Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00271169 Renewal 08/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 was admitted to the provider's program effective 04/09/2025. Documentation in the Individual Record shows that a fire safety training was not provided for this individual until 04/23/2025. This training was not provided upon admission to the facility as required.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Individual 1 first attended program on 4/23/25, it would appear that the 4/9/25 date was provided in error. In order to ensure that Via is tracking this correctly, the orientation checklist that is used will be updated to ensure program coordinators are using program start dates rather than intake dates as the correct date for admission to service. 08/26/2025 Implemented
2390.151(a)Individual #2's two most recent Individual Assessments occurred on 01/30/2024 and 02/18/2025---more than 365 calendar days apart. An assessment was not conducted annually for this individual as required.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Via's Electronic Record System allows for tracking of various required documents that expire throughout the year. An addition to the system was made to ensure that program coordinators are tracking Annual Assessments, the coordinators will be required to input the current Annual Assessment dates so that they track when those assessments expire on Via's end, rather than relying on scheduled Individuals Support Plan meetings. 08/26/2025 Implemented
SIN-00251378 Renewal 09/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual #1 was not informed of the Individual's rights annually and Individual #1 was not informed of the Individual's rights upon admission. Individual #1 was informed of the Individual's rights on 4/12/23 and was not informed of the Individual's rights again until 6/13/24. Individual #1 was admitted to the program on 1/23/24 and was no informed of the Individual's rights.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Via informed both individuals of their Individual Rights, however it was not done in a timely fashion. All program specialists will be informed, by email, that the Individual Rights annual paperwork must be done with no delay in signing and scanning the document to Via's Electronic Health Record System. A copy of this email will be provided to ODP on 10/07/2024. 10/07/2024 Implemented
SIN-00233006 Renewal 09/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.56The water temperature in the main program bathrooms was tested to ensure the availability of hot water. The water in the main women's bathroom did not rise above 96 degrees during testing.A facility shall have hot and cold running water that is suitable for drinking purposes, in bathrooms and kitchen areas.Via will work with the Maintenance Supervisor to determine how to increase the water temperature, in all bathrooms, to reach an acceptable level of over 100 degrees. 09/29/2023 Implemented
2390.85(a)-2The hypothetical location of the fire in fire drills dated 8/30/23, 5/30/23 and 1/24/23 were all noted to be "M-6." "M-6" is noted to be the "workshop entrance" on the "Fire Exit Labels" section of the provider fire drill form. No additional denotation of "M-6" was listed. The hypothetical location on the fire drills completed on 4/27/23 and 10/26/23 was noted to be "E-8." "E-8" is noted to be "Stairway Exit by Front Office on First Floor" on the "Fire Exit Labels" section of the provider fire drill form. No additional denotation of "E-8" was listed. The hypothetical locations of the fire during fire drills shall be different for each drill.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.Via will edit the fire drill log to allow for a narrative regarding location, rather an an assigned fire location label. Additionally, a reminder will be added to the fire drill log that the location cannot be a location used in the previous 12 months. 10/05/2023 Implemented
2390.86At the time of inspection the licensed upstairs training/conference room of the program did not have "EXIT" signs placed at the two exits of the room.Signs bearing the word "EXIT" in plain legible letters shall be placed at exits.Via will add exit signage above both doors in the upstairs conference room. 10/05/2023 Implemented
SIN-00211121 Renewal 09/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(5)Individual 1's Individual Assessment, dated 08/22/2022, does not contain information regarding the individual's ability to self-administer medications. The assessment contains two items relating to this ability. The first item reads "Does the participant take medications while at program?" and the assessment records an answer of "no." The second item reads "Does the participant require assistance self-medicating while at program?" and the assessment records an answer of "no." Neither of these items addresses Individual 1's underlying ability to self-administer medications, which is independent of whether or not the individual actually takes medications while at program. The assessment should reflect the individual's actual level of functioning as it pertains to self-administering medications should the need ever arise for the individual to do so. The assessment must include the following information: The client's ability to self-administer medications.The plan of correction will encompass two steps, one specific to this event and the other a plan to maintain compliance. The first was the revision of Ruthann's 2022 annual assessment to include whether or not she has the ability to self-administer medication. This was completed on 9/29/22 by the program specialist, Lauren Goldberg. A copy will be submitted as supporting documentation. 09/29/2022 Implemented
