| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #2 had a physical examination completed on 1/3/21, and then again on 2/4/22, exceeding the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Specialists will review medical appointments, including tuberculin evaluations, on a monthly basis to ensure all required medical appointments are being scheduled and attended per regulations. Program Specialists will communicate required appointments with house supervisors and staff to ensure appointments are made and individuals receive the care they need. [Documentation of staff training, related to medical appointment documentation, dated 11/9/22, was received on 2/6/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.141(c)(6) | 6400.141(d) states: Immunizations, vision and hearing screening and tuberculin skin testing may be completed, singed, and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified registered nurse practitioner or licensed physician's assistant. Individual #1 had a tuberculin evaluation completed on 9/21/22 that was completed by a medical assistant. Individual #2 had a tuberculin evaluation completed on 12/8/21; however, the reading did not include the name, initials, or credentials of the person who completed the reading. Therefore, compliance could not be measured. | 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. | Provider staff will be asked to work with the medical provider reading an individual's TB test to ensure tuberculin skin testing is completed, singed, and dated by a registered nurse, licensed practical nurse, a licensed physician, certified registered nurse practitioner, or a licensed physician's assistant. [Documentation of the revised individual physical examination form was received on 2/6/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
11/07/2022
| Implemented |
| 6400.214(b) | On 9/22/22, the most recent available Individual Support Plans for Individual #1 and Individual #2 was for fiscal year 21-22. The current Individual Support Plans for fiscal year 22-23 were not available in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| All Program Specialists and Program Managers will be given access to HCSIS to allow for immediate electronic access to an individual's ISP. [Documentation of staff that have been provided access to HCSIS was received on 2/6/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
09/26/2022
| Implemented |
| 6400.44(b)(2) | Individual #1's assessment, dated 9/20/21, states that the individual is able to swim independently; however, the Individual Support Plan, last updated 6/17/22, states that the individual requires monitoring in a swimming pool and total supervision in a large body of water. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | The Program Specialist will review the individual's assessment during the month leading up to the ISP meeting to ensure assessments are accurately reflected in the individual's ISP at the ISP meeting. [Documentation of notification to the Support Coordinator of discrepancies between the Assessment and ISP, dated 1/31/23, was received on 2/6/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.213(1)(i) | Individual #2's record did not include characteristics or identifying marks. Individual #1's photograph is dated for 10/4/2017, exceeding the annual requirement. | Each individual's record must include the following information: Personal information, including: (ii) race, height, weight, color of hair, color of eyes and identifying marks and (vi) a current, dated photograph | The individual's identifying characteristics were entered into the electronic individual record on 09/23/2022. [Documentation of Individual #2's Individual Details document has been updated to include identifying characteristics was received on 2/6/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
09/23/2022
| Implemented |