Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(c) | The 5/17/22 Self-Assessment has an identified violation, but not an acceptable, attached, plan of correction. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The plan to address noncompliance regarding the agency self- assessment started with the retraining on self-assessment form and areas of the Director and Program specialist of the Lancaster area. The Director of operations reviewed the self-assessment form and all sections of it, how to accurately document and how to address areas of non-compliance as well as sample plan of corrections with the Director of the Lancaster region and program specialist. |
07/19/2022
| Implemented |
6400.61(a) | Individual #1's assessment and ISP state that poisons are to be locked. During the physical site walkthrough on 6/22/22 the following poisonous substances were found unlocked under the kitchen sink- Lysol foaming bathroom cleaner spray, Hot shot ant, roach & spider killer spray, glade spray. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | 7/7/22 the Director of Lancaster was retrained on individual #1 poison safety level, which specifies that all poisons should be locked. On 7/12/22 - The Director of Lancaster completed retraining of direct care staff on poison safety protocol for individual # 1 -which includes that all poisons should be locked in the home. |
07/14/2022
| Implemented |
6400.141(c)(1) | Individual #1's annual physical 11/15/21- Medical history section was missing PDD ( pervasive developmental disorder), ADHD Mitral value d/o, reflux, anxiety, ( ISP) ( diagnosis on psychiatric forms) | The physical examination shall include: A review of previous medical history. | The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the medical history filled out and all other sections as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. |
07/12/2022
| Implemented |
6400.141(c)(12) | Individuals #1's annual physical 11/15/21 does not contain physical limitations. This section is missing from the form. | The physical examination shall include: Physical limitations of the individual. | The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the physical limitations section filled out and all other section, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. |
07/12/1922
| Implemented |
6400.141(c)(13) | Individuals #1's annual physical 11/15/21 does not contain a section for allergies or contraindicated medications. This section is missing from the form. | The physical examination shall include: Allergies or contraindicated medications. | The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the allergies section filled out and all other sections, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. |
07/12/2022
| Implemented |
6400.141(c)(14) | Individuals #1's annual physical 11/15/21 does not contain Medical information pertinent to diagnosis and treatment in case of an emergency. This section is missing from the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the medical information pertinent to diagnosis section filled out and all other sections, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. |
07/12/2022
| Implemented |
6400.141(c)(15) | Individuals #1's annual physical 11/15/21 does not contain instructions for the Individuals diet. This section is missing from the form. | The physical examination shall include:Special instructions for the individual's diet. | The Director of Lancaster was retrained (7/7/21), by the director of Operations on the expectations regarding what should be filled out on an annual physical and the proper form to be utilized. He then trained the direct care staff (7/12/22) on what needs to be completed by a doctor on an annual physical and the importance of having the diet section filled out and all other sections, as well as what form to take on an annual physical appointment for an individual. Upcoming annual physical for individual #1 has been scheduled and a new annual physical form will be updated at that time by the PCP. |
07/12/2022
| Implemented |
6400.181(e)(7) | Individual #1's annual assessment 11/25/21 does not have if the Individual can move away quickly from heat sources. It has that Individual #1 would require prompts and will stay away from things that are hot. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Director of Lancaster and program specialist were retrained on what components are required in an annual assessment with additional attention on heat sources and how quickly and individuals can move aways from them. On 7/12/22, The director of Lancaster (fire safety trainer) had a discussion with individual #1 regarding fire safety awareness, including assessing how quickly y she could move away from a heat source. during the assessment, the individual #1 was able to move away quickly from a hypothetical heat source and an email was sent on 7/18/22 to her Supports Coordinator to let her know of the ISP update regarding her safety awareness as it pertains to moving away from a heat source quickly. individual #1 assessment was also updated on 7/19/22 to reflect the results of the training/observation on 7/12/22 |
07/19/2022
| Implemented |
6400.166(a)(2) | The medication records from July 2021 through June 2022 for Individual #1 did not include the name of the prescriber of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The most recent medication administration record (MAR) for July has been updated to reflect prescriber of medications. The director of Operations trained the director of Lancaster on 7/7/22 on the importance of having MARS that are in compliance and reflecting the name of all prescribers of medication listed for the individual. |
07/14/2022
| Implemented |
6400.166(a)(11) | The medication records from July 2021 through June 2022 for Individual #1 did not include the diagnosis or the purpose of the medication prescribed. | 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 most recent medication administration record (MAR) for July has been updated to reflect prescriber of medications. The director of Operations trained the director of Lancaster on 7/7/22 on the importance of having MARS that are in compliance and reflecting the diagnosis and or purpose of medication listed for the individual. |
07/14/2022
| Implemented |
6400.167(a)(1) | The following medication errors were found during the annual inspection on the medication record for Individual #1: July 3, 8,9 Multivitamin cap 8am signed as administered, but the rest of the month was not initialed as administered Aug 3 & 17, 2021 Vienva-28 take 1 tab daily -- these days was not initialed as administered
Dec 24,25 &26, 2021-Busprirone HCL 10mg 1tab 3x's day 8pm -these days were not initialed
Dec 6, 2021- Daily Vite 1 tab daily 8am- was not initialed as administrated.
April 1 thru 17th, 2022- Atomoxetive HCL 25mg 8am this was a duplicate on the MAR's =staff initialed as medication being administered. This would mean they administered this medication 2 times.
April 1 thru 12th, 2022- Cetarize HCL 10mg 8am- staff initialed this medication as being administered, the was duplicated on the MAR's. This showed that staff administered this medication twice. | Medication errors include the following: Failure to administer a medication. | On 7/12/22, direct care Staff had a medication administration refresher completed by a med trainer which addressed aspect of medication administration, documentation, documentation when on client is on a home visit, as well as recognizing med errors and next steps. On 7/7/22, Director of Lancaster was training on how to do compliance checks of the MAR and next steps regarding med errors. the med errors were also submitted via EIM. |
07/31/2022
| Implemented |