SIN-00193863 Renewal 11/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.32(c)Staff #1 has a Bachelor's degree in Journalism which does not meet the requirement.A chief executive officer shall meet one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years of work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years of work experience in administration or the human services field.On 12/1/21 a waiver of regulation request was submitted to ODP, asking that the CEO's degree be accepted as the current CEO has been at Via for 14 years, and has served in the position of CEO since January of 2019. This predates the regulation that indicates the degree does not meet requirements. 12/09/2021 Implemented
2390.49(c)(3)Staff #2 and Staff #3 did not have training in the area specific to Individual RightsThe annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Via's Incident Management/Restrictive Procedures Training (developed by Via) was previously thought to address Individual Rights as a part of our annual training curriculum. During the licensing review it was determined that this area was not adequately addressed. Via's Vice President of Services, Denise Pioli, has taken the Individual Rights training on myodp in order to determine if this training will be used or adapted for staff moving forward. That training was completed on 1/11/22, and the certificate awarded. 01/11/2022 Implemented
SIN-00155149 Renewal 04/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.20Monthly safety inspections were not conducted n 6/2018, 10/2018 and 11/2018.A facility shall have a written accident prevention policy. The accident prevention policy shall include the requirement for monthly inspection of the physical site, production process and machines and equipment. In order to ensure that monthly safety inspections are completed two members of Via¿s Health and Safety Committee are assigned the checklist, with staff in the 2390 program acting as back up should the need arise. The Director of Human Resources utilizes a recurring appointment in her Outlook calendar to remind the scheduled staff that the monthly inspection must be completed. The safety checklists are then turned in to the Director of Human Resources, who has assumed responsibility for ensuring that they are completed every month going forward. All other safety measures were adequate during the inspection process. 01/14/2019 Implemented
2390.33(c)(1)Staff #1's qualifications were not in his record and could not be measured.A program specialist shall meet one of the following groups of qualifications: Possess a master's degree or above from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field. Possess a bachelor's degree from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field; and 1 year experience working directly with disabled persons.Staff #1 is no longer working as a program specialist. Program Manager, who meets licensing credentials, has been assigned to this caseload. Please see attached credentials. 05/20/2019 Implemented
2390.87The most current fire safety training for Staff #2 is dated 9/20/2017. Staff #3 had fire safety training on 9/20/2017. She did have it again until 10/10/18, which exceeds the annual requirement. Individual #3 had fire safety training on 4/26/2017 and not again until 8/15/18. Individual #7 was admitted on 9/24/18. He didn't have fire safety training until 9/26/2018.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.In order to ensure compliance with annual fire safety training for staff a Fire Safety Video will be shown to the Pre-Vocational team every three months at their weekly morning meeting. The Program Manager will collect sign in sheets to turn in to the Human Resources department to track yearly. Staff will continue to attend Via¿s yearly safety training meeting, at which time fire safety will also be discussed. In regard to newly hired individuals there will be an indicator added to the Participant Orientation checklist that will need to have the date of the fire safety training filled in, as a prompt for the Program Specialist. ((Staff #2 will receive fire safety training by 6/30/19 - CH 6/17/19 )) 05/20/2019 Implemented
