| 2380.181(a) | The annual assessment for Individual # 2 was completed late. His assessment last year was completed on 7/3/18 and not again until 8/15/19. | 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. | The program specialist has created a spreadsheet to track and maintain due dates of assessments to ensure they are being completed within 1 year prior to or 60 calendar days after admission to the facility and then updated annually thereafter. The program specialist will review the tracking spreadsheet on a weekly basis and complete all assessments timely to avoid any of them being late. Additionally, internal quarterly audits will be completed to by trained group of staff using the Adult Training Facility licensing instrument. |
11/21/2019
| Implemented |
| 2380.181(e)(5) | Individual #1's Assessment dated 09/06/19 does not assess her ability to self-medicate. The assessment instead states "Individual does not take any medications at CPS. She does not administer her own medications at home and has not expressed a desire to do so. She is fully reliant on others to prepare medications at the prescribed time". | The assessment must include the following information: The individual's ability to self-administer medications. | The program specialist is responsible for completing assessments timely. Individual #1's assessment has been updated to include the individuals' specific abilities to self-administer medications. Additional and concentrated regulation trainings have been implemented at monthly staff meetings and will continue as a way to review what is required. These trainings are presented by UCP's Senior Director of Operations. Additionally, internal audits will be completed on a quarterly basis using the Adult Training Facility licensing instrument to make sure all documentation is complete and accurate and that processes are being followed as required by the regulations. |
11/21/2019
| Implemented |