| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | There were no financail records kept at the home for September 2016 to June 2016 for individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | The family for the individual is payee and provides cash to their sister. Staff have been securing the money but not completing a balance sheet. The staff and the Client Accounting Assistant has been educated to understand the need to monitor indivudals who need assistance with their money. The AA has set up a petty cash account at home for Indivudal #1. Attachment: Petty Cash Voucher SG-9 The money management processes of each person was reviewed to assure that any person who needs any assistance from staff will be part of the Client Accounty Assistance monthly petty cash balancing process. Training Log 2 |
10/10/2017
| Implemented |
| 6400.74 | There was no non skid on the basement steps. | Interior stairs and outside steps shall have a nonskid surface.
| A work order was issued for the use of non skid surfaces in all homes. Maintnenace repaired / replaced the non skid strips and are checking all residences to assure compliance. Attachment: Photo steps SG-7 Maintenance staff were educated on the need to assure a safe home and will inspect all exits monthly. Attachment: Training #1 |
09/12/2017
| Implemented |
| 6400.103 | The emergency shelter location was not located on the written emergency procedures for individual #1. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Chief Executive Officer has been educated on the need to assure that all Emergency Evacuation Procedures are specific to the individal living in the home. The emergency evacuaton procedures were updated to reflect each indivudal and their home. The policies for each person and home were updated with current personal information. I have attached the face sheet of the policy for this home. For the full policy see EM 8. Attachment: Policy - SG-6 Training Log 3 |
09/25/2017
| Implemented |
| 6400.141(c)(11) | The 5/2/17 physcial for individual #1 did not contain health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Medical Support staff have been educated to undersand the need to have the physician complete the individuals physical. The physical for indivdual #1 now includes missing information and has been provided to the Support Coordinator. Attachment: SG- a, 5b. Physical Ind #1 Medical Support Supervisor will review all physicals upon completion and will initial to indicate completion. MSS has reviewed all current physicals to assure that each section is complete with no findings. Attachment: Physical 5. Training Log 3 |
09/28/2017
| Implemented |
| 6400.141(c)(14) | The 5/2/17 physcial for individaul #1 did not contain medical information pertinent to diagnosis. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical Support staff have been educated to undersand the need to have the physician complete the individuals physical. The physical for indivdual #1 now includes missing information and has been provided to the Support Coordinator. Attachment: SG- 5a, 5b. Physical Ind #1Medical Support Supervisor will review all physicals upon completion and will initial to indicate completion. MSS has reviewed all current physicals to assure that each section is complete with no findings. Training Log 3 |
09/28/2017
| Implemented |
| 6400.142(f) | There was not dental hygiene plan for individual #1. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The Medical Support staff are responsible for assuring that dential hygiene plan is included in the ISP. Medical Support staff provided track changes to the Support Coordinator on 10/2/2017 . Indiviudal # has had a new plan in place. Attachment : SG-1 Assessment / Track Changes. All records were reviewed to assure that dental hygiene plans were developed when indicated. Training Log 3 |
10/02/2017
| Implemented |
| 6400.145(1) | The emergency medical plan for individual #1 did not contain the location of the hospital. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | The Administrative Assistant has been educated on the need to include the full address of the hospital identified on the Emergency Evacuation Plan. The address has been added and all files have been reviewed and corrected. Attachment: Emergency Evac Plan SG-4 Training Log 3 |
09/25/2017
| Implemented |
| 6400.163(c) | Individual #1 is diagnosed with psychiatric illness and takes medication to treat symptons but has not had a medication review since August 2016. | 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. | Medical Support Staff have been eduated to understand the need for persons with mental health diagnosis medications reviewed every three months. The Program Specialist is responsible to review all medical appointments in the Quarterly Review and will assure that the review occured. Indiviudal #1 has had her medictions reviewed. Attachment: SG-3 Med Review. All records were reviewed to assure that all indiudals with mental health diagnoses and psychiatric medications were being reviewed. Attachment SG-3 Training Log 3 |
10/02/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment did not show progress and growth in motor and communication skills. | 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 Programs Specialist was educated to understand the importance of the documentation of indiviudals progress over the past year in Motor and communication skills. Individual 1 Assessment was compelted and provided to the Support Coordinator as part of the annual information gathering. A review of other assessments showed compliance with the regulation. Does not appear to be a systemic problem . Attachment SG-1, SG-2 Training Log 3 |
09/29/2017
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment did not show progress and growth in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The Programs Specialist was educated to understand the importance of the documentation of individuals progress over the past year in activities of residential living. Individual 1 Assessment was completed and provided to the Support Coordinator as part of the annual information gathering. A review of other assessments showed compliance with the regulation. Does not appear to be a systemic problem . Attachment SG-1, SG-2 Training Log 3 |
09/29/2017
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment did not state if they can 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 Programs Specialist was educated to understand the importance of the documentation of indiviudals progress over the past year in ability to swim. Individual 1 Assessment was compelted and provided to the Support Coordinator. Attachment SG-1, SG-2 training log 3 |
09/29/2017
| Implemented |
| 6400.213(11) | Individual #1's assessment dated 9/26/16 states diabetic diet; physical dated 5/2/17 states regular diet. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The Program Specialist and Medical Support staff to understand the importance of assuring the all content is consistency. The Program Specialist is responsible for assuring consistency in the documentation at the quarterly review. On 10/1/2017 an updated assessment and track changes was provided to the SC. The physical for Individual 1 was corrected and the updated physical was provided to the support coordinator. Attachment: SG-1 Assessment SG-2 Letter to SC All agency records were reviewed and any non compliance issues were corrected. Training Log 3 |
09/25/2017
| Implemented |