| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 did not have a completed annual physical examination prior to 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 |
| 6400.151(a) | Staff #1 had an annual physical on 3/28/21 and the next physical was completed on 11/28/23. This exceeds the time frame. This staff is the CEO however she is very hands on with the individuals and does have regular contact with the individuals served. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | To ensure that the deficient practice does not reoccur, the facility will implement the following corrective action: The Program Director will meet with the Program Manager & Program Specialist for a review of all current staff most recent physical examinations.
The program Manager will schedule all residential staff for their physical examinations with the Patient First Provider (Contracted Service) in sufficient time frames to ensure the exams occur in compliance with the regulation.
As a quality assurance measure, the Program Manager will forward monthly documentation to the Program Director as to any staff due dates for the up-coming month- If there are no due dates, documentation will indicate as such. |
01/10/2024
| Implemented |
| 6400.32(a) | Individual #1 signed his rights on 10/27/23. However, the document did not include all rights as required by this chapter. | An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age. | The provider recognizes the importance of 6400.32a. The individual will be given the proper form to sign that includes all the rights per regulation after they have been educated on the individual rights. Individual #2 was informed and explained of his rights upon admission but the documentation could not be found at the time of inspection. Individuals have signed individual rights in accordance with the regulations.
The Executive director and program specialist will ensure that documentations are kept and presented at the time of inspection. The executive director and program specialist will ensure that upon admission and annually individuals are educated and given the proper form to sign. |
01/10/2024
| Implemented |