| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.137(a) | On 2-25-16, Individual #1 was prescribed Chlorpromazine 75 mg, take 2 times daily. Individual #1 continued to be administered Chlorpromazine 50 mg 2 times daily. | Prescription medications and insulin injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The life sharing provider spoke to Individual # 1's PCP regarding the dose of Chlorpromazine. The 25mg dose of Chlorpromazine was a mistake that was sent by the pharmacy or the PCP. The PCP maintained that Individual # 1 was on the correct dose and the 25mg dose should not be give. The life sharing provider failed to call the pharmacy when a different dose of Chlorpromazine arrived for Individual # 1. The life sharing provider discarded the 25mg blister pack after clarifying everything with the physician. The life sharing provider was retrained in medication administration by the Program Director. [Within 30 days of receipt of the plan of correction and continuing at least monthly, the program specialist(s) shall review all individuals medications, physicians' prescription orders and current medication administration records for all individuals to ensure all individual are being administered medications as prescribed, according to the directions of the licensed physician. Documentation of medication reviews shall be kept and reviewed at least quarterly by the CEO. Within 60 days of receipt of the plan of correction, the CEO shall develop, implement and train all family living providers on policies and procedures to include protocol on receiving prescription medications with discrepancies and/or changes. Documentation of all medication reviews, policies, procedures and trainings shall be kept. (AS 9/8/16)] |
07/22/2016
| Implemented |
| 6500.151(f) | The program specialist did not provide the assessment for Individual #1 dated 12/4/15 to entire plan team including behavior supports and day program. | The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development of the ISP, the annual update, and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | Community Living & Learning, Inc. has updated the signature page of the Assessment to include all team members and the date that the assessment was sent out to them. Community Living & Learning, Inc. is also working with the Support Coordinator to make sure the current list of plan team members is accurate. The assessment was sent out to Shawn McGill Consulting and ACORE on July 1, 2016.[Within 30 of receipt of the plan of correction, the CEO will review the responsibilities of the program specialist position with the program specialist(s) including 6500.43(d)(1)-(20) and 6500.151(f) and sign upon review. Within 60 days of receipt of the plan of correction, the program specialist(s) will review all individuals' ISPs, invitation letters and other records to ensure all plan team members are provided the assessment as required. Correspondence confirmation that the program specialist provided the assessments to all plan team shall be kept and a 25% sample of the correspondence shall be reviewed by the CEO at least quarterly for 1 year to ensure the program specialist provide individual assessments to all plan team members at least 30 days prior to an ISP meeting as required. Documentation of quarterly reviews shall be kept. (AS 8/5/16)] |
07/22/2016
| Implemented |
| 6500.156(d) | The family living specialist did not provide Individual #1's ISP review documentation dated 2-12-15, 4-15-16 and 10-13-16 to the all plan team members including behavioral supports and day program. | The family living specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | ACORE acknowledge that they received individual # 1's ISP review documentation. The Program Specialist will ensure that the date the ISP review is sent is clearly dated on each signature page. The Program Director will double check ISP review signature pages to ensure that this is completed.[The program specialist provided Individual #1's assessment, ISP reviews, option to decline and restrictive procedure plan on 7/20/16. Within 30 of receipt of the plan of correction, the CEO will review the responsibilities of the program specialist position with the program specialist(s) including 6500.43(d)(1)-(20) and 6500.156(d) and sign upon review. Within 60 days of receipt of the plan of correction, the program specialist(s) will review all individuals' ISPs, invitation letters and other records to ensure all plan team members are provided all individuals ISP review documentation as required. Correspondence confirmation that the program specialist provided all individuals ISP review documentation to all plan team shall be kept and a 25% sample of the correspondence shall be reviewed by the CEO at least quarterly for 1 year to ensure the program specialist provide all individuals ISP review documentation to all plan team members at least 30 days prior to an ISP meeting as required. Documentation of quarterly reviews shall be kept. (AS 9/8/16)] |
07/22/2016
| Implemented |
