| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Hand Care system was located in the woman's and men's restroom. The container states contact poison control if ingested. All individuals are not poison safe in the facility. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The soap in the dispensers were removed and replaced with non-toxic hand soap. The Coordinator is responsible for ensuring that all poisionous solutions are made inaccessible to individuals. The Program Specialist will monitor the purchase of cleaning products including soap to ensure it is non-toxic. UCP will monitor this during their quarterly audits of CPS programs. All staff were retrained on this regulation and POC. (see attachment #1 and #16) |
06/27/2019
| Implemented |
| 2380.70(b) | The first aid room did not contain a cot or a bed, a pillow, a blanket, and first aid kit in the first aid area. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | The Program Manager purchased a cot, pillow and blanket as well as a privacy screen to use in the first aide room. The first kit was placed in this room along with the other items. The Program Specialist is responsible for ensuring that a first aide room is available for anyone who may require it. The program manager is responsible for checking to ensure all items are in the room during her weekly visits. UCP will monitor during its quarterly audits. All staff were retrained on this regulation and POC. (see attachment #1 and #14 and #15) |
07/15/2019
| Implemented |
| 2380.83(a) | The written evacuation procedure does not include the means of transportation to be used to the emergency shelter location in the event of a building evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | The evacuation plan was updated to include the mode of transportation in case of an emergency relocation. The program specialist will be responsible for ensuring all staff DSP's are trained on the procedure. The program manager will review the evacuation plan to ensure this is completed. UCP will monitor the evacuation plans to ensure the mode of transportation is listed in the event of an emergency during quarterly audits. All Staff were retrained on this regulation and POC. (see attachment #1 and #13) |
07/11/2019
| Implemented |
| 2380.111(c)(5) | Individual #1's physical examination forms stated that she received a negative Tuberculin skin test on 3/11/16 and not again until 8/14/18, outside of the every 2 year time frame requirement. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. | All individuals will be notified in writing of their annual physical/TB due date within 30 days. The Program Specialist is responsible for tracking all due dates and ensuring timely and accurate completion. The program manager will review each individual's physical once its been completed for thoroughness and to ensure TB test has been completed as necessary. UCP will monitor during quarterly audits of its CPS program. All staff were retrained on this regulation and POC. (see attachment #1 and #11 and #12) |
08/30/2019
| Implemented |
| 2380.125 | Individual #3's March through June 2019 medication administration records (mars) did not list the time of administration or the person who administered his Lorazepam 2mg. | Documentation of medication errors and follow-up action taken shall be kept. | The March through June 2019 MAR for individual #3 was corrected reflecting the time the medication is to be administered. ALL MARS will be prepared by the Coordinator monthly to reflect specific administration times as directed by the prescribing physician. The program specialist will review the MAR monthly to ensure that all medication are given and that the times are listed for administration. UCP will monitor this during quarterly audits of the CPS program. All Staff were retrained on this regulation and POC. (see attachment #1 along with # 9 and #10) |
07/29/2019
| Implemented |
| 2380.176(a) | Individual's records are all kept unlocked and unattended at the program. Record information included their daily outcomes, goals, names, and other identifying information. | Individual records shall be kept locked when they are unattended. | At the time of the inspection all individual records were moved to the CPS supervisor's office where they were kept locked in a cabinet. All CPS supervisors and DSP's were trained on this regulation and all staff are required to ensure that individual records are locked when unattended in the program. The Program Manager will reviewing this practice during weekly site visits to ensure compliance. This will be monitored during quarterly audits of CPS program. All staff were retrained on this regulation and POC. (see attachment #1 and #7 and #8) |
06/27/2019
| Implemented |
| 2380.181(d) | The assessment reviewed during the inspection wasn't signed by the Program Specialist. | The program specialist shall sign and date the assessment. | Individual #2's assessment was signed by the acting Program Specialist. The program specialist is responsible for signing all prepared assessments. The program manager will review all prepared assessments to ensure their signature is on the document. This will also be monitored during quarterly audits conducted by external team members. All Staff were retrained on this regulation and POC. (see attachment #1 and #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(1) | The assessment reviewed during the inspection was left blank in the section covering Functional strengths, needs and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #2's assessment was updated to reflect the functional strengths. needs and preferences of the individual. The program specialist is responsible for writing assessments that indicated functional strengths and needs as well as preferences of the individual. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and the POC. (see attachment #1 and #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(2) | The assessment reviewed during the inspection was left blank in the section covering The likes, dislikes and interests of the individual, including vocational and employment interests. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | Individual #2's assessment was updated to reflect the individuals likes, dislikes and interest, including vocational and employment interests. The program specialist is responsible for writing assessments that indicate an individuals likes and dislikes in all areas. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and POC. (see attachment #1 along with Attachment ##5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(3)(ii) | The assessment reviewed during the inspection was left blank in the section covering the individual's current level of performance and progress in the following areas: Communication. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication. | Individual #2's assessment was updated to reflect the individual's current level of performance and progress in the area of Communication. The program specialist is responsible for writing assessments that indicated progress and current skill level for the individual in the area of communication. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and POC. (see attachment #1 and #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(9) | The assessment reviewed during the inspection was left blank in the section covering Documentation of the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #2's assessment was updated to reflect the individuals disability including functional and medical limitations. The program specialist is responsible for writing individual assessments to include the individuals disability and any health and medical limitations. