Plan of Correction/Appeals
POC Approved Y/N
the IP so that the OT services could be provided in the facility.
Was the IP revised based on the changes in the individuals needs/wants?
The licensee failed to ensure that the IP was revised based on the changes in the individuals' needs/wants. A review of the unusual incident log found many entries to state "continue to follow the IBP as written", there was no evidence that when a trend or pattern was identified, that the team met to discuss the trend or pattern so that the IP could be reviewed and, if necessary, revised to meet the needs of the individual. For ID # 2, the individual had at least 2 MUIs filed for choking incidents. His supervision level was increased to 1:1, but only during mealtimes. On 2/7/14, ID # 2 had an incident of choking on Saran Wrap while he was not receiving 1:1 supervision. There was no evidence that the IP was revised to address choking incidents at times other than mealtime. ID # 7 has a PICA diagnosis and is required to be in the line of sight of staff. Even with this supervision level, ID # 7 has had numerous incidents in which he has been able to eat inedible items including a piece of clay, hair grease, alcohol prep pad. The IP for ID # 7 has not been revised to address the fact that the current supervision level is not meeting his needs.
Does the IP address the individual's assessed needs in the area of supervision?
The licensee failed to ensure that the IP addressed the individual's assessed needs in the area of supervision. ID # 7 had numerous UIs addressing his ingestion of inedible objects. ID # 7 has a diagnosis of PICA. The UIs show that there is a need for additional supervision in order to ensure the individual is not able to ingest inedible objects, these results were not addressed in the individual's IP.
If the individual(s) being served are unable to self-medicate, is the medication stored in a secure location based on the individual and the environment they live in?
The licensee failed to ensure that medication is stored in a secure location based on the individual and the environment. A walkthrough of the facility on 3/11/14 revealed medication for ID # 16 was not stored securely. ID # 16 is unable to self-medicate. In addition, at