| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(e)(3)(iv) | Individual #2's ISP dated 7/14/22 addresses the use of a weighted fork and spoon while attending the day program. The Individual does have access to these items; however, this information is not listed in the current assessment. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | UCP has created a Smartsheet that will track the due dates and completion dates for each assessment. Automatic email notifications will be sent to the program specialist 30 days in advance of a due date.
Attachment #1 Individual #2 Assessment dated 01/14/2022
Attachment #2 Individual #2 Addendum to 01/14/2022 Assessment |
12/28/2022
| Implemented |
| 2380.39(c)(3) | Staff # 1 received training in individual rights on 02/15/21 and not again until 03/15/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | UCP has created a Smartsheet to track annual training including a schedule of monthly required trainings that the CPS Supervisor maintains for compliance. Each month, all staff complete the scheduled training, and the CPS Supervisor uploads the training sign off sheet to the Smartsheet. |
12/28/2022
| Implemented |
| 2380.126(a)(7) | The medication administration record for individual #1 did not contain the dose of medication to be taken upon administration (1 pill or 2 pills, for example). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The UCP Medication Administration trainer will be notified when a new individual enters CPS and takes medications while at CPS and when a current individual is prescribed a new medication and has changes to an existing medication. |
12/28/2022
| Implemented |
| 2380.126(a)(8) | The medication administration record for individual #1 did not contain information on the route of medication to be taken (i.e., if the medication is to be taken orally or via injection should be indicated). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The UCP Medication Administration trainer will be notified when a new individual enters CPS and takes medications while at CPS and when a current individual is prescribed a new medication and has changes to an existing medication. |
12/28/2022
| Implemented |
| 2380.126(a)(9) | The medication administration record for individual #1 did not contain instructions on the frequency of the medication (for example, it does not indicate it is a PRN medication). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The UCP Medication Administration trainer will be notified when a new individual enters CPS and takes medications while at CPS and when a current individual is prescribed a new medication and has changes to an existing medication. |
12/28/2022
| Implemented |
| 2380.126(a)(11) | The medication administration record for individual #1 does not indicate the diagnosis or purpose of the medication (i.e., for seizures instead of for anxiety because this medication is used for both purposes) | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The UCP Medication Administration trainer will be notified when a new individual enters CPS and takes medications while at CPS and when a current individual is prescribed a new medication and has changes to an existing medication. |
12/28/2022
| Implemented |
| 2380.126(d) | The medication administration record for individual #1 does not contain the directions of the prescriber listed. Staff were instructed to follow the seizure plan; however, medication directions need to appear on the MAR for the health and safety of the individual and to ensure medications are administered appropriately, without error and according to Physicians orders. | The directions of the prescriber shall be followed. | The UCP Medication Administration trainer will be notified when a new individual enters CPS and takes medications while at CPS and when a current individual is prescribed a new medication and has changes to an existing medication. |
12/28/2022
| Implemented |