Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.113(a) | Individual #1's date of admission was 3/1/14. Fire department notification letter was not completed until 4/28/14. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | NHS Cambrian Hills Center cannot correct the failure to notify the fire department prior to individual #1 moving to this home.
NHS has edited the Consumer Admission Checklist to reflect the need for prior notification to the local Fire Department to be submitted by the assigned Program Specialist prior to admission (Copy Attachment #15). The Program Specialist has been retrained on this responsibility (Attachment #16).
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09/15/2014
| Implemented |
6400.164(a) | Individual #1 was to start Ortho TM Cyclen on 7/15/14 but the med log did not note the medication starting as prescribed. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Medication Ortho TM Cyclen for Individual #1 was prescribed on 7/15/2014. The Team Supervisor who accompanied individual #1 to the appointment was verbally directed by the prescribing physician to complete the current cycle of previously prescribed Orsythia /Alesse, and therefore begin the newly prescribed Ortho TM Cyclen on 8/3/2014. NHS received signed verification from prescribing physician that the start date of 8/3/2014 was appropriate (Documentation attached #17).
To appropriately document medication change effective dates in the future, staff will utilize the Physician/Consult/Communication Form at every medical appointment (Completed sample attached #18). Attending staff will assure that when the effective/start date is not within the next 24 hours, the physician must document on the case note the expected start date. All team members were trained in this process (Attached Verification #19). It is the responsibility of the Medical Coordinator to verify all medication or treatment changes are implemented as prescribed with a final sign off on the Physician/Consult/Communication Form. When a new medication or new diagnosis is present, the employee immediately calls the Medical Coordinator or designee, who will be responsible for necessary follow up. Both forms are to be delivered or faxed to the Medical Coordinator within 24 hours.
The Medical Coordinator has been trained in this responsibility (Training verification attached#20).
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09/15/2014
| Implemented |
6400.167(b) | On 7/15/14, physician ordered Individual #1's Omeprazole to be changed to twice per day. This was not completed as prescribed until 7/19/14. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | NHS recognizes that the medication for individual #1 Omeprazole was not started as prescribed on 7/15/2014, and this cannot be corrected.
To appropriately document medication change effective dates in the future, staff will utilize the Physician/Consult/Communication Form at every medical appointment (completed sample attached #18), as well as the standard case note. Attending staff will assure that when the effective/start date is not within the next 24 hours, the physician must document on the case note the expected start date. When a new medication or new diagnosis is present, the employee immediately calls the Medical Coordinator or designee, who will be responsible for necessary follow up. Both forms are to be delivered or faxed to the Medical Coordinator within 24 hours.
All team members were trained in this process (Attached Verification# 19). It is the responsibility of the Medical Coordinator to verify all medication or treatment changes are implemented as prescribed with a final sign off on the Physician/Consult/Communication Form. The Medical Coordinator has been trained in this responsibility (Training verification attached # 20).
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09/15/2014
| Implemented |
6400.186(a) | ISP reviews on 7/11/14 and 4/8/14 for Individual #1 were not completed in a timely manner. There was no indication that the reviews were sent to team members and both reviews were date stamped 8/1/14. | 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. | NHS recognizes that the ISP reviews for Individual #1 were time stamped well past the required due date.
In an effort to avoid this in future reviews all Program Specialists were trained in the responsibility to complete and print each review within 15 days of the end of the 3 month period. This revised process is also to include an immediate, documented and dated review with the individual and mailing to the support team with a Plan verification Sheet, with a copy placed in the Program Record (Sample of 3 Month review with all requirements met attached #21 ) (Training verification attached #22). Additionally, records will be randomly audited by the management team for compliance to this process on a monthly basis (Audit tool attached #23).
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09/08/2014
| Implemented |
6400.186(e) | There was not documentation that the option to decline ISP reviews was given to team members for Individual #1. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | NHS recognizes that the option to decline ISP reviews for individual #1 was missing from the record.
All Program Specialists have been retrained in the expectation to use the NHS form at planning meetings that provides the team members the option to decline ISP reviews. Any team member not in attendance will be provided the option to decline via email or regular mail, when the NHS Plan is sent (Training verification attached #24, and Completed sample attached #25). Additionally, records will be randomly audited by the management team for compliance to this process on a monthly basis (Audit tool attached#23).
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09/14/2014
| Implemented |
6400.213(11) | The ISP for individual #1 does not include that sharp objects need to be locked in her home. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The team that supports individual #1, as well the individual agrees that sharp objects need to be locked in her home as a personal safety measure. Requested changes in the ISP to reflect this consensus have been sent to the Supports Coordinator on 9/15/2014 (Attached #26).
All Program Specialists have been retrained in their responsibility to identify any content discrepancy or necessary revision in the ISP and send effective communication to the Supports Coordinator to correct the noted discrepancy (Training verification attached #27). Records will be randomly audited by the management team for compliance to this process on a monthly basis (Audit tool attached#23).
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09/15/2014
| Implemented |