| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill conducted on 5/22/22 at 5:08 did not include the designation of AM/PM for the time of day that the fire drill occurred. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | UCCH provider reviewed the fire drill forms, the designation of AM/PM was not documented. The residential supervisor shall make sure all fire drills forms are completed thoroughly. The designation od AM/PM shall be documented on all fire drill forms completed per regulation 6400.112(c). |
02/10/2023
| Implemented |
| 6400.151(a) | A staff person who comes into direct contact with the individuals shall have a physical examination within 12 months prior to employment. Staff #1's date of hire is 8/1/21 and their physical examination occurred on 8/4/21. This exceeds the requirement. | 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. | This error was noted beforehand in the year 2021, HR specialist was hired to keep track of all employees' onboarding process which includes their physical examinations and corrections were made moving forward. This shall be completed prior employment with UCCH in order to remain complaint. |
02/10/2023
| Implemented |
| 6400.151(c)(2) | Staff #1's date of hire is 8/1/21 and their initial chest x-ray with results noted occurred on 8/4/21. This exceeds the requirement. | 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. | This error was noted beforehand in the year 2021, which UCCH proceeded in hiring a HR specialist to keep track of all employees' onboarding process and corrections were made moving forward with employees completing their TB testing prior to being hired by UCCH in order to remain complaint. |
02/10/2023
| Implemented |
| 6400.165(g) | Individual #3 is prescribed medication to treat symptoms of a psychiatric illness. Individual #3 had psychiatric medication reviews 11/1/22 and 12/13/22 and the form used for both appointments did not include documentation of the reason for prescribing the medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Psychiatric medication management form has been reviewed and revised by the CEO. The program specialist shall make sure that the residential supervisor completes their section prior to the appointment date, and have the psychiatrist completes all sections on the forms which must include the reason for prescribing the medication, continuity of medication and necessary dosage. The program specialist shall check all forms and make sure all sections are completed before filing in the individual medical binders. If the doctor misses any blank, the program specialist shall fax form back to the doctor's office and follow up to make sure it has been completed and fax or emailed back to UCCH. |
02/10/2023
| Implemented |
| 6400.182(c) | Individual #3's Individual Support Plan (ISP) states he is unable to manage his own finances, therefore, his sister is representative. Individual #1 has a debit card from his rep payee in which $20 is deposited weekly for his spending money. Individual #1 can manage up to $25 on his own without staff guidance. Individual #1 holds on to his card and gives staff his receipts. Individual #1's assessment dated 12/6/22 states that his finances are managed by his sister as she is representative payee. Individual #3 receives $10 weekly. He can independently hold his money, but he needs verbal instructions to understand the value of money and to spend wisely. The individual plan shall be revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist has reviewed the individual's assessment. An update has been completed and would be sent to the support coordinator to reflect changes to the individual ISP. |
02/10/2023
| Implemented |