| 6400.44(b)(1) | The initial assessment for Individual #1, dated 11/12/15, was not completed by the Program Specialist. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | We are unable to correct the assessment(s) completed by the Program Supervisor, then reviewed and finalized by the Program Specialist. As of 5/25/16, the procedure for completing the assessment was changed to, include the Supervisor in the assessment process, but have the Program Specialist actually complete and sign the assessment. The cover sheet to the assessment was changed to indicate that the Program Specialist did complete the assessment. All supervisory and administrative staff were trained on 6400.44(b)(1) and 6400 regulatory Q&A from October of 2015. Training verification and a copy of the assessment cover sheet will be forwarded. |
06/09/2016
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 10/30/15 had a Tuberculin skin test completed on 12/17/15. | 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. | Individual #1 was taken under emergency circumstances (less than 12 hour notice). She came with a physical, but not a TB test. We were unable to obtain a test within the 30 day allowance for emergency placement due to her newly appointed guardian being unable to obtain insurance cards. We are unable to correct this citation. To prevent this from occurring in the future, we will re-train all management staff on the regulation. If we accept someone in an emergency situation in the future (who does not have a current TB test), we will obtain the testing at an urgent care facility and the agency will cover the cost of testing. |
06/09/2016
| Implemented |