist , that will be sent to the director and team for review |
07/24/2019
| Implemented |
| 6400.195(b) | The restrictive procedure plan did not state the time frame the restrictive procedure would be applied. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | The restrictive procedure plan was updated and the it now reflects the time frame the restrictive procedure should be applied. The plans will be reviewed annually by the team at the ISP for time frame of the restrictive procedure ( if applicable) |
07/24/2019
| Implemented |
| 6400.196(a) | The record did not include staff training for the use of restrictive procedure. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | The behavior plan was updated and staff #1 was retrained on the restrictive procedure . All staff will continue to be trained on the restrictive procedure plan. The plan will also be reviewed ( when applicable) during staff meeting to ensure that compliance is met. |
07/24/2019
| Implemented |
| 6400.213(1)(i) | Individual #1 demographics could not be located in the record at inspection, ie. weight, height, identifying marks and hair and eye color. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1 demographic record was updated with identifying marks , hair and eye color . A plan was also put in place to review ( quarterly) each cluster and ensure that the demographic information is up to date for each cluster/region. 1st review was of the Lansdale cluster which includes individual #1. |
06/28/2019
| Implemented |