| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The kitchen sink faucet fixture was damaged and could not be set when not in use. | Floors, walls, ceilings and other surfaces shall be in good repair. | The COO contacted PPHS' maintenance on 4/5/4023 to put in a work order to have the sink faucet fixture repaired. The fixture was repaired on 04/10/2023. |
04/10/2023
| Implemented |
| 6400.181(e)(9) | The program assessment did not include whether or not Individual 1 has the ability or limitation to provide medical services to oneself. The Individual accurately checks blood sugar twice daily and the plan does not discuss the individual's limitations to check their sugar levels. The assessment does not discuss level of independence individual and there was no diabetic protocol located in individual file for staff to provide assistance or to clarify if any assistance is needed. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Immediately following the inspection, the Program Specialist received in-service training on the regulation 165 (g): 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.
Upon completion of the training, on 4/5/23, Program Specialist who is responsible to for correcting the problem was knowledgeable of her responsibility to ensure that in the absence of a psychiatrist, the prescribing PCP will complete the 90-day medication review form to document the reason(s) for prescribing the medication, the need to continue the medication and the necessary dosage. |
04/05/2023
| Implemented |
| 6400.165(g) | The record did not contain written notice from the PCP indicating that the past psychotropic medication orders should have continued unchanged at the September and June 2022 monitoring dates for Individual 1. The PCP must provide written notice to the agency that the medication list was reviewed and approved for continuance, even if an in-person appointment is not able to be completed. | 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. | Immediately following the inspection, the Program Specialist received in-service training on the regulation 165 (g): 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.
Upon completion of the training, on 4/5/23, Program Specialist who is responsible to for correcting the problem was knowledgeable of her responsibility to ensure that in the absence of a psychiatrist, the prescribing PCP will complete the 90-day medication review form to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
04/05/2023
| Implemented |