| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | The most recent ISP for Individual #1 dated 10/30/2014 states Individual #1 was seen by the primary care physician on 11/26/2014. At that appointment the physician prescribed a Hoyer lift. The home did not arrange for an appropriately sized Hoyer lift for Individual #1. On 12/8/14, Individual #1 fell when getting out of bed. Staff person #2 was unable to assist Individual #1 off the floor. The individual was on the floor for approximately 30 minutes. Staff person #1 arrived at the home and was able to assist Individual #1 into a reclining chair. | 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.
| Upon receipt of Physicians Medical reports, nursing will review recommendations/prescriptions and ensure that the necessary medical protocols and supplies are available to staff within the necessary time frames. [Per correspondence with provider sling was ordered on 12/3/14, and staff were trained on the use of the hoyer lift with Individual #1 on 1/8/15. (CHG 2/3/15)] |
02/01/2015
| Implemented |
| 6400.185(b) | On 12/8/2014 at approximately 3:30 AM, Staff person #1 observed Staff person #2 sleeping. Staff person #1 attempted several times to awaken Staff person #2 but was unable to do so. At approximately 4:20 AM, Staff person #1 left the home while Staff person #2 was still sleeping. Staff person #3 arrived at the home at approximately 4:49 AM to relieve Staff person #2. Individual's #1, #2, #3, and #4 require 24 hour awake supervision according to their most recent ISP's. On 12/8/2014 between 4:20 AM and 4:49 AM, Individual's #1, #2, #3, and #4 did not receive the level of supervision specified in their ISP's. | The ISP shall be implemented as written. | The Program Manager will ensure than staff are trained in the ISP and any subsequent changes. In matters of safety, an addendum will be written for the ISP, and forwarded to the SC for inclusion. [Per correspondence with provider sling was ordered on 12/3/14, and staff were trained on the use of the hoyer lift with Individual #1 on 1/8/15. (CHG 2/3/15)] |
02/15/2015
| Implemented |
| 6400.186(a) | The program specialist did not complete an ISP review of the services and expected outcomes for Individual #1 for the period 4-2-14 to 7-1-14. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The Director of Waiver Residential Services will review the Monthly/Quarterly Review Tracking Checklist twice a month to ensure completion and review the monthly and quarterly progress reports to ensure accuracy. The Director of Waiver Residential Services will conduct trainings in ISP Reviews and Monthly and Quarterly Reports for all Program Managers and Program Specialists. |
02/15/2015
| Implemented |
| 6400.186(b) | Individual #1 did not sign and date the ISP review completed for time period 7-2-14 to 10-1-14.
Individual #2 did not sign and date the ISP review completed for time period 4-12-14 to 7-11-14. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Effective immediately, The Director of Waiver Residential Services will review the Monthly/Quarterly Review Tracking Checklist twice a month to ensure completion and review the monthly and quarterly progress reports to ensure accuracy. The Director of Waiver Residential Services will conduct trainings in ISP Reviews and Monthly and Quarterly Reports for all Program Managers and Program Specialists. |
02/15/2015
| Implemented |
| 6400.186(d) | The following ISP review documentation for Individual #1 was not sent to the SC and plan team members within 30 calendar days after the ISP review meeting: 10-1-14 review sent 12-30-14; 7-1-14 review sent 9-4-14; 4-1-14 review sent 5-8-14; and 10-1-13 review sent 3-4-14.
The following ISP review documentation for Individual #2 was not sent to the SC and plan team members within 30 calendar days after the ISP review meeting: 7-11-14 review sent 9-4-14. | The program 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. | The Program Manager will ensure that the Program Specialist sends the ISP review documentation and will ensure that the correspondence is attached to the quarterly review prior to filing. The Director of Waiver Residential Services will conduct trainings in ISP Reviews and Monthly and Quarterly Reports for all Program Managers and Program Specialists. |
02/15/2015
| Implemented |