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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | Individual #1, date of admission 9/14/18, had a Tuberculin evaluation via Mantoux method that was planted on 3/19/2019; however, the tuberculin evaluation was not read within 48-72 hours, making the test invalid. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Program specialist is responsible for tracking all individual's TB test and results. The program specialist has been retrained on the regulation for understanding and compliance. The program specialist will check all individual's TB implantation and read dates during her bi-annual complete check of each individual's client binder to ensure compliance.
Individual #1, got a new TB test on 11/23/2020 and was read 11/25/2020 with a negative result. [Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall conduct an audit of individual files to ensure that Tuberculin evaluations are completed timely and according to standard medical practices. Documentation of individual file audits shall be kept. DPOC by HDKP, HSLS on 12/28/2020]. |
11/25/2020
| Implemented |
| 6400.151(c)(3) | Direct Services Worker #1, date of hire 7/21/2020, had a physical examination, dated 7/17/2020; however, the physical examination did not include a signed statement that the employee is free from communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | All new hires will be required to use agency's updated physical form which states the employee is free from communicable disease. If new hire has a form from another source it must state employee is free from communicable disease. The CEO is responsible for compliance. [Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of staff files to ensure that staff physical examinations contain a statement that the employee is free from a communicable disease or that the staff person has a communicable disease, what specific precautions must be implemented to prevent the spread of disease to individuals. Documentation of staff file audits shall be kept. DPOC by HDKP, HSLS on 12/28/2020]. |
11/18/2020
| Implemented |
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