| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The license for this chapter expires on 12/7/2019. A self-assessment wasn't completed until 9/24/2019. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Self-Assessment tool will be scheduled to be completed in July or August in 2020 and each successive year, which is within 3-6 months prior to the expiration date of the agency¿s certificate of compliance. This will be monitored by Martha Gonzalez, Director of IDD Residential Services. |
12/21/2019
| Implemented |
| 6400.82(f) | Hand soap was not accessible in the bathrooms at this residence. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Hand soap will be available at 18 1/2 Street and all residential sites.
Program Specialists will be trained by Martha Gonzalez, Director of IDD Residential Services to assure Hand Soap is available by 1/15/2019.
Program Specialists will monitor with weekly monitoring. |
01/15/2020
| Implemented |
| 6400.142(a) | Individual #1 (DOB: 7/31/1958) had a dental appointment on 4/19/2018. She didn't have another dental appointment until 7/17/2019, which exceeds the annual requirement. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 1 was scheduled for a dental exam on 4/22/2019, but it was rescheduled by the dentist to 6/5/2019. Further, Individual 1, refused appointment on 6/5/2019. See attachment 7. While Individual 1 did attend the appointment on 7/17/2019, a Desensitization Plan was written on 8/12/2019. |
12/21/2019
| Implemented |
| 6400.181(e)(12) | This area was not assessed in Individual #1's assessment dated 7/19/2019. Repeat Violation: 1/15/2019. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist completed individual¿s recommendations for specific areas of training, programming and services by 12/20/2019. See Attachment 6
Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 1/15/2020.
All Assessments will be reviewed and updated for accuracy by Program Specialist by 1/31/2020.
A new Annual Assessment form will begin implementation effective 3/1/2020. See Attachment 10. |
03/01/2020
| Implemented |
| 6400.181(e)(13)(viii) | This area was not assessed in Individual #1's assessment dated 7/19/2019. Repeat Violation: 1/15/2019. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Program Specialist completed individual¿s current progress and growth in managing personal property by 12/20/2019. See Attachment 6.
Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 1/15/2020.
All Assessments will be reviewed and updated for accuracy by Program Specialist by 1/31/2020.
A new Annual Assessment form will begin implementation effective 3/1/2020. See Attachment 10. |
03/01/2020
| Implemented |
| 6400.18(b)(2) | A medication error is an incident that needs to be reported in EIM within 72 hours. Individual #1 is prescribed Nystatin (QID at 7am, 12pm, 4pm and 9pm). This medication was not applied on 9/23/19 (4pm & 9pm), 9/24/19 (7am, 12pm, 4pm and 9pm), 9/25/19 (7am), 10/27/19 (7am, 12pm, 4pm and 9pm), 10/28/19 (7am, 12pm, 4pm and 9pm) and 10/29/19(7am, 12pm, 4pm and 9pm). EIM's were not completed for these omissions. On 10/12/2019, there were 3 medications that were given at the wrong time: Quetiapine (300mg at 6pm), Multivitamin (4pm) and Calcium Carbonate (6.25ml at 7pm). EIM's were not done for these medication errors. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | EIM report 8633890 was entered to document omissions of Nystatin (QID) for dates missed.
EIM report 8633953 was entered to document 3 medications errors of wrong time of Quetiapine, Multivitamin and Calcium Carbonate.
Upon discovery of omitted medications or wrong time administrations, an EIM report will be filed by Program Specialist. This is effective immediately and will be monitored by Martha Gonzalez, Director of IDD Residential Services. |
12/21/2019
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Nystatin (QID at 7am, 12pm, 4pm and 9pm). This medication was not applied on 9/23/19 (4pm & 9pm), 9/24/19 (7am, 12pm, 4pm and 9pm), 9/25/19 (7am), 10/27/19 (7am, 12pm, 4pm and 9pm), 10/28/19 (7am, 12pm, 4pm and 9pm) and 10/29/19(7am, 12pm, 4pm and 9pm). On 10/12/2019, there were 3 medications that were given at the wrong time: Quetiapine (300mg at 6pm), Multivitamin (4pm) and Calcium Carbonate (6.25ml at 7pm). | A prescription medication shall be administered as prescribed. | All medications will be given as prescribed. Staff will report medication errors to Program Specialists when observed and Program Specialists will complete Medication Audits weekly to assure compliance. See Attachment 3 for a copy of the Medication Audit form. This is effective immediately and will be monitored by Martha Gonzalez, Director of IDD Residential Services. |
12/21/2019
| Implemented |
| 6400.181(f) | Individual #1's ISP meeting was held on 8/14/2019. Her assessment wasn't completed until 7/19/2019. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are trained in providing The Assessment to the SC and the plan team members at least 30 calendar days prior to an ISP meeting by 1/15/2020.
All documentation of Assessment distribution will be reviewed and updated for accuracy by Program Specialist by 1/31/2020. |
01/31/2020
| Implemented |