| 6500.156(e) | The family living specialist did not notify all plan team members including the behavior supports of the option to decline ISP review documentation for Individual #1. | The family living specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist reviewed the declination form with the behavior support provider and gave them the option to decline the ISP review documentation for individual #1. The declination form will be kept in individual # 1's program binder.[The program specialist provided Individual #1's assessment, ISP reviews, option to decline and restrictive procedure plan on 7/20/16. Within 30 of receipt of the plan of correction, the CEO will review the responsibilities of the program specialist position with the program specialist(s) including 6500.43(d)(1)-(20) and 6500.156(e) and sign upon review. Within 60 days of receipt of the plan of correction, the program specialist(s) will review all individuals' ISPs, invitation letters and other records to ensure the program specialist notifies all the plan team members of the option to decline the ISP review documentation as required. Correspondence confirmation that the program specialist notified all the plan team members of the option to decline the ISP review documentation shall be kept and a 25% sample of the correspondence shall be reviewed by the CEO at least quarterly for 1 year to ensure the program specialist notified all the plan team members of the option to decline the ISP review documentation as required. Documentation of quarterly reviews shall be kept. (AS 9/8/16)] |
07/22/2016
| Implemented |
| 6500.164(d) | There was not a written record of the meeting and activities for Individual #1's restrictive procedure review committee meeting on 2/3/16. | A written record of the meetings and activities of the restrictive procedure review committee shall be kept. | The Armstrong/Indiana Human RIghts Committee will be looking into a possible secretary to type up meeting minutes at the 8/3/2016 meeting. In the meantime the Program Specialist will be responsible to write up minutes for their specific plan that was reviewed. [Within 1 month of receipt of the plan of correction and continuing at least monthly for 6 months and then as determined by the restrictive procedure review committee, the program specialist(s) and CEO shall attend, present the restrictive procedure including corresponding data and other required information as specified in 6400.195(e)(1)-(8) and record the activities of the meeting including the aforementioned requirements. Revisions to the restrictive procedure as determined by the restrictive procedure review committee shall be implemented within 5 days of the meeting. Program Specialists and CEO shall be responsible to ensure staff training is followed and documented in accordance with 6400.196(a)-(d). (AS 9/8/16)] |
07/22/2016
| Implemented |
| 6500.165(d) | The restrictive procedure plan for Individual #1 updated 5-27-16 was not signed by chairperson of the restrictive procedure review committee. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the family living specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months. | The plan was signed by the chairperson Shari Montgomery indicating that she reviewed the restrictive procedure plan on 2/4/16. The Armstrong/Indiana Human Rights Committee will have an acting chair person in the future in the event that the usual chairperson is absent.[The chairperson signed a restrictive procedure plan, updated 5/27/16, 6/28/16 on 8/8/16. Within 1 month of receipt of the plan of correction and continuing at least monthly for 6 months and then as determined by the restrictive procedure review committee, the program specialist(s) and CEO shall attend, present the restrictive procedure to the committee including corresponding data and other required information as specified in 6400.195(e)1-(1)-(8) and record the activities of the meeting including the aforementioned requirements. Revisions to the restrictive procedure as determined by the restrictive procedure review committee shall be implemented within 5 days of the meeting. Program Specialists and CEO shall be responsible to ensure staff training is followed and documented in accordance with 6400.196(a)-(d). The CEO shall be responsible to ensure the current and each revision of the restrictive procedure is reviewed, approved, signed and dated by the chairperson and the family living specialist prior to the use of the restrictive procedure. Documentation by CEO of the process shall be maintained. (AS 9/8/16)] |
07/22/2016
| Implemented |
| 6500.176 | There was no documentation of transmittal of the Individual #1's restrictive procedure plan to the day program. | The individual's day service facility shall be sent copies of the restrictive procedure plan and revisions of the plan. Documentation of transmittal of the restrictive procedure plan shall be kept. | Community Living & Learning, Inc. sent out the restrictive procedure plan to ACORE on 7/20/2016. CLL will keep proof of the transmittal of the plan in the future. [The program specialist provided Individual #1's assessment, ISP reviews, option to decline and restrictive procedure plan on 7/20/16. Within 30 days of receipt of the plan of correction, the CEO shall develop, implement and train staff on policies and procedures to ensure all day service facilities are sent the restrictive procedure plan for all individual on a restrictive procedure plan to include keeping documentation of the transmittal. CEO shall review a copy of the transmittal and document the review to ensure documentation of the transmittal is kept. (AS 9/8/16)] |
07/22/2016
| Implemented |