| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(3) | Individual #1 received their most recent tetanus booster on 9-17-08. This exceeds the 10-year recommendation for tetanus booster immunizations. | 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. | Individual #1 went to get a tetanus shot, it was updated on the Immunization tracker. [Additional information provided by the agency via email on 10/24/23: A Tetanus immunization was completed for Individual #1 on or about 9/5/23. Documentation of monthly audit of immunization tracker by Program Specialist and Director will be maintained. DPOC by HDKP, HSLS, on 11/1/2023]. |
09/06/2023
| Implemented |
| 6400.141(c)(12) | Individual #1 had a physical examination completed on 7-11-23; however, the physical examination did not address physical limitations. This section of the form is blank. | The physical examination shall include: Physical limitations of the individual. | On-site Companionship has included a provider's note to explain the importance of all sections to be completed. When physicals are received they will be reviewed and sent back if incomplete. This review will be done by the program specialist. [Additional information provided by the agency via email on 10/24/23: An audit of all individual physical examinations was completed on or about 8/21/23 by the Program Specialist and Director. Documentation of the audit of individual physical examinations will be maintained. Continuing audits of individual physical examinations will be documented and maintained. DPOC by HDKP, HSLS, on 11/1/2023]. |
09/12/2023
| Implemented |
| 6400.141(c)(15) | Individual #1 had a physical examination completed on 7-11-23; however, the physical examination did not address special instructions for the individual's diet. This section of the form is blank. | The physical examination shall include:Special instructions for the individual's diet. | On-site Companionship has included a provider's note to explain the importance of all sections to be completed. When physicals are received they will be reviewed and sent back if incomplete.This review will be done by the program specialist. [Additional information provided by the agency via email on 10/24/23: An audit of individual physical examinations was completed on or about 8/21/23 by the Program Specialist and Director. Documentation of this audit has been maintained. Documentation of continuing audits of individual physical examinations will be maintained. DPOC by HDKP, HSLS, on 11/1/2023]. |
09/12/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review, by a licensed physician, on 8/31/22, and then again on 4/14/23. This exceeds the every 3-month requirement. Individual #1 was due for a psychiatric medication review on or before 7-19-23. Individual #1's psychiatric medication review, completed 8-31-22, does not list the dosages of the prescribed medications. Individual #1's psychiatric medication review, completed 4-14-23, did not include a list of medications or the required dosages. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | On-Site Companionship has completed the request for paperwork to try to receive the consultation forms for the missing appointment dates. [Additional information provided by the agency via email on 10/24/23: The agency plans to send required documentation to the reviewing physician's office via facsimile (fax) on the day of the appointment if the required information is not obtained during the appointment. The agency re-trained staff on the requirements of psychiatric medication reviews on or about 8/29/23 and again on 9/14/23. DPOC by HDKP, HSLS, on 11/1/2023]. |
08/10/2023
| Implemented |
| 6400.166(a)(13) | On 8/8/23, Individual #1's August Medication Administration Record (MAR) did not indicate the Direct Service Worker's initials of the staff that administered the following medications on 8-3-23 at 8:00 AM: Vitamin D3, 1000 UI, take 1 tablet daily; Sertraline, 100 mg tablet, take 2 tablets every morning. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff are required to be Med Trained before their ability to pass medication to consumers. As a result, staff who are not Med Trained will not be allowed to pass medication to consumers. Current OCS staff have been reoriented and trained on how to properly complete the Medication Administration Record (MAR) as of 8/29/23. Staff members who are not completing MAR in its entirety will have Med administration responsibilities revoked until retraining and observation from training specialist. [Additional information provided by the agency via email on 10/24/23: Daily audits of Medication Administration Records (MAR) are not being documented. Weekly checks of the MARs are being documented by Team Leads. This documentation is submitted weekly to an executive level manager. Documentation of weekly checks of MARs by Team Leads will be maintained. The agency anticipates transitioning to electronic MARs on or about 11/1/23. DPOC by HDKP, HSLS, on 11/1/023]. |
08/29/2023
| Implemented |