Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.20 | Individual #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 |