2390.112(b)Written records of orientation were not in the records for Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, Individual #6, Individual #7, Individual #8, Individual #9 and Individual #10.Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client.Effective 05/20/19 a Participant Orientation Checklist will be implemented for anyone newly hired to the Pre-Vocational Department. The Admissions Manager will complete the following and/or indicate the items are complete: Intake Meeting Date, Program Application complete, initial releases signed, date the acceptance letter was mailed, admission date, the date tax forms and e-verify were completed, whether an OVR closure letter was required and received, the date of the physical and TB screening. Additionally, the Admissions Manager will note known allergies, whether there is a seizure protocol, exceptional medical/physical needs, whether there is a behavior support plan, and who the assigned Program Specialist will be. This document, upon completion, will be given to the Program Specialist prior to the individual¿s start date. The Program Specialist will indicate whether the participants profile is created in SET-Works, Via¿s electronic health record system. Additionally, the Program Specialist will indicate the date the participant was oriented with the facility, the fire safety training date, and the date that the Meet and Greet occurred with the participants instructor. The Program Specialist will also indicate that the individual was given the participant handbook, which outlines working hours, benefits, and leave policy. The completed Participant Orientation Checklist will be scanned into SET-Works, as well as the Civil, Legal, and Human rights checklist which is signed by the participant during the intake process. ((All staff orientation records will be reviewed by 6/30/19. All staff will receive orientation by 7/15/19 as necessary -CH 6/17/19)) 05/20/2019 Implemented
2390.151(a)Individual #1 had an assessment on 4/7/17 and not again until 5/2/18. Individual #7 was admitted on 9/24/18; he didn't have an initial assessment until 12/18/18. Individual #8 was admitted on 12/12/18; he didn't have an initial assessment until 3/5/19. Individual #9 was admitted on 12/17/18; she didn't have an initial assessment until 2/20/19. Individual #10 was admitted on 1/8/19; she didn't have an initial assessment until 3/15/19.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.An unanticipated error occurs with our electronic record system, SET-Works, which has been automatically updating program specialist¿s signatures (the indicator utilized to reflect the date of the assessment) each time the document is opened or adjusted. In order to immediately ensure an accurate signature date SET-Works was contacted on 4/30/19 to determine if the automatic time stamp could be disabled for the required participant forms. SET-Works staff indicated that the time stamp could not be disabled but offered that two fields could be added that would allow staff to enter the date and time a form was created. This was immediately implemented and should resolve issues related to Via¿s electronic record system moving forward. 04/30/2019 Implemented
2390.151(f)Individual #2's ISP meeting was held on 10/31/18; his assessment wasn't completed until 10/31/18. Individual #3's ISP meeting was held on 10/1/18; his assessment wasn't completed until 10/3/18. Individual #4's ISP meeting was held on 12/12/18; his assessment wasn't completed until 12/20/18.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).An unanticipated error occurs with our electronic record system, SET-Works, which has been automatically updating program specialist¿s signatures (the indicator utilized to reflect the date of the assessment) each time the document is opened or adjusted. In order to immediately ensure an accurate signature date SET-Works was contacted on 4/30/19 to determine if the automatic time stamp could be disabled for the required participant forms. SET-Works staff indicated that the time stamp could not be disabled but offered that two fields could be added that would allow staff to enter the date and time a form was created. This was immediately implemented and should resolve issues related to Via¿s electronic record system moving forward. 04/30/2019 Implemented
2390.156(a)Individual #3 had ISP Reviews on 4/3/18, 7/11/18, 10/3/18 and 4/29/19. The period between 10/3/18 and 4/29/19 exceeds the 3 month requirement. Individual #4 had ISP Reviews on 6/3/18, 9/3/18, 12/20/18 and 2/28/19. The period between 9/3/18 and 12/20/18 exceeds the 3 month requirement. Individual #10 was admitted on 1/8/19. She didn't have an initial ISP Review until 4/16/19. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.An unanticipated error occurs with our electronic record system, SET-Works, which has been automatically updating program specialist¿s signatures (the indicator utilized to reflect the date of the review) each time the document is opened or adjusted. In order to immediately ensure an accurate signature date SET-Works was contacted on 4/30/19 to determine if the automatic time stamp could be disabled for the required participant forms. SET-Works staff indicated that the time stamp could not be disabled but offered that two fields could be added that would allow staff to enter the date and time a form was created. This was immediately implemented and should resolve issues related to Via¿s electronic record system moving forward. 04/30/2019 Implemented
