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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | · Individual #1's ISP states, "CONSTIPATION: individual #3's WATER INTAKE SHOULD BE MONITORED DUE TO IT AFFECTING HIS ELECTROLYTES."
· Individual #1's bowel protocol states "If individual #3 has not had a bowel movement for three (3) days his PCP is to be contacted".
· Individual #1's PCP was not contacted after the following dates of no bowel movement: August 21, 2024, to August 26, 2024, (Five days), September 6, 2024, to September 10, 2024 (Four Days), September 24, 2024, to September 29, 2024 (Five days), September 30, 2024, to October 4, 2024 (Five days).
· The Fatal Five, previously known as the Fatal Four of which constipation is one, are the top five preventable conditions that often result in death for people with an intellectual and developmental disability (IDD). | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Individual #1 has not displayed any signs of constipation or any medical symptoms related to his bowel protocol. As of 10/10/2024 documentation has been available that follows the written bowel protocol.
An incident report was filed, investigated and found to be confirmed for Neglect Failure to Provide Needed care due to a lack of documentation and not any negative outcomes regarding his current health status. Refer to Incident #9498680 for additional corrective actions.
¿ Program Specialist will review 100% of individuals ISP to ensure health services of bowel and fluid protocols are followed according to physician prescribed orders. Any discrepancies noted will be reviewed with the individual¿s team and/or medical professionals for further clarification to provide the recommended services.
¿ Residential Supervisors will complete weekly reviews of ADL¿s to ensure documentation supports health services written within the ISP. Program Specialists will verify that weekly reviews have been completed by the Residential Supervisors. Program Specialists will complete bi-weekly reviews of ADL¿s to ensure documentation supports health services written within the ISP. Documentation will be maintained in the electronic health record.
Residential employees will be re-trained in The Fatal Five¿ to provide education on a group of preventable conditions that are often fatal for people with IDD.
Residential employees will be trained in ¿Guidelines for Effective Documentation in IDD to provide essential elements of documentation and provide tools to ensure documentation is effective to improve care and quality of services. |
12/31/2024
| Implemented |
| 6400.144 | · Individual #1's bowel protocol states "If individual #3 has not had a bowel movement for three (3) days his PCP is to be contacted".
· Individual #1's PCP was not contacted after the following dates of no bowel movement: August 21, 2024, to August 26, 2024, (Five days), September 6, 2024, to September 10, 2024 (Four Days), September 24, 2024, to September 29, 2024 (Five days), September 30, 2024, to October 4, 2024 (Five days).
· Individual #1's nails protocol states "nails are to be checked once a week by Staff to ensure they do not need to be trimmed".
· Individual #1's nails were checked on the following dates: August 27, 2024, September 10, 2024, and September 29, 2024.
· Individual #1's weight protocol states "PCP is to be called if he gains more than 5lbs in one week. His ISP does not indicate that and will need to be updated. According to the HRST Roll Out Plan individual #3's weight is to be checked once a week and documented in weight chart in his file".
· Individual #1's weight was not checked or documented from August 19, 2024, to September 5, 2024. | 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.
| Individual #1 has not displayed any signs of constipation or any medical symptoms related to his bowel protocol. As of 10/10/2024 documentation has been available that follows the written bowel protocol.
Individual #1¿s nail care is completed during his showers per interview of staff. The protocol to document nails being trimmed is no longer appliable and has been discontinued on 10/24/2024.
¿ Individual #1¿s ISP has been updated to reflect the recommendation for weekly weights by his medical professional on 11/18/2024.
Individual #1s last weight was documented in his electronic health record on 11/4/2024 and his protocol was followed.
An incident report was filed, investigated and found to be confirmed for Neglect Failure to Provide Needed care due to a lack of documentation and not any negative outcomes regarding his current health status. Refer to Incident #9498680 for additional corrective actions.
Individual #1 has not displayed any signs of constipation or any medical symptoms related to his bowel protocol. As of 10/10/2024 documentation has been available that follows the written bowel protocol.
Individual #1s nail care is completed during his showers per interview of staff. The protocol to document nails being trimmed is no longer appliable and has been discontinued on 10/24/2024.
¿ Individual #1¿s ISP has been updated to reflect the recommendation for weekly weights by his medical professional on 11/18/2024.
Individual #1s last weight was documented in his electronic health record on 11/4/2024 and his protocol was followed.
An incident report was filed, investigated and found to be confirmed for Neglect Failure to Provide Needed care due to a lack of documentation and not any negative outcomes regarding his current health status. Refer to Incident #9498680 for additional corrective actions.
Residential Supervisors will complete weekly reviews of ADL¿s to ensure documentation supports health services written within the ISP. Program Specialists will verify that weekly reviews have been completed by the Residential Supervisors. Program Specialists will complete bi-weekly reviews of ADL¿s to ensure documentation supports health services written within the ISP. Documentation will be maintained in the electronic health record.
Program Specialists will be retrained in Policy #6.7 Assessment and Individual Support plan to ensure the ISP is implemented as written by documenting health promotions/protocols developed for individuals¿ health and safety concerns or recommendations from their medical professionals.
Residential employees will be trained in Guidelines for Effective Documentation in IDD to provide essential elements of documentation and provide tools to ensure documentation is effective to improve care and quality of services. |
12/31/2024
| Implemented |
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