| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 physical was dated 6/26/23 and his date of admission was 6/21/23. The physical was not completed prior to the admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Provider will ensure that Individual #1¿s next annual physical exam date falls within the required 365-day +15-day grace period. To ensure that the deficient practice does not reoccur, the executive director, site supervisor, and Program Specialist will identify the most recent Annual Physical date for Individual #1 and the (3) remaining individual and schedule the follow-up Annual Physical (60) days in advance to ensure there is ample opportunity to have the appointment date within the 365 days + 15-day grace period time frame.
The provider will also ensure that individuals are not admitted until a complete physical examination is completed.
The program specialist and program director will be responsible for ensuring that this is completed |
01/10/2024
| Implemented |
| 6400.141(c)(9) | individual #1's date of birth is 8/9/56. The physical dated 6/26/23 did not have a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | To ensure that the deficient practice does not reoccur, the executive director, Site Supervisor, and Program Specialist will convene and develop a Prostate evaluation form that specifies prostate test, and any other related to test men¿s reproductive health.
In addition, documentation on the form will include the follow-up appointment either within a year period as per regulation or documentation from the physician for no or less frequent prostate examinations.
The prostate examination form will document whether the individual complied with the examination or refused treatment. To ensure that Individual #1, and other individuals meet prostate requirement, the Program Specialist and executive director will identify the most recent prostate evaluations for individuals and identify the Due Date for each individual.
As a quality assurance measure, the Program Specialist will document any medical intervention, within the body of the Monthly Progress Note, and include Due Dates for all required medical interventions pertinent to regulation and to the individual. For the Annual Physical Form, the Site Supervisor will provide relevant details, date, and exam specifics, on to the form for review by the Primary Physician for the Annual Physical Examination. |
01/10/2024
| Implemented |
| 6400.141(c)(14) | Individual physical was dated 6/26/23 did not have anything filled out in the area of medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The program specialist will consult with the PCP to get the missing information documented and attach it to the annual physical in the client file by 01/10/2024. In addition, all physical exams for all individuals will be reviewed to ensure that the section asking for information pertinent to diagnosis in case of emergency has been completed. If any are missing the program specialist will ensure that the PCP is consulted to provide the missing information and that information will be documented and attached to the annual physical in the client file by 01/30/2024.
The house supervisors and program specialist will be trained on completing the physical examination and all 6400 regulations associated with the annual physical by 01/30/2024. Each year for all individuals, the house supervisor will ensure that all sections on the physical examination are completed by the physician. The program specialist along with the executive director will do a final review when processing all completed physicals to ensure that all sections are filled in. |
01/10/2024
| Implemented |
| 6400.165(f) | Individual #1 is prescribed Xanax .25mg to be given as needed for anxiety. The agency did not have a SEEP plan in place to address his social, emotional and environmental needs related to the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A PRN psychotropic medication protocol has been put in place per individual physician as a guideline to follow when the individual exhibits certain symptoms. Provider will ensure to update this protocol according to the guidelines of the physician. |
01/10/2024
| Implemented |
| 6400.165(g) | Individual #1 had psychiatric medication reviews dated 8/31/23; 10/12/23, 11/20/23. These reviews did not document the medication and necessary dosage. The review on 11/20/23 reflects to "see list" but there was no list attached. | 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. | To address the deficient area noted in 6400.165 (g), the facility will implement the following corrective actions: The executive director and Program Specialist will convene to review all Prescription Medications namely medications prescribed to treat symptoms of a diagnosed psychiatric illness for Individual #1, and other individuals.
Based on the most recent medication review, a new 3-month Due Date will be established and adhered to for compliance in the Prescription Medications Requirement. The Program Specialist will document medication reviews within Monthly Progress Notes as a quality assurance measure to monitor adherence to the Prescription Medication requirement. |
01/10/2024
| Implemented |