2390.156(b)Individual #2 didn't sign his ISP Review dated 1/29/19. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.On 05/21/19 the program manager discussed the importance of this regulation with the Program Specialist who did not ensure the signature was complete and documented that conversation in the employee record system. Additionally, it was documented that it is essential to ensure compliance with client signatures moving forward. 05/21/2019 Implemented
SIN-00134638 Renewal 05/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1's date of admission was 11/06/17 and did not receive initial fire safety training until 1/18/18. Individual #3's date of admission was 10/30/17 and did not receive initial fire safety training until 3/12/18. Staff #1's current annual fire safety training occurred on 3/19/18 and the previous fire safety training was on 8/22/16. Staff #2's current annual fire safety training occurred on 2/23/18 and the previous fire safety training was on 8/01/16.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.All Prevocational staff were informed of the requirement prior to inspection as this was identified as a citation for another program. All expiration dates for individuals receiving service in the agency database. A monthly report will be produced to identify which individuals need fire safety training in the upcoming month. Via recently purchased the College of Direct Supports which allows the agency to track training expirations and prompt staff to take the training. 06/25/2018 Implemented
2390.151(a)Individual #1 was admitted on 11/06/2017 and did not have an assessment. Individual #2 was admitted on 1/10/2018 and the initial assessment was not completed until 4/10/2018. Individual #4's current annual assessment was dated 2/07/2018, and the previous assessment was dated 1/13/2017.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.An audit was conducted to ensure current program specialists are up to date with reports and the result was all were on track. It should be noted that the two missing reports were the responsibility of a former Via employee. A Via employee has been designated to randomly check 5 individuals¿ reports in the agency database on a monthly basis. The results will be tracked and reported in the agency quality improvement plan. ((Program Specialist will complete an assessment for Individual #1. - CH 6/27/2018)) 06/25/2018 Implemented
2390.156(a)The record for Individual #4 did not contain ISP Reviews of the ISP (ARU 5/08/17) for quarters one and two. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.An audit was conducted to ensure current program specialists are up to date with reports and the result was all were on track. It should be noted that the two missing reports were the responsibility of a former Via employee. A Via employee has been designated to randomly check 5 individuals¿ reports in the agency database on a monthly basis. The results will be tracked and reported in the agency quality improvement plan. 06/25/2018 Implemented
SIN-00111918 Renewal 05/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.40(b)For the training year (2015-2016), staff #1 had 20.75 hours of training, which is 3.25 hours less than the 24 hours requirement.Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually.The initial correction was the Director, Lowell King, met with this staff and his supervisor to review the regulation. The long term correction is that a required training matrix and memo reviewing staff responsibilities will be distributed. 06/23/2017 Implemented
2390.87Individual #1 was admitted to program on 3/13/2017. He didn't receive initial fire safety training until 4/26/2017.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.A memo, written by Marianne Bear, Vice President of Quality Improvement was distributed to all Prevocational Program Specialists to remind them they are responsible for ensuring fire safety training is provided on the first day of program. This date was added to the report due date spreadsheet. The spreadsheet will be maintained on the agency shared network drive and the Director, Lowell King, will e-mail a copy of it to all Program Specialist at the beginning of each month. 06/23/2017 Implemented
2390.151(a)Individual #2 was admitted to program on 8/2/2016. He didn't have an initial assessment until 10/18/2016, which exceeds the 60 day requirement. Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The immediate correction was for the Director, Lowell King, to inform the Program Specialist responsible of the error and provide a review of the regulation. The long term correction is the development of a spreadsheet with due dates for required reports. The spreadsheet contains formulas that calculate the dates of all required reports. The Vice President of Quality Improvement developed the spreadsheet and will train Prevocational Program Specialists, the Director and the Quality Improvement Coordinator how to use it. The spreadsheet will be maintained on the agency shared network drive and the Director, Lowell King, will e-mail a copy of it to all Program Specialist at the beginning of each month. 06/23/2017 Implemented
