| 6400.141(a) | Individual #1 has a physical exam completed on 1/22/25. The physical did not include all required components. Individual #1 did not have a vision screening completed. Documentation under the health risk assessment of the after-visit summary states "patient rates overall health as very good, patient feels that their physical health rating is the same. Patient is satisfied with their life. Eyesight was rated the same." There is no documentation that the physical completed an examination of Individual #1's vision as the information contained in the health risk assessment of the after-visit summary was information that was provided by the individual. Individual #1's physical exam did not include immunizations. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Agency Residential Director, Beryl Matengo, requested the accompanying documentation from the 1/22/25 examination form from the Medical Provider; Included the examination form from the 12/7 /24 visit; arranged for and completed another visit to included the immunizations and the Vision and Hearing areas. The Agency has also edited the Annual Physical Form to better comply with the areas required under these regulations for clarity to the Medical Provider. Please see documents and images sending via email. |
03/28/2025
| Implemented |