Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(3) | Up to date immunizations were not found in individual #1's record. Verification of the DTAP immunization was missing from record and most recent physical examination left field blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | We have requested copies of this person's immunization. He has a physical due in February where we will get this test done if there is no record of it with his PCP. |
02/14/2020
| Implemented |
6400.141(c)(10) | Communicable diseases precautions were not noted on admission physical exam completed on 2/1/19 for individual #1. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. This information will now be part of the new admission checklist to ensure individual is free from communicable disease. | We have requested the immunization records. Our physical form has been updated to include this question 12/31/19. |
02/14/2020
| Implemented |
6400.168(d) | Staff 1 did not have an updated annual medication practicum in the year 2019 and actively administers medications. (expired 4/2019). Staff member is a certified trainer but the practicum to administer was expired . | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | Staff is retaking the online medication administration followed by the face-to-face training. Staff will continue to train and observe but will NOT administer medication until the medication training is complete. |
12/17/2019
| Implemented |
6400.181(d) | The program specialist did not sign and date the assessment print dated on 3/23/19 for individual #1. | The program specialist shall sign and date the assessment at the time the assessment is completed. Signatures also will be part of the annual binder checklist to ensure completion. | The Program Specialist will sign immediately and file in the corresponding binder immediately after reviewing with individual. |
12/20/2019
| Implemented |
6400.34(a) | Individual #1's record did not contained a signed copy of individual rights or verification that they have been explained to the individual. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. An annual binder checklist has been developed along with annual self audits to ensure completion. | Program Specialist will file the completed form immediately in the corresponding person's binder. |
01/01/2020
| Implemented |