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and POC. (see attachment #1 along with #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(10) | The assessment reviewed during the inspection was left blank in the section covering a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual #2's life time medical history was attached to the assessment following the licensing. The program specialist is responsible for ensuring that each assessment includes a life time medical history of the individual. This document will be attached to each assessment by the program specialist. The program manager will review all assessment and ensure that the life time medical history is attached. UCP will monitor this process during quarterly audits of CPS programs. All staff were retrained on this regulation and POC. (see attachment #1 #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(13)(i) | The assessment reviewed during the inspection was left blank in the section covering the individual's progress over the last 365 calendar days and current level in the following areas: Health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | Individual #2's assessment was updated to reflect the individuals progress over the last 365 days with respect to Health The program specialist is responsible for writing assessments that indicated progress over the previous year. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and POC. (see attachment #1 #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(13)(iii) | The assessment reviewed during the inspection was left blank in the section covering the individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Individual #2's assessment was updated to reflect the individuals progress over the last 365 days with respect to personal adjustment. The program specialist is responsible for writing assessments that indicated progress over the previous year. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and the POC. (see attachment #1 along with #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(13)(iv) | The assessment reviewed during the inspection was left blank in the section covering the individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Individual #2's assessment was updated to reflect the individuals progress over the last 365 days with respect to socialization The program specialist is responsible for writing assessments that indicated progress over the previous year. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and POC. (see attachment #1 , #5 and #6) |
07/29/2019
| Implemented |
| 2380.181(e)(13)(v) | The assessment reviewed during the inspection was left blank in the section covering the individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Individual #2's assessment was updated to reflect the individuals progress over the last 365 days with respect to Recreation. The program specialist is responsible for writing assessments that indicated progress over the previous year. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and the POC. (see attachment #5 and #6 along with #1) |
07/29/2019
| Implemented |
| 2380.181(e)(13)(vi) | The assessment reviewed during the inspection was left blank in the section covering the individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Individual #2's assessment was updated to reflect the individuals progress over the last 365 days with respect to community integration. The program specialist is responsible for writing assessments that indicated progress over the previous year. The CPS manager will review all assessments written to ensure this area is covered. Beginning immediately UCP will conduct quarterly audits of all CPS programs to ensure compliance with the Chapter 2380 regulation. All staff were retrained on this regulation and POC. (see attachment #1 and #5 and #6) |
07/29/2019
| Implemented |
| 2380.182(a) | Individual Support Plan (ISP) reviews reviewed during inspection didn't cover three-month period reflecting Annual Review Update date of ISP.
REPEAT from 7/5/18 annual inspection: Individual #1's Individual Support Plan (ISP) review that covered the time period from 8/1/18-10/31/18 was not completed (signed and dated by the program specialist and the individual) until 5/6/19. The individual attended program up until 11/27/18, then was out of program until 5/6/19. | The program specialist shall coordinate the development of the individual plan, including revisions, with the individual and the individual plan team. | The Quarterly review for individual #2 was revised to include the correct dates reflecting a 3 month period. In addition the quarterly for 02/16/2019-05/17/2019 was also revised to accurately reflect the review period. The Program Specialist created a spreadsheet to track dates of all ISP's and quarterlies to be able to ensure proper and timely completion. The CPS manager is responsible for ensuring all ISP quarterlies are completed on time and accurately. UCP will monitor during completion of Quarterly Audits by external team members. All staff were retrained on this regulation and the POC. (see attachment #1 #2, #3 and #4) |
07/29/2019
| Implemented |
| 2380.188(a) | Individual #3 requires total assistance with medication administration. On 8/13/18 the agency did not provide a certified medication administration trained staff to the individual for him to receive his 1pm dose of Lorazepam as ordered by his physician. The agency also did not attempt to contact the individual's physician to notify them of the individual's missed dose of medication and what steps to take next. The agency did not notify the individual's mother until 3:15pm of the medication omission. | The facility shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | All DSP's will be required to attend an pass the medication administration course within 3 months of their date of hire. When a medication error occurs such as omission, the individuals' medical provider will be contacted for direction on corrective actions. The Program Supervisor will be responsible for completing the call and will notify the program manager who will enter the medication error into EIM. Effective immediately UCP will conduct quarterly audits of the CPS program to ensure compliance with this regulation. All staff were retrained on this regulation as well as the POC. (see attachment #1) |
10/31/2019
| Implemented |
| Article X.1007 | Staff #4 was hired on 6/3/19 and didn't have a criminal history clearance in training record | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Staff #4 Criminal History check was completed immediately after licensing. All newly hired staff will undergo the appropriate background checks prior to starting orientation. The HR business associate is responsible for ensuring this is completed and will notify the appropriate supervisor of the completion prior to the scheduling of the orientation. The program manager will review with the trainer on the day of orientation that all clearances have been completed prior to the individual coming to the worksite. UCP will monitor during quarterly audits of its CPS programs. All staff were retrained on this regulation and POC. (see attachment #16 and #17 along with #1) |
06/27/2019
| Implemented |