| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | It could not be determined if physical was completed by a physician for staff member #1. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | All Achieve staff who have direct contact with the consumers for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.
The physical form for Staff # 1 did not have physician's signature, rather had a physician's address label stamped on the physical health form. This has been corrected, with physician's signature for staff #1.
To assure all physical forms are in compliance with this regulation, CCIU HR staff and Achieve Executive Director will verify physical form is complete and signed by a licensed physician, certified nurse practitioner or certified physician's assistant and within 12 months of employment and every 2 years thereafter. Additionally, a notation to the CCIU Health form verifying the individual is free of communicable diseases including Tuberculosis either via tuberculin skin testing with negative results every two years, or via initial chest X-ray with results noted, will be on record in staff files.
Physical forms have been sent to incoming volunteers as well as notification of need for updated physicals to existing "back up" and contracted staff to meet these standard requirements.
To assure all staff comply with maintaining current physicals, the Achieve Executive director will monitor staff hire date, receipt of signed physical, and due date of subsequent physicals. Staff will be notified via email from the ED within 60 days of subsequent physical due dates, and will be unable to attend work past due date, until updated physical is received. |
02/27/2020
| Implemented |
| 2380.173(1)(v) | Individual #2's record did not have a current dated photograph. | Each individual's record must include the following information: Personal information including: A current, dated photograph. | All consumer files at Achieve Day program include a face sheet with a dated photo of consumer. Program specialist has verified this information is on file for all current consumers. Revised Face Sheet for individual #2 with dated photo is included.
To assure that in the future all files include the photo date, program specialist will complete and initial each face sheet form on date of admission. The form will have required fields, and document can not be finalized if required fields/information is not fully entered including the photo date. Targeted timeline for new form completion is 3/31/2020. |
03/31/2020
| Implemented |
| 2380.181(e)(14) | The ability to swim was not addressed in the 10/29/19 assessment for individual #2. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | In each assessment for consumers completed by the Achieve program specialist, the individual's knowledge of water safety and ability to swim needs to be addressed.
The assessment document has been revised to adequately reflect these abilities, and addendum to this assessment is included for individual #2.
To assure these skills are isolated and addressed in each Consumer's assessment, the new assessment form will be utilized and completed by program specialist. |
02/27/2020
| Implemented |
| 2380.36(a) | It could not be determined if staff member#2's training was completed prior to working with individuals as orientation record was not signed or dated by staff or administration. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | Achieve Day program provides orientation for staff relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals. A summary sheet documents the trainings and dates completed, in addition to a verification signature from staff and program specialist. Additionally, acknowledge forms are signed which outline the specific trainings on policies as noted on the form and reviewed at Orientation as referenced in the onsite orientation binder.
The Revised form is included in addition to revised Staff #2 training form. All existing and new staff will complete the revised form by 3/2/2020 in collaboration with program specialist.
To assure that staff trainings are completed as required prior to working with consumers, the tracking form will be completed with dates of training, initials of staff, and confirmed by program specialist and staff signatures and dated. |
03/02/2020
| Implemented |
| 2380.173(1)(i) | Individual #2's record did not document an admission date. | The name, sex, admission date, birthdate and Social Security number. | All consumer files at Achieve Day program include a face sheet with name, sex, admission date, birthdate, and social security number.
Program specialist has verified this information for all current consumers as of 2/27/2020.
To assure that in the future all files include this required information, program specialist will complete and initial each face sheet form on date of admission. The new form in development will have required fields, and document can not be finalized if required fields/information is not fully entered. Targeted timeline for new form completion is 3/31/2020. |
03/31/2020
| Implemented |