| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(e) | Staff #2 had fire safety on 2/18/16 and then again 3/13/17. | Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Program Specialist was retrained on the corresponding regulation. In the case of a transfer form one UCP program to another, the staff will have fire safety instruction documented on the onsite training log prior to beginning work at the new site. It is the Program Specialist responsibility to assure that direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1 &12 |
12/19/2017
| Implemented |
| 2380.111(c)(3) | Individual #1's physical dated 4/3/17 did not include immunizations. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical for individuals #1 was revised to show that the doctor does not recommend immunizations at this time. This individual had a chest x-ray on 8/10/2015 in lieu of the Mantoux TB testing. The chest x-ray was negative and the individual remains symptom free. Attached is also her residential desensitization plan to help with her combativeness with medical professionals. An additional new physical from another individual is attached to show that the regulation was met. Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to insure that the physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1,9,10 |
12/19/2017
| Implemented |
| 2380.111(c)(11) | Individual #1's physical dated 4/3/17 states regular diet and ISP states low fat/low sodium diet. Individual #2's physical 3/20/17 states regular diet but ISP stated chopped meals. | The physical examination shall include: Special instructions for an individual's diet. | The existing physicals for individuals #1 & #2 were revised to include the correct diet information. Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to insure that the physical examination shall include: Special instructions for an individual's diet. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1,9,10,11 |
12/19/2017
| Implemented |
| 2380.181(a) | Individual #1 has assessment dated 8/9/16 but no other in record. Individual #2 DOA of 5/15/17 and assessment was completed on 10/17/17. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individuals #1¿s assessment was done on 12/15/2017 so there would be one present for 2017. It will be done at the appropriate time next year. To address the issues with Individual #2¿s assessment, an additional assessment for another new individual was attached to show it was done in the proper time frame. Program Specialist was retrained on the corresponding regulations. It is the Program Specialist responsibility to insure that the assessments are done in the proper time frame. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1,6,7 |
12/19/2017
| Implemented |
| 2380.181(e)(9) | Individual #2's assessment dated 10/17/17 did not include documentation of the individual disability. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | Individual #2¿s assessment was revised to include documentation of the individual disability. Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to include documentation of the individual disability on. Individual¿s assessment. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1& 8 |
12/19/2017
| Implemented |
| 2380.181(f) | Individual #2's assessment dated 10/17/17 was not sent to entire team. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | The Assessment for individual #2 was revised to include all team members and sent out to those who were not initially included .Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1,3,6,7 |
12/19/2017
| Implemented |
| 2380.186(a) | Individual #1 ISP reviews dated 10/17/17 and was only ISP review in record. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | The ISP reviews for individual #1 were not done by the former supervisor. Moving forward, they will be done by the new supervisor in a timely manner. ISP reviews for the entire year for another consumer have been attached. Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to create ISP reviews in the stated time frames. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment #1&2 |
12/19/2017
| Implemented |
| 2380.186(d) | Individual #2's ISP review dated 10/30/17 was not sent to entire team. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The ISP reviews for individual #2 was revised to include all team members and sent out to those who were not initially included. Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to send documents to all of the team members on the ISP reviews. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment #1,3,5 |
12/19/2017
| Implemented |
| 2380.186(e) | Individual #1 and #2 did not have option to decline in the record. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The quarterly correspondence letter for individuals #1 & #2 were revised to include the option to decline. Program Specialist was retrained on the corresponding regulation. It is the Program Specialist responsibility to provide the recipients of the ISP reviews the option to decline receiving them. UCP¿s Program Managers are responsible for ensuring that this practice is completed during their on-site weekly visits to their programs. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days.
See attachment # 1,4,5 |
12/19/2017
| Implemented |