| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(i) | The bedroom window in the left corner of Individual #1's bedroom does not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | The bedroom window covering was addressed on site and pictures presented to the licensures at the exit interview.
All homes were inspected between May 4-5, 2016 by Barb Kowalsky and Ed Kuznik. All other bedrooms had appropriate coverings for the windows.
CLC¿s process for ensuring ongoing compliance with the 6400 regulations 61A-86 pertaining to the physical site has been revised to prevent this issue in the future. Our process was daily and required a daily check by the supervisors ¿ a single check mark indicating that all items were compliant. The physical site checks are now weekly and each inspection item has been written out on the form with the expectation of checking for compliance and marking compliance for each item each week. Inspections are to be completed by the Residential Program Supervisor and submitted each week to the Program Specialists along with any corresponding corrections or work orders. (Checklist will be sent)
Residential Program Supervisors received training on May 12, 2016 for implementation of this process, which is being implemented starting May 15, 2016. Supervisors absent from the meeting and the remaining residential staff will receive training between May 13th and May 23rd. (Training verification will be sent to licensing by June 1, 2016) |
05/13/2016
| Implemented |
| 6400.141(c)(13) | Individual #2's current physical examination read NKDA; the previous physical examination and the emergency medical information sheet read that Individual #2 is allergic to penicillin. | The physical examination shall include: Allergies or contraindicated medications. | TB¿s physician was contacted and he provided a statement confirming TB¿s allergy to Penicillin. (Statement from Physician sent 5/13).
All 57 residential annual physicals were reviewed and compared to the client record to determine the extent to which this is an issue. Four additional physicals were found to have allergy information different from what was indicated in the record (KH, KK, CB and RK). These will be rectified (either the chart or the physical ¿ whichever is appropriate) with the consultation of the physician by May 31, 2016. (Documentation will be sent to licensing by 5/31)
Supervisory staff will receive retraining on the completion of the annual physical appointment; which includes a review of the client record, the staff completion of some portions of the physical exam including the allergy section, and sharing of our Emergency Medical Information form with the physician at every appointment. The EMI information and physical forms should contain identical information with the exception of any changes made by the physician at the appointment. The EMI is then updated after the appointment to include any such changes.
In addition, a process has been implement (5/13/16) which includes a level of review of the physical form by our consulting RN. The RN will ensure the physical is complete and that there are no concerns about any of the information on the exam form including contradicting information and missing allergies, etc; the RN will follow up with the PCP as needed for any clarifications. Once the RN review is complete, the physical will be distributed to client files.
Residential Program Supervisors received training on May 12, 2016 for implementation of this form. The new physical form is being implemented immediately. Supervisors absent from the meeting and the remaining residential staff will receive training between May 13th and May 23rd. (Training verification will be sent to licensing by June 1, 2016) |
05/13/2016
| Implemented |
| 6400.141(c)(14) | The current physical examination for Individual #2 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's physician was contacted by the CLC consulting RN to clarify if there were any medical information pertinent to diagnosis and treatment in case of an emergency that needed added to the physical exam for Individual #1'. The outcome of this conversation was noted on the physical exam by the RN. (Sent to licensing 5/13)
The consulting RN reviewed all 57 annual physicals; 11 additional physicals were missing this specific information. A review of our physical revealed that this section is likely to be overlooked by the doctor/staff due to where it was located on the form. In addition, it is difficult to determine what should actually be included in this section; what was documented in this section on those physicals found complete varied from the individual¿s next of kin or substitute decision maker¿s phone number to a reiteration of the `Brief Medical History¿ section of the physical and everything in between. The CLC RN will have conversations with the physicians for the other 11 individuals whose physicals were also blank in this section and document the outcome of these conversations. (Physicals with this clarification will be sent by June 1, 2016)
Additional safeguards will be implemented to ensure this section, and no other sections of the annual physical form are blank going forward. The physical form has been revised. The same items / sections appear on the form, however the format is much easier to follow for both the staff and physician. In the specific section ¿Medical Information Pertinent to the Diagnosis and Treatment in Case of Emergency¿ now includes a space for comment as well as a statement to ¿see the attached Emergency Medical Information¿ form. Sections that are appropriate for staff to complete prior to the appointment are shaded and primarily kept together at the beginning of the form. These sections are demographics, history, medication and allergy type information that the doctor generally asks the patient during the exam. They are also already curre |
05/13/2016
| Implemented |
| 6400.181(e)(12) | The current assessment for Individual #2 did not include 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. | TB¿s current assessment has been updated to include recommendations. (recommendations added to assessment, sent 5/13)
Upon review of additional assessments it was discovered that the program specialists are using two different versions of the assessment; one that includes a final ¿Recommendations¿ section and one that does not. All of the assessments without a recommendation section will be amended by May 31, 2016.
Program Specialists will receive training on using the most current assessment format, which includes the recommendations for specific areas of training, programming and service. (Training verification will be sent by June 1, 2016)[At least quarterly for at least one year, the Residential Director will review a 25% sample of assessments to ensure all required information is present and that individuals are being assessed as required. Documentation of reviews shall be kept. (AS 6/2/16)] |
05/13/2016
| Implemented |
| 6400.186(e) | The program specialist did not notify all of Individual #2's plan team members including the day program of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Individual #1's work program was sent the ¿Option to Decline Quarterly Information¿ form on May 9, 2016. (Form sent to licensing 5/13)
After review of additional charts it was determined that the original mailing to families and team members was likely purged; leaving only those returned forms in the chart with no documentation of who was sent the form. Future communication to teams about their option to decline quarterly information as well as any returned forms from team members will be stored in the individual file in a protective sleeve with instructions to not remove this information on the table of contents. (Table of Contents sent 5/13)
The ¿Option to Decline Quarterly Information¿ form was revised on May 9, 2016 to include documentation of who was mailed the form and on what date. The administrative staff responsible for mailing out the Quarterly Reports will send new ¿Option to Decline Quarterly Information¿ forms to all teams over the next three months. This will capture all Individual¿s and teams at the time of their next due quarterly. Completion will be by August 31, 2016. (New form sent 5/13).
Program Specialist and Administrative Assistant will receive training on the new form and process by May 31, 2016. (Training verification will be sent by June 1, 2016) |
05/13/2016
| Implemented |