| 6400.15(a) | Self-assessments for homes were not entirely completed (individual and staff health were partially finished or wholly blank), (all sections starting at page three are blank); (individual health, individual records sections were partially finished or wholly blank); (the day and recreational services sections were blank). | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Chief Operations Officer (COO) completed a new self-assessment tool on April 07, 2023. The COO ensured that all sessions of the self-assessment tool were entirely completed. The COO is the responsible staff person to ensure that this problem is fixed. |
04/07/2023
| Implemented |
| 6400.165(g) | The record did not contain written notice from the PCP indicating that the past psychotropic medication orders were reviewed and should continue 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 |