2390.151(d)There is no Program Specialist signature/date on Individual #1's assessment dated 5/15/2017, Individual #3's assessment dated 11/7/2016, and Individual #4's assessments dated 3/4/2016 and 3/4/2017.The program specialist shall sign and date the assessment.Via¿s Annual Assessment form was revised to include signature and date lines. Older versions of this form were deleted from the network folder containing forms for the Prevocational Program and replaced with the new version by Marianne Bear, Vice President of Quality Improvement. An e-mail was sent to all agency Program Specialists directing them to delete all old forms from their personal and shared network drives. 06/23/2017 Implemented
2390.156(a)Individual #4 had an ISP Review on 3/5/2016. He didn't have another ISP Review until 7/6/2016 which exceeds the 3 month requirement. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.The immediate correction was for the Director, Lowell King, to inform the Program Specialist responsible of the error and provide a review of the regulation. The long term correction is the development of a spreadsheet with due dates for required reports. The spreadsheet contains formulas that calculate the dates of all required reports. The Vice President of Quality Improvement developed the spreadsheet and will train Prevocational Program Specialists, the Director and the Quality Improvement Coordinator how to use it. The spreadsheet will be maintained on the agency shared network drive and the Director, Lowell King, will e-mail a copy of it to all Program Specialist at the beginning of each month. 06/23/2017 Implemented
2390.156(b) Individual #3 & his Program Specialist didn't sign or date his ISP Reviews dated 5/6/16, 8/6/16, 11/6/16 and 2/6/17; Individual #4 & his Program Specialist didn't sign or date his ISP Reviews dated 7/6/16, 9/26/16, 12/26/16, and 3/26/17; Individual #5 & his Program Specialist didn't sign or date his ISP Reviews dated 7/21/2016. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.Via¿s ISP Review form was revised to include signature and date lines. Older versions of this form were deleted from the network folder containing forms for the Prevocational Program and replaced with the new version by Marianne Bear, Vice President of Quality Improvement. An e-mail was sent to all agency Program Specialists directing them to delete all old forms from their personal and shared network drives. 06/23/2017 Implemented
SIN-00094763 Renewal 05/10/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 was admitted to VIA Day Program on 4/20/2015. She did not receive Fire Safety training until 5/22/2015.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.For non-compliance with 2390.87; staff and clients as appropriate shall be instructed upon admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers, a written record of the training shall be kept; short-term correction is that all clients in the prevocational program have been trained in fire safety. The long-term plan of correction is inform prevocational program specialists of the non-compliance and the corrective action via a memo that must be signed by the program specialist and maintained in his/her personnel file. Ongoing monitoring will be completed by an existing promoted instructor whose job responsibilities include ensuring all new client orientation requirements by ODP and the agency are completed. The memo to program specialists was distributed with a deadline of return with signature by 6/10/16. The designated prevocational instructor is in place and has been informed of her responsibilities relative to new client orientation in her job description and has carried out this task as required. Monitoring of this corrective action is the responsibility of the Director, Lowell King. 06/10/2016 Implemented
2390.151(a)Individual #1 was admitted to program on 4/20/2015. She didn't have an initial assessment until 7/11/2015, which surpassed 60 days. Individual #5 had an assessment done on 1/14/2015 and not again until 2/8/2016, which surpassed 1 year.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.For non-compliance with 2390.151(a), each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and updated assessment thereafter, correction of past non-compliance is not possible. The long-term plan of correction is to inform prevocational program specialists of the non-compliance and the corrective action via a memo that must be signed by the program specialist and maintained in his/her personnel file. Ongoing monitoring will be completed by a newly promoted prevocational instructor whose job responsibilities include collecting, filing and documenting completion of reports, including the submission of required reports. The memo to program specialists was distributed with a deadline of return with signature by 6/10/16. The newly promoted prevocational instructor will be in place by 6/20/16. All corrections are the responsibility of Lowell King, Director. 06/20/2016 Implemented
