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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(11) | Individual #1's physical examination completed 5/6/16 did not include health maintenance needs and the need for blood work. This section was left blank. | 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. | Valley Community Services will ensure the physical examination shall include and assessment of the individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals. Individual #1¿s physical has been resent to physician for completion. (Attachment C.) The program managers will be retrained prior to January 31, 2017 on regulation 6400.141(c)(11). To ensure no further infractions occur, the program managers will send completed physicals to Quality Assurance department for approval. This will start 02/01/2017 and end 05/01/2017 to ensure compliance. [Individual #1's physical examination documentation dated 5/6/16 was updated to include health maintenance needs and the need for blood work. Immediately and upon completion, a designated staff person shall review all individuals' current physical examinations to ensure all required information is included as per 6400.141(c)(1)-(15) and there are not any required areas left blank. Missing information shall immediately be obtained from the completing health care professional completing the form. (AS 2/23/17)] |
01/19/2017
| Implemented |
| 6400.144 | On 9/21/16, Individual #1's psychiatrist recommended hospitalization or different group home if increase in aggression or destructive behaviors. Individual #1 had 1 episode in September, 0 episodes in October and 10 episodes in November of aggressive behavior. Individual #1 had 1 episode in September, 2 episodes in October and 5 episodes in November of property destruction. Individual #1 had 4 episodes in September, 12 episodes in October and 15 episodes in November of Verbal Aggression/Verbal threats. As of 12/8/16, Individual #1 remained in the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Valley Community Services will ensure health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribe for are arranged or provided. Individual #1 recommendations were reviewed by the team on 09/30/2016. (Attachment B) The team discussed the current crisis plan for Individual #1, ensuring that at any time the individual and/or others are in clear and present danger, the individual will be sent for assessment to a psychiatric hospital. Also, during the team meeting on 09/30/16, Individual #1's supports coordinator placed him on a waiting list with other providers for new placement. [Within 30 days of receipt of the plan of correction, all staff working with Individual #1 shall be trained by the program specialist in the current crisis plan; as well as, health services including psychological services planned or prescribed for Individual #1. Documentation of trainings shall be kept. (AS 2/23/17)] |
01/19/2017
| Implemented |
| 6400.163(c) | Individual #1's psychiatric medication reviews completed 9/21/16 did not include the reason for prescribing Divalproex SOD DR 500mg and Quetiapine Fumarate 600 mg. Individual #1's psychiatric medication reviews completed 11/14/16 did not include the reason for prescribing Vistaril 100 mg, Trileptal 300 mg, Divalproex SOD DR 500mg and Quetiapine Fumarate 100 mg. | 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. | Valley Community Services will ensure medication prescribed to treat symptoms of a diagnosed psychiatric illness is reviewed at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The medical review form will be adjusted to highlight each of the mediations prescribed to treat symptoms of a diagnosed psychiatric illness. Upon review of the current format, it is necessary to inform all medical professionals of each of the mediations prescribed to the individual; however, to ensure the reviewer is clear to which medication the licensed physician is reviewing, the need to continue the medication and the necessary dosage, these medications will be highlighted. Program managers will be trained on 6400.163(c) prior to January 31, 2017 by the Operations Director. To ensure compliance, Quality Assurance department will complete random reviews on a quarterly basis.[Upon completion, a designated staff person shall review all individuals' psychiatric medication review documentation to ensure all required information is included as per 6400.163(c) and there are not any required areas left blank. Missing information shall immediately be obtained from the completing health care professional completing the form. (AS 2/23/17)] |
01/31/2017
| Implemented |
| 6400.164(b) | On 11/2/16, at 8:00 PM, Quetiapine Fumarate 600 mg, Senna Laxative 17.2 mg, Atorvastatin 20 mg, Chlorhexidine 0.12% rinse prescribed to Individual #1 were not initialed as administered. On 11/2/16, at 10:00 PM Divalproex SOD DR 500 mg and Doc-q-lace 100 mg prescribed to Individual #1 were not initialed as administered. On 11/16/16, at 8:00pm, Chlorhexidine 0.12% rinse prescribed to Individual #1 was not initialed as administered. On 11/16/16, at 10:00 PM, Divalproex SOD DR 500 mg and Doc-q-lace 100mg prescribed to Individual #1 were not initialed as administered. On 11/19/16, at 8:00 PM, Quetiapine Fumarate 100 mg and Hydroxyzine PAM 100 mg prescribed to Individual #1 were not initialed as administered. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Valley Community Services will ensure medication administration is logged immediately after each individual¿s dose of medication. The Operations Director will retrain all staff on regulation 6400.164(b) prior to January 31, 2017. The program manager was trained as a practicum observer on 12/16/2016. (Attachment A) During this training, the program manager was instructed to a) assign a medication checker who will review the MAR after medication administration to ensure documentation is completed b) review the MAR each day worked to ensure no ¿blanks¿ are present. To ensure no further infractions occur, the Quality Assurance department will complete random MAR reviews on a quarterly basis for compliance. |
01/19/2017
| Implemented |
| 6400.185(b) | Individual #1's ISP for the 2015-16 year states that "[Individual #1] receives 24 hour 1:1 supervision... 1:1 supervision will be line of sight..." Interviews revealed Individual #1's line of sight supervision is not always being provided stated in the ISP. Incidents of neglect and failure to provide needed supervision occurred on 9/21/16, 9/26/16 and 11/29/16. | The ISP shall be implemented as written. | Valley Community Services will ensure the ISP is implemented as written. Individual #1 is to receive 24 hour 1:1 supervision, supervision will be line of sight. The staff at Autumn CLA have been retrained on the 1:1 plan for Individual #1 immediately. However, the Program Specialist will retrain the staff at Autumn CLA prior to January 31, 2017 at which time the staff will have the opportunity to discuss any ongoing concerns. To ensure the ISP is implemented as written, the program manager will assign a staff person on the schedule as the designated 1:1 for individual #1. The program manager will be responsible to review weekly all relevant paperwork ensuring the 1:1 is successfully implemented. To ensure no further infractions occur, the program specialist will review all paperwork monthly. [Prior to working with Individual #1 and other individuals in the community homes, the program specialist shall educate direct service workers on the ISPs including the supervision needs of all individuals and the agency's policies and procedures to ensure ISPs are being implements as written including supervision needs. Documentation of all trainings shall be kept as required. (As 2/23/17)] |
01/19/2017
| Implemented |
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