Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(14) | The 8/13/14 physical exam for Individual #1 did not contain medical information pertinent in case of an emergency. Oxygen is required to be worn 24x7 per ISP. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Supervisor is responsible for ensuring all medical information is contained on the annual physical. This was corrected on 5/4/2015. Individual #1 annual physical that is due yearly in August is also being submitted to show it is corrected on the most recent physical. Physicals will also ne checked by Program Specialists to ensure all medical information pertaining to emergencies is on the physical. |
05/04/2015
| Implemented |
6400.151(c)(2) | Staff person #1's TB test was administered out of the 2 year time frame- 8/31/12- 3/6/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | These non-compliances were found during our self-audit in February of 2015. Since then, we have implemented the following: Shifted job duties: The HR employee now responsible for tracking physicals and TBs has direct access to our current electronic database (prior to this, the person responsible for tracking did not have direct access to the database because of IT difficulties). This employee has also added reminders to her google calendar to look at physical/TB dates and send out notices to employees 3-4 months before they are due. The employee also keeps a paper list on her desk where she documents correspondence she has had with staff regarding their appointments, etc. HR members complete filing at least twice per month and now also audit the paper physicals/TBs each time for a double-check. |
03/01/2015
| Implemented |
6400.181(e)(13)(ii) | The 9/8/14 annual assessment for Individual #1 did not contain progress in the area of Communication. It was exactly the same as 2013. | 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. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Motor and Communication Skills. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year.
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09/28/2015
| Implemented |
6400.181(e)(13)(iii) | The 9/8/14 annual assessment for Individual #1 did not contain progress in the area of activities of residential living. It was exactly the same as 2013. | 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. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Activities of Residential Living. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. |
09/28/2015
| Implemented |
6400.181(e)(13)(iv) | The 9/8/14 annual assessment for Individual #1 did not contain progress in the area of personal adjustment. It was exactly the same as 2013. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Personal Adjustment. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. |
09/28/2015
| Implemented |
6400.181(e)(13)(vi) | The 9/8/14 annual assessment for Individual #1 did not contain progress in the area of Recreation. It was exactly the same as 2013. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Recreation. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. |
09/28/2015
| Implemented |
6400.186(c)(2) | The following ISP reviews for Individual #1 4/6/15, 1/12/15, 10/10/14 and 7/7/14 was not reviewing the outcomes of Artistic and social expression in their entirely. There was no community activities listed for these ISP reviews. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | All Supervisors and Program Specialists were retrained on June 1, 2015, to ensure all information from the monthly is transferred to the quarterly to show outcomes and community activities in their entirety. Both Program Supervisors and Program specialists are responsible to ensure this is completed during quarterly reviews. A quarterly for individual #1 will be submitted to show this was been remedied and a training form that all supervisors and Program Specialists have been retrained, |
06/01/2015
| Implemented |