| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | INDIVIDUAL #1'S FINANCIAL RECORD DOCUMENTS A DISBURSEMENT OF $16.05 ON 08/31/2016 FOR WHICH THERE WAS NO RECEIPT IN THE RECORD. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | On 4/20/17 the receipt in question was located (it was a receipt from a group outing).
The Director conducted training with the Manager of Residential Services and Program Specialists on 4/20/17 and the Residential Managers on 4/27/17. The training focused on a simplified procedure of tracking, collecting and keeping receipts of expenditures made on behalf of the individuals. This includes single receipts that account for expenditures done on behalf of individuals in groups. Records of all receipts, including group receipts, will be kept by the Residential Managers at the facility. Documentation of group receipts will indicate the dollar amount for each individual associated with the purchase. Residential Managers will review receipts and ledgers on a weekly basis. Program Specialist will review receipts and ledgers of all individuals on their case load on a monthly basis and will make notation on their monthly checklists. |
04/27/2017
| Implemented |
| 6400.141(c)(8) | INDIVIDUAL #1'S PREVIOUS MAMMOGRAM WAS DATED 07/08/2014 AND THE MOST RECENT MAMMOGRAM WAS DATED 08/17/2016 WHICH IS A PERIOD GREATER THAN 2 YEARS. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The Manager of Residential Services will conduct retraining of Program Specialists regarding the tracking of medical appointments including physical examinations for all individuals on their caseloads. The Health Services Manager will conduct same retraining with nursing staff. The Program Specialists will review medical appointments including physical examinations on a monthly basis and will coordinate with the nurses assigned to the individuals on their caseloads to monitor the completion of all medical appointments/examinations due. The Program Specialists will submit tracking reports to the Manager of Residential Services quarterly for review and follow up as needed. |
06/02/2017
| Implemented |
| 6400.142(a) | INDIVIDUAL #1'S PREVIOUS DENTAL EXAMINATION WAS DATED 03/09/2016 AND THE MOST RECENT DENTAL EXAMINATION WAS DATED 04/03/2017 WHICH IS A PERIOD GREATER THAN 1 YEAR. | 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. | The Manager of Residential Services will conduct retraining with Program Specialists regarding the tracking of medical appointments for all individuals on their caseloads. The Health Services Manager will conduct same retraining with nursing staff. The Program Specialists will review medical appointments on a monthly basis and will coordinate with the nurses assigned to the individuals on their caseloads to monitor the completion of all annual medical appointments due. The Program Specialists will submit tracking reports to the Manager of Residential Services for review and follow up as needed. |
06/02/2017
| Implemented |
| 6400.144 | INDIVIDUAL #1'S MAR LISTED A PRESCRIPTION FOR NEOSPORIN WHICH WAS NOT AVAILABLE AT THE HOME. | 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.
| The Manager of Residential Services will conduct retraining with the Program Specialists and Residential Managers focusing of review of medication log compared to medications in the medication cabinet to ensure that medication listed on the medication log is available at the site. The Residential Manager will complete a weekly medication check and submit checklist to the Program Specialist once a week. The Program Specialist will review and crosscheck the medication listings of all individuals on their caseloads monthly. If during the weekly review a medication is noted as not on site, Nursing staff will be notified. |
06/02/2017
| Implemented |
| 6400.181(e)(13)(viii) | THE ASSESSMENT FOR INDIVIDUAL #1 DATED 01/04/2017 DID NOT LIST PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF MANAGING PERSONAL PROPERTY. | 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. | The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. |
06/02/2017
| Implemented |