Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00156526 Renewal 06/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)Provider cited themselves for 151(c)(2) but did not provide a corrective action to address the citation.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The corrective action to address the citation identified on the agency¿s self-assessment form was amended (attachment #1). Upon the completion of the self-assessment for the Silvan home the audit team was not able to find the TB test for a staff member. Upon further investigation the TB test was found however the audit team forgot to amend the LII to indicated that the TB test was found. As a result of this error the Residential Director amended the LII on June 28, 2019 to accurately correct the self-assessment to indicate the error and that a POC was not necessary. (see attachment #1) The Senior Director of Operations will retrain the Residential Audit team on the process of the agency¿s self-assessment / and this POC to ensure there is a corrective action for any citations identified by August 31, 2019. In addition internal Audits will be conducted quarterly using the self-assessment, after each audit is completed the Residential Service Manager and Residential Service Supervisor will review the quarterly internal audit self-assessment and develop a corrective action to address the citations within 30 days of receiving the quarterly audit self-assessment tool. The Residential Director will review the self-assessment tool and the corrective action to ensure compliance. 08/31/2019 Implemented
SIN-00136538 Unannounced Monitoring 06/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.20Individual #1 had a seizure protocol indicating to call 911 for any seizures lasting longer than 5 minutes. Individual #1's Individual Support Plan (ISP) reviews indicated active seizures. Seizure logs were not completed to document the date, time, or duration of the seizures.The home shall maintain a record of individual illnesses, seizures, acute emotional traumas and accidents requiring medical attention but not inpatient hospitalization, that occur at the home. The Residential Manager who was responsible for oversight of Individual #1 was trained on this regulation on June 18, 2018. Refer to attachment #1. In addition a universal seizure log was developed and sent to all residential supervisors for immediate usage on June 14, 2018 refer to attachment #13 for verification. This seizure log was placed in individual #1 record on June 15, 2018. Refer to attachment #14. Residential DSP¿s will complete the seizure log anytime an individual supported has a seizure, they will record the date, time, duration of the seizure as well as conditions present during the seizure. Refer to Attachment #15 for verification. Residential Supervisors will monitor the logs weekly to ensure they are accurate. Compliance with this regulation will be monitored during quarterly audits by a division audit team. In addition UCP is restructuring its residential division and will include a nurse to support the division. This position will review all health concerns and conduct monthly file audits including the seizure records of individuals to assess compliance with this regulation and make recommendations for additional evaluation and treatment. Please refer to attachments #2, #3, and #11 for the residential restructure and the duties of the Program Specialist and the Nurse. 10/01/2018 Implemented
6400.44(b)(10)Individual #1's monthly documentation was not signed or dated by the program specialist.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes.The Residential Manager who was responsible for oversight of this individual was retrained on this regulation on June 18, 2018. Refer to attachment #1. Individual #1¿s monthly documentation was reviewed and signed off by the Residential Manager/Specialist. Refer to attachment #12 beginning immediately all monthly progress reports will be reviewed and signed by the Residential Manager/Program Specialist prior to completing the quarterly ISP reviews. Compliance with this regulation will be monitored during quarterly audits by a division audit team. In addition UCP is restructuring its oversight of the residential program to include two Program Specialist to support 36 individuals. This Program Specialist will focus their attention on the clinical needs of the individual and will not have any oversight over the operations of the home. Transition to this model will be in place by September 1, 2018 refer to attachments #2 and #3 for specific details of the residential restructure plan and the duties of the Program Specialist position. 09/01/2018 Implemented
6400.141(c)(3)Individual #1's 4/10/18 physical exam did not include immunizations. This section of the physical exam form was not completed.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The Residential Manager who was responsible for oversight of this individual was retrained on this regulation on June 18, 2018. Please refer to attachment #1. She amended the 04/10/18 physical examination form to indicate that this gentlemen declines to participate in receiving immunizations. Please refer to attachment #10 for verification. Beginning immediately all physical examination forms will be completed in their entirety. The Residential Supervisor will be responsible for attending the physical examination appointments for all individuals under their purview. It will be the Residential Manager¿s responsibility to check the form prior to filing in the individual¿s record to ensure all information is accurate and accounted on the document. Compliance with this regulation will be monitored during quarterly audits by a division audit team. In addition UCP is restructuring its residential division and will include a nurse to support the division. This position will monitor all individual health concerns and review physical examinations of individuals monthly. Please refer to attachment #3 for residential restructure and #11 for details related to the nurse¿ responsibility. The nurse will be hired by October 1, 2018. 10/01/2018 Implemented
6400.163(c)REPEATED VIOLATION - 2/23/18. Individual #1's 3/6/18 psychiatric medication review did not include the reason for prescribing the medication, the need to continue the medication, or the dosage of medication. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Residential Manager who was responsible for oversight of this individual was retrained on this regulation on June 18, 2018. Refer to Attachment #1. She contacted Individual #1¿s psychiatrist to have the 03/06/18 appointment record amended to include all necessary information. Refer to attachment #8 and #9 for verification. UCP developed a new quarterly medication review form to ensure all information necessary under regulation is properly assessed. Beginning immediately this form will be used exclusively when taking individuals to their psychiatric medication reviews. It will be reviewed after the appointment has been attended by the Residential Manager to ensure all required information is entered on the document. Compliance with this regulation will be monitored during quarterly audits by a division audit team. 09/01/2018 Implemented
