| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | Furnace was inspected and cleaned on 02/21/2016 and not again until 11/09/2017. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace inspections will all be done within the same month to easily monitor the dates to remain in compliance. date scheduled for 03-27-2018 |
03/02/2018
| Implemented |
| 6400.143(a) | Individual #1 refused a dental appointment on 07/07/2017 and 02/13/2018, and refused an allergy appointment on 01/27/2018. Continued attempts to train the individual about the need for health care was not documented in the individual's record. Plan of refusal that is in place is not specific to individual needs. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Sunset's Medical Coordinator and other team members will ensure all proper services are provided as outlined within the individual's ISP. This will be documented accordingly and any information related to a diagnosis's training. |
03/14/2018
| Implemented |
| 6400.144 | Individual #1 is to check her blood pressure and blood sugar daily, per her physician. There are no protocols in place that give specifics surrounding these checks (e.g. what is the follow up treatment for a high sugar reading and what is considered a high sugar reading). | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Sunset's Medical Coordinator and other team members will ensure all proper services are provided as outlined within the individual's ISP. This will be documented accordingly and any information related to a diagnosis. |
03/12/2018
| Implemented |
| 6400.151(a) | Staff #1's date of hire was 11/03/2017. Physical completed on 11/01/2017, and TB test read on 11/08/2017. Staff #2's hire date was 01/02/2018. Physical completed 01/03/2018, and TB test read on 01/05/2018. Staff #3's hire date was 10/06/2017. Physical completed on 10/11/2017, and TB test read on 10/13/2017. | 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. | The Medical Coordinator will also keep an electronic ledger to maintain compliance with any type of staff rendering any type of supports be given a physical and TB/Mantoux test prior to providing any residential supports be that it is close contact. This will be done within 12 months prior to employment and every 2 years thereafter. |
03/10/2018
| Implemented |
| 6400.163(c) | Individual #1's 02/23/2018 psychiatric medication review did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 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. | Sunset's Medical Coordinator will keep an electronic ledger to use as a reference point with ensuring that all diagnosis will be reviewed by a physician at least every 3 months which but is not limited to listing reasons to increase, decrease or discontinue individual's medications. |
03/10/2018
| Implemented |
| 6400.181(a) | Individual's annual assessment was dated 12/20/2017. Previous assessment was not dated. Unable to determine timeframe of the completion of the assessments. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Sunset's Program Specialist will ensure individual's assessment or assessment is conducted 1 year prior to or 60 calendar days after admission. It will be updated annually thereafter as stated within the regulations. Lastly, an assessment will be conduct an assessment 6 months prior to admission. |
03/04/2018
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment dated 12/20/2017 did not include the following information: Recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist will document legibly specific training, areas of training as well as recommendations of programming and services. |
03/08/2018
| Implemented |
| 6400.213(11) | Individual #1's current assessment states the individual needs to be arms length at all times when crossing roads, sidewalks, and parking lots. Individual is to be line of sight at all other times during community outings. At home the individual is to remain within hearing distance of staff with 15 minute visual checks. Individual has 15 minute private time during showering, in her bedroom, and living room, with visual checks every 15 minutes. Current ISP states that due to increasing anxiety and mental health issues, individual needs constant supervision within the home. Assessment states individual keeps track of own finances concerning spending money received that is earned through paychecks. This is not mentioned in the ISP. And in fact, provider agency does assist and keep track of financial information, per individual's request. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Sunset's Program Specialist will maintain a communicative relationship with each individual's SC to ensure any/all information or PHI is accurate. |
03/10/2018
| Implemented |