| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Direct Service Worker #2, date of hire 11/20/22, had an initial physical examination completed 9/11/21. [Repeat violation 3/4/22] | 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 Agency has re-implemented the staff hiring checklist. The checklist has been revised to include the completion date of the physical and TB test. The human resources team is responsible for ensuring the date of the completed physical and TB was completed within 12 months prior to the hire date of the staff. If it is found that the physical and/or TB is expired, the staff will be required to have a new physical and/or TB completed PRIOR to the staff working with an individual. Staff without a current physical and/or TB will not be permitted to work with any individuals until the completion and verification of the physical and/or TB. The human resources team has been trained on this policy. |
03/03/2023
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #2 does not have tuberculin testing. [Repeat violation 3/4/22] | 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 Agency has re-implemented the staff hiring checklist. The checklist has been revised to include the completion date of the physical and TB test. The human resources team is responsible for ensuring the date of the completed physical and TB was completed within 12 months prior to the hire date of the staff. If it is found that the physical and/or TB is expired, the staff will be required to have a new physical and/or TB completed PRIOR to the staff working with an individual. Staff without a current physical and/or TB will not be permitted to work with any individuals until the completion and verification of the physical and/or TB. The human resources team has been trained on this policy. In addition, the date of completion will be noted in the google calendar, with a renewal completion reminder set for 30 days prior to the physical and TB expiration date of the current TB, ensuring the physical and TB renewals are completed 30 days prior to the expiration of the current records. |
03/03/2023
| Implemented |
| 6400.181(e)(12) | The assessment, completed 9/6/2022 for Individual #1 did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | All assessments with ¿no recommendation, have been updated and will be sent to the support¿s coordinators by Friday, March 10, 2023. |
03/10/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed Atomoxetine to treat attention deficit hyperactivity disorder and has not had a medication review. [Repeat violation 3/4/22] | 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. | The individual has an appointment scheduled with his primary care physician, whom prescribed the medication. Documentation of this appointment will be filed in the individuals electronic file. |
03/11/2022
| Implemented |