6400.181(e)(10)Individual #1's 3/29/18 assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The Residential Manager who was responsible for Program Specialist duties was retrained on this regulation on June 18, 2018. Refer to Attachment #1. She attached the prepared Life Time Medical History to the individual¿s assessment. Beginning immediately all prepared Life time medical histories will be attached to the assessment by either staple or paperclip. See attachment #7. Compliance with this regulation will be monitored during quarterly audits by a division audit team. Please refer to attachment #2 and #3 for the Residential Re-structure plan and specific duties of the Program Specialist. 09/01/2018 Implemented
6400.183(5)Individual #1's Individual Support Plan (ISP) did not include a social, emotional, environmental needs (SEEN) plan.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The Residential Manager who was responsible for Program Specialist duties was retrained on this regulation on June 18, 2018. Refer to Attachment #1. She contacted the Individuals Supports Coordinator to ensure the inclusion of the SEEN plan into the ISP, see attachment #5 and #6. Beginning immediately any individual who requires a SEEN plan will have it included in their ISP. The Program Specialist will be responsible for ensuring this is completed. Compliance will be monitored quarterly during internal audits by a division audit team. Please refer to attachment #2 and #3 for the Residential Re-structure plan and specific duties of the Program Specialist. 09/01/2018 Implemented
6400.186(a)REPEATED VIOLATION - 6/28/17. Individual #1's Individual Support Plan (ISP) review covering the period of time between 10/11/17 and 1/10/18 and the ISP review covering the period of time between 1/11/18 and 4/10/18 were completed on 5/15/018.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. The Residential Manager who was responsible for Program Specialist duties was retrained on this regulation on June 18th, 2018. Refer to Attachment #1. Beginning immediately all ISP reviews will be completed no later than 15 days after the quarter has ended by a Program Specialist. Compliance will be monitored quarterly during internal audits by a division audit team. In addition UCP is restructuring its oversight of the residential program to include two Program Specialist to support 36 individuals. The Program Specialist will focus their attention on the clinical needs of the individual and will not have any oversight over the operations of the home. Transition to this model will be in place by September 1, 2018. See attachments #1, #2 and #3 for verification and information on the restructure. 09/01/2018 Implemented
6400.186(b)Individual #1's ISP reviews completed on 5/15/18 were not reviewed with him or signed and dated by him.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The Residential Manager who was responsible for Program Specialist duties was retrained on this regulation on June 18 , 2018. Refer to Attachment #1. She met with the individual and reviewed the documents and had him sign them on June 15, 2018. See attachment #4. Beginning immediately all ISP reviews completed will be reviewed and signed off by the individual. Compliance will be monitored quarterly during internal audits by a division audit team. In addition UCP is restructuring its oversight of the residential program to include two Program Specialist to support 36 individuals. The Program Specialist will focus their attention on the clinical needs of the individual and will not have any oversight over the operations of the home. Please refer to attachments #2 and #3 regarding the residential plan and on the duties of the Program Specialist. 09/01/2018 Implemented
SIN-00097314 Renewal 06/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were six gallon jugs of paint unlocked in the garage. Germ-X was unlocked in the bathroom and kitchen. Dish Soap was unlocked in the kitchen.Poisonous materials shall be kept locked or made inaccessible to individuals. Regulation 5400.62(a) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #5). The six gallon jugs of paint were removed from the garage (Attachment #6) and the individual's in this home are safe around poisons per their ISP, so the dish soap and Germ-X can be unlocked. 07/19/2016 Implemented
6400.106There was no documentation to show the oil furnace was cleaned and inspected annually. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Regulation 6400.106 was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #3). The furnace was cleaned and inspected on 11/25/2015, (Attachment #4) however no documentation for the 2014 cleaning and inspection could be located. The vendor was called but has not yet located the 2014 work order. The Program Manager will track the dates for furnace inspections of all the homes and ensure they are completed on an annual basis. 07/19/2016 Implemented
6400.112(c)REPEATED VIOLATION - 2/17/15 The 11/23/15, 1/28/16, and 6/28/16 fire drill logs did not include the time of the drill.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Regulation 6400.112(c) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #1) Fire Drill logs for July and August drills were completed correctly to include the time of the drill (Attachment #2). CHS Program Manager will monitor fire drill logs monthly to ensure on-going compliance. 08/05/2016 Implemented
SIN-00060274 Renewal 02/11/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The self-assessment was completed 1/28/14 and the expiration date is 3/1/14.(a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. Program Manager was retrained on the regulation by the Assistant Director of Adult Services on 03/04/2014(Attachment #1). All future self-assessments will be completed by November 1, four months prior to the expiration of the certificate of compliance. 03/04/2014 Implemented
6400.112(c)The fire alarm was not checked to see if they were operative in Feb & March 2013 according to the fire drill records. (c) A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Program Manager was retrained on the regulation by the Assistant Director of Adult Services on 03/04/2014(Attachment #2). All house managers were trained to complete fire drill records in the same manner. Fire drill record of March 2014 shows that the systems were operable ((Attachment #3) 03/04/2014 Implemented
SIN-00207345 Renewal 07/05/2022 Compliant - Finalized
SIN-00190376 Renewal 08/03/2021 Compliant - Finalized
SIN-00114085 Renewal 06/28/2017 Compliant - Finalized
SIN-00077972 Renewal 02/17/2015 Compliant - Finalized
SIN-00046485 Renewal 02/06/2013 Compliant - Finalized