Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.104 | There was no documentation notifying the local fire department of indivduals who need assistance to evacuate. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| There was a notification to the fire department, however the notification did not include the exact location of the bedrooms in the event of an actual fire. Both individuals in this home are fully ambulatory and are able to evacuate independently, however the notification has been updated to include more information about the residents in the home and the location of their respective bedrooms. Please see attachment for updated notification. |
08/17/2017
| Implemented |
6400.112(e) | The sleep drills were held on 01/16/2016 and 08/22/2016. | A fire drill shall be held during sleeping hours at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. The provider failed to do this and had a lapse in sleep drills. It is essential that the provider practice drills during multiple hours to ensure that the individuals¿ know how to react in the event of fire were to occur in the overnight hours. Please see attached sleep frills addressing this issue. |
08/17/2017
| Implemented |
6400.141(a) | Individual # 1's previous physical examination was dated 03/02/2016 and the most current physical examination was dated 03/21/2017. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The medical book review showed a lapse in physical of just over the 2 week grace period. The provider made every attempt to have the annual physical completed within the required period however the doctor¿s office could not accommodate this need. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individual¿s served. |
08/17/2017
| Implemented |
6400.141(c)(6) | Individual # 1's previous TB test was dated 03/03/2015 and the most recent TB test was dated 05/08/2017. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The medical book reviewed showed a lapse in TB testing over 2 months. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individuals served. Quarterly audits are completed of our medical books to ensure compliance in this area. |
08/17/2017
| Implemented |
6400.141(c)(7) | Individual # 1's most recent gynecological examination was dated 11/12/2015. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The medical book reviewed showed that Individual #1 had not had an annual gynecological and breast examination. The doctor indicated that Individual #1 should have this every 2 years which would make her due in 11/2017. The provider is seeking documentation from the doctor to further clearly indicate this.
The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individuals served. Quarterly audits are completed of our medical books to ensure compliance in this area. |
08/17/2017
| Implemented |
6400.142(a) | Individual # 1's most recent dental examination was dated 03/01/2016. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The medical book reviewed showed a lapse in dental care for Individual #1. It is required that an individual have an examination at least annually. The provider is fully aware of this requirement and had several appointments cancelled by the office that was being used for dentistry. As a result of these frequent cancellations, a new dental provider was located and will be utilized moving forward. Please see attached dental visit form to show her most recent appointment. |
08/17/2017
| Implemented |
6400.163(c) | Individual # 1's psychiatric reviews were completed on 07/11/2016, 11/18/2016 and 03/30/2017. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | It is essential that individuals¿ who receive psychiatric care receive a medication review every 90 days or more frequently if needed. As a result of cancellation with the doctor¿s office there was a lapse in psychiatric care. Please see attachment to note that this is currently being followed up on and addressed to ensure compliance. |
08/17/2017
| Implemented |
6400.181(e)(13)(i) | Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The assessment failed to address progress, growth, and change in the area of health in M. Schechtman¿s assessment. It is essential this be included so that change can be noted year to year and so current need level is accurately reflected in documentation. This has been addressed and included in the assessment and is attached. |
08/17/2017
| Implemented |
6400.181(e)(13)(ii) | Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The assessment failed to address progress, growth, and change in the area of motor communication skills in M. Schechtman¿s assessment. It is essential that this be included so that change can be noted year to year, and so current need level is accurately reflected in documentation. This has been addressed and included in the assessment and is attached. |
08/17/2017
| Implemented |
6400.181(e)(13)(viii) | Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Progress needs to be noted in the assessment of the individual¿s skills around maintaining personal property. This was included in the assessment but not in the required detailed to give a clear picture of progress and growth in the individual¿s ability to maintain his personal property. Additional information has been added to the assessment to ensure that an accurate picture of progress and growth in the area of maintaining one¿s personal property is clearly demonstrated. |
08/17/2017
| Implemented |
6400.181(e)(13)(ix) | Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Progress needs to be noted in the assessment of the individual¿s skills around community integration. This was included in the assessment but not in the required detailed to give a clear picture of progress and growth in the individual¿s access and ability to integrate into the community. Additional information has been added to the assessment to ensure that a clear picture of progress and growth in the area of community integration is accurately represented. |
08/17/2017
| Implemented |
6400.181(e)(14) | Individual # 1's annual assessment dated 01/02/2017 did not document the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The assessment failed to address the individual¿s ability to swim. Te assessment did document details around water safety; this point was not noted and should be included in all assessments to give a clear picture of the individual¿s abilities. In addition to noting, a baseline of this skill, progress and growth in this area shall be documented. |
08/17/2017
| Implemented |
6400.186(c)(2) | Individual # 1's three month ISP review documentation dated 05/11/2016, 08/11/2016, 11/11/2016 and 02/11/2017 reviewed the outcomes and did not review medical information, therapies, etc. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | It is essential that the ISP quarterly review communicates information regarding and medical appointments or therapies that occurred during the time period reviewed. Any medical information related to health promotions or therapies described and documented in the ISP, should be reviewed and reflected in the quarterly ISP. Please see attached ISP review which demonstrates this occurring. |
08/17/2017
| Implemented |
6400.186(c)(4)(iii) | The methodology used to track progress towards Individual # 1's outcome of community involvement remained the same over two plan years and was not modified. | The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. | It is essential that outcomes and progress related to outcomes be reviewed quarterly or more frequently if needed. Should it be noted that achievement hasn¿t been reached in an outcome; tweaks should be made to the methodology to ensure that the individual is moving forward and getting closer to achieving the outcome. The individual reviewed had an outcome for community involvement over 2 ISP plans, with no change in methodology for achieving success in that outcome. As a result of this review, the methodology was tweaked to ensure that this is being properly worked on and monitored. |
08/17/2017
| Implemented |
6400.186(d) | There is no documentation Individual # 1's three month ISP review documentation dated 05/11/2016, 08/11/2016 and 11/11/2016 were sent to team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | ISP reviews should be sent to team members to include the Supports coordinator within 30 calendar days of the ISP review. Email correspondence of the distribution of ISP reviews will be filled into program books to shoe the accurate distribution of documentation. |
08/17/2017
| Implemented |