Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.214(c) | Individual #1's ISP located in the individual record had three different ISP dates listed as 11/2/22,11/29/23, and 7/15/24. | Record information required in § 6400.213(2)¿(14) that is not current shall be kept at the residential home or the administrative office.
| § 6400.214.(c) Record location.
(c) Record information required in § 6400.213(2)¿(14) that is not current shall be kept at the residential home or the administrative office.
At the time of the inspection Individual #1 had ISPs with three different dates in the home.
The Program Specialist was responsible for the error and has the responsibility to correct the error.
The obsolete ones have been retrieved and the most current one is now in the home. A copy of the first two pages of the current one is attached as Attachment #12.
All records of all ISG individuals have been reviewed to ensure that obsolete information is not kept in the home. |
10/01/2024
| Not Implemented |
6400.217 | Individual #1 did not have a release of information upon admission. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| § 6400.217. Release of information.
¿Written consent of the individual, or the individual¿s parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.¿
The Program Specialist is responsible for all Intake paperwork, including Consent forms.
Individual #1 and his mother signed the releases of information at admission. Apparently, they were not correctly filed in their folder. These were detected in the home after the inspection. The Consent forms are attached as Attachment #13. As a corrective measure, the forms have been properly filed in the correct folder.
The Program Specialist has looked through all ISG individuals¿ records to ensure that all Consent forms are properly filed. |
10/01/2024
| Implemented |
6400.213(1)(i) | Individual #1's record had a DOA of 12/1/2003. The proper DOA was 12/1/2023. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | § 6400.213.(1)(i) Content of Records
Each individual¿s record must include the following information:
(1) Personal information, including:
(i) The name, sex, admission date, birthdate and Social Security number.
The Program Specialist is responsible for the individual¿s record.
Individual #1¿s record had a wrong date of admission on his Individual Record. This has been corrected by the Program Specialist and all documents have been switched with the corrected copy.
All ISG individuals¿ records have been reviewed for correctness. |
10/01/2024
| Implemented |