Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.44(b)(1) | The program specialist did not complete Individual #1's assessment dated 4/3/16. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | The Program Specialist will complete all individuals' annual assessments, sign and date. Annual calendars will be developed by Program Specialist and approved by CEO by 11/1/16.
A quality assessment tool will be completed by Program Specialist and reviewed by CEO beginning on 11/1/16 and each month thereafter.
An in-service occurred on 10/31/16, attended by all Program Specialists. In-service done on 10/31/16 included all of the above requirements. Documentation of in-service done. In-service signed and dated by all Program Specialists. |
11/03/2016
| Implemented |
6400.141(c)(6) | Individual #1 had a Tuberculin skin test read on 1/7/13 and then again on 2/2/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | On 10/31/16 CEO met with Program Specialist to discuss 6400.141(c )(6). The Program Specialist will develop new calendars to track every 2 year physical requirements, including Tuberculin skin testing by Mantoux method with negative results. If Tuberculin skin test is positive, an initial chest x-ray with results noted.
An in-service occurred on 10/31/16 with all Program Specialists on the above requirement. Documentation of in-service done and signed and dated by all Program Specialists.
A quality assessment tool will be completed by Program Specialist and forwarded to CEO for review beginning on 11/1/16 and each month thereafter. |
11/03/2016
| Implemented |
6400.181(d) | The program specialist did not sign and date Individual #1's assessment dated 4/3/16. | The program specialist shall sign and date the assessment. | The Program Specialist will complete all individuals' annual assessments, sign and date. Annual calendars will be developed by Program Specialist and approved by CEO by 11/1/16.
A quality assessment tool will be completed by Program Specialist and reviewed by CEO beginning on 11/1/16 and each month thereafter.
An in-service occurred on 10/31/16, attended by all Program Specialists. In-service done on 10/31/16 included all of the above requirements. Documentation of in-service done. In-service signed and dated by all Program Specialists. |
11/03/2016
| Implemented |