| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Direct Service Worker #1 had a physical examination completed on 8/20/14 and then again on 9/21/16. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Direct Service worker had their physical 9/21/16. The Director of Human Resources will track each UCIP staff on an monthly calendar to track their physical due date. She will send a monthly calendar out to each Manager. Each Manager will distribute an physical to any staff that is due in the upcoming month. The staff will schedule that physical appointment and let the Manager know when it is scheduled, so the Manager can make sure it is in the time frame. [At least quarterly for 1 year, a designated management or human resource staff person shall review the tracking system and a 25% sample of physical examinations to ensure timely completion. (AS 4/6/17)]
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03/31/2017
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1 had a Tuberculin skin test completed on 8/22/14 and then again on 9/23/16. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The DSW's Tuberculin skin test was completed on 9/23/16. The Director of Human Resources will track every UCIP staff on an monthly calendar. She will then send the monthly calendar to each Manager. The Manager will distribute n physical form to each staff prior to their due date. The staff will then schedule the physical appointment and let the Manager know. This physical form also has the Tuberculin skin test on it to be completed at the time of the physical.[At least quarterly for 1 year, a designated management or human resource staff person shall review the tracking system and a 25% sample of physical examinations including Tuberculin testing to ensure timely completion. (AS 4/6/17)] |
03/31/2017
| Implemented |
| 6400.168(a) | Direct Service Worker #2 completed and passed the Department's Medications Administration Course on 12/12/14 and then again on 12/12/16. Direct Service Worker #2 administered medications between 12/12/15 through 12/11/16. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | The DSP passed the Medication course on 12/12/16. The Program Specialist who was trained 12/16/15 through 12/16/18 did the med passes with her. The UCIP trainer will track all UCIP staff yearly and send out the appropriate med paperwork to each Manager prior to the med passes being due. Once the completed med passes are done, they are given back to the med trainer to file. [At least quarterly for 1 year, a designated management staff person shall review the tracking system and a 25% sample of completed medication training to ensure only staff persons who have completed and passed the Department's Medications Administration Course are administering medications.(AS 4/6/17)] |
03/31/2017
| Implemented |
| 6400.168(e) | Direct Service Worker #1 completed medication training on 12/2/15. The trainer did not sign or date the annual practicum recertification. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | The med trainer signed the form on 2/9/17. Once the med forms are completed by the Program Specialist they will turn them into the UCIP trainer for his review for completeness. He will then double check each form for signatures before they are filed.[At least quarterly for 1 year, a designated management staff person shall review the tracking system and a 25% sample of completed medication training to ensure only staff person who have completed and passed the Department's Medications Administration Course are administering medications.(AS 4/6/17)] |
03/31/2017
| Implemented |