| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(f) | Individual 3 is diagnosed with deafness. Individual 3's bed shaker is not in working condition. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | The PS/house manager will test the bed shaker monthly when completing the monthly fire safety equipment checks. This was replace immediately when discoverd at inspection time. |
07/08/2016
| Implemented |
| 6400.141(c)(6) | Individual 5's last tuberculin test with a negative result was 3/12/14. Another TB test with a negative result was due on 3/12/16 (over 3 months late). | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | the PS and/or house manager will implement a tracking method to assure all required medical evaluations are completed timely. |
10/31/2016
| Implemented |
| 6400.144 | Health services for individual 6 were not arranged and provided for her as prescribed. On 3/21/2016, bloodwork was ordered to be drawn within 2 weeks. This bloodwork was not drawn between 3/21 and 4/3/2016. The weight of individual 6 was not taken daily from March 21, 2016 through April 20, 2016 as ordered on 3/21/2016. From 3/21 through 4/20 the doctor was to be contacted when an increase of 3 pounds occurred overnight. Again, on 5/2/2016, the doctor ordered daily weights be taken at home for individual 6 but were not taken from 5/2 - 5/10/2016. On May 10, 2016, there was an order for daily blood pressure readings to be taken for individual 6. However, on May 12, May 21, and June 1, 2016, the blood pressure was not taken. | 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.
| The house manager and/or PS will be monitoring and tracking all written recommendation of any medical professional, to assure the health needs of each individual are being met. |
10/31/2016
| Implemented |
| 6400.167(b) | Individual 6 was not administered medications as prescribed. On March 21, 2016, Lasix was ordered to be increased from 20 mg to 40mg daily. However, individual 6 was administered 20 mg of Lasix until Mach 26, 2016, at which time it was increased to 40 mg. On April 15, 2016 Lasix was discontinued by the doctor. However, individual 6 was administered Lasix through April 26, 2016. On May 11, 2016, the doctor ordered daily weights be taken at home and if individual 6 experienced a 5 pound weight increase a 20 mg Lasix was to be administered. However, there was a 20 pound weight gain between 5/16 and 5/17/2016; there was a 10 pound weight gain between 5/17 and 5/18/2016; and there was a 6 pound weight gain between 5/25 and 5/26/2016 without the Lasix being administered to individual 6. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | All medical recommendations will be followed up on and/or implemented within 24 hrs. This will be monitored by the PS and/or the house manager.
(New procedures have been created regarding medical appointments, receiving and following doctors' orders and medical follow-up. Staff have been trained as of 9/30/16. - CH 11/16/16 via email with Renee Smith-Rickert, Futures ID Director) |
10/31/2016
| Implemented |
| 6400.181(d) | The program specialist failed to sign Individual 6s annual assessment. | The program specialist shall sign and date the assessment. | The assessment for 6S will be signed by 10/30/16. Effective immediately, all asssessments will be signed by program specialists before the assessment is distributed and filed. |
10/16/2016
| Implemented |
| 6400.213(1)(i) | Individual 6s record did not contain information on her identifying marks. The records of Individuals 5 and 6 do not contain information on his and her religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | The Face Sheet for Futures CLA has been updated to include identifying marks. This form will be used for all current individuals and new admissions. The Face Sheet will be completed in its entirety and there will be no blanks. If information is unknown that will be noted on the Face Sheet. |
08/30/2016
| Implemented |