2390.151(d)There is no program specialist signature on the 11/17/2015 assessment for Individual #4.The program specialist shall sign and date the assessment.For non-compliance with 2390.151(d), the program specialist shall sign the assessment, correction of past non-compliance is not possible. The long-term plan of correction is to add a signature line to the assessment, inform prevocational program specialists of the non-compliance and the corrective action via a memo that must be signed by the program specialist and maintained in his/her personnel file. Ongoing monitoring will be completed by a newly promoted prevocational instructor whose job responsibilities include collecting, filing and documenting completion of reports, including the presence of required signatures. The memo to program specialists was distributed with a deadline of return with signature by 6/10/16. The newly promoted prevocational instructor will be in place by 6/20/16. Both actions are the responsibility of the Director, Lowell King. 06/20/2016 Implemented
2390.156(b)For the years of 2015 and 2016, the ISP Reviews that were completed did not have signatures on them for Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, Individual #6, Individual #7, Individual #8 and Individual #9. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.For non-compliance with 2390.156(b), the program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP, correction of past non-compliance is not possible. The long-term plan of correction is to add a signature line to the quarterly and annual forms, inform prevocational program specialists of the non-compliance and the corrective action via a memo that must be signed by the program specialist and maintained in his/her personnel file. Ongoing monitoring will be completed by a newly promoted prevocational instructor whose job responsibilities include collecting, filing and documenting completion of reports, including the presence of required signatures. Signature lines added to the forms were completed by Lowell King, Director, on 5/13/16. The memo to program specialists was distributed with a deadline of return with signature by 6/10/16. The newly promoted prevocational instructor will be in place by 6/20/16. All corrections are the responsibility of Lowell King, Director. 06/20/2016 Implemented
SIN-00073524 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62In the conference room, there are no emergency telephone numbers posted near or on the telephone. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.The non-compliance area 2380.62, ¿Telephone numbers of the nearest hospital, police department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line¿ was corrected on January 6, 2015 when the list of emergency numbers was laminated and taped next to the telephone in the conference room. The plan to prevent future non-compliance is to add this requirement to the agency safety checklist, conducted by members of the Via Health and Safety Committee on a monthly basis. Also add to the checklist the requirement that any missing emergency phone list need to be replaced immediately. The Vice President of Quality Improvement is responsible for revising the checklist and reviewing the checklist monthly. 01/06/2015 Implemented
2380.111(c)(5)The physical dated 02/26/2014 for individual #1 does not have a tuberculin skin test. The last tuberculin skin text for individual #1 was on 12/14/2012. The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.The non-compliance area 2380.111(c)(5), ¿The physical examination shall include tuberculin skin testing with negative results every two years; or if the tuberculin skin test is positive, an initial chest x-ray with results noted¿ was corrected on January 6, 2015 when the agency received a complete physical for this individual with tuberculin skin test results dated March 13, 2014. An audit on January 19, 2015 of the physicals of the remainder of the participants in the program resulted in no other non-compliances. The plan to prevent future occurrences is to create a master spreadsheet listing the dates of the most recent physical with TB test and the due date for the next physical/TB test for each individual in the program. This spreadsheet will be maintained on a shared agency network drive so it is accessible to the Program Specialist, Director and Quality Improvement staff who are responsible for monitoring compliance. The Program Specialist is responsible for developing the spreadsheet by January 23, 2015. The Director is responsible for monitoring compliance on a monthly basis, including informing any participant not in compliance with this area, that he or she may not attend the program until the physical/TB test is received by the agency. 01/06/2015 Implemented
SIN-00086244 Change in Location Capacity 11/10/2015 Compliant - Finalized
SIN-00074331 Change in Location Capacity 02/09/2015 Compliant - Finalized
SIN-00045534 Initial review 02/07/2013 Compliant - Finalized