Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241943 Renewal 04/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1, date of admission 10/2/23, had a physical examination completed 12/18/23. Individual #2 had physical examinations completed 5/17/22 and then again 3/19/24. [Repeat Violation 4/20/23]Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.To address the concerns raised, we have implemented a comprehensive plan of correction aimed at ensuring accurate and up-to-date records for our clients' physicals and Mantoux tests, as well as overall compliance with licensing requirements. Here is an overview of the steps we have taken: 1. **Implementation of On-Target Platform**: We are in the process of implementing On-Target, an electronic platform designed to assist in keeping accurate records for client physicals and Mantoux tests. This system will streamline our record-keeping process and enhance accuracy. 2. **Appointment of Day Program Director**: We have hired a dedicated Day Program Director who will oversee all aspects of client records, including programming. This individual will be responsible for pulling weekly reports on physical and Mantoux dates for day program clients. 3. **Client Reminder System**: If a physical or Mantoux test is within three months of the due date, a reminder paper will be sent to the appropriate contact for the client. This proactive approach will help ensure timely compliance with testing requirements. 4. **Weekly Supervision Meetings**: The Program Director will conduct weekly supervision meetings to review reports and address any issues or discrepancies in client records. This regular review process will enable us to promptly address any compliance issues as they arise. 5. **Welcome Letter for New Clients**: A "Welcome Letter" will be sent to all new clients admitted to the Day Program, along with a copy of the physical form to be filled out by their physician before their start date. This will set clear expectations and facilitate compliance from the outset. 6. **Appointment of Assistant Director**: We have also hired an Assistant Director who will review client files every three months to ensure ongoing compliance. The findings will be reviewed with the Program Director to address any areas needing improvement. We are confident that these measures will help us achieve and maintain compliance with licensing requirements. We appreciate your feedback and oversight, and we are committed to continuously improving our practices to ensure the safety and well-being of our clients. 04/30/2024 Implemented
2380.111(c)(5)Individual #1, date of admission 10/2/23, had a Tuberculin skin testing with negative results completed 12/20/23.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.To address the concerns raised, we have implemented a comprehensive plan of correction aimed at ensuring accurate and up-to-date records for our clients' physicals and Mantoux tests, as well as overall compliance with licensing requirements. Here is an overview of the steps we have taken: 1. **Implementation of On-Target Platform**: We are in the process of implementing On-Target, an electronic platform designed to assist in keeping accurate records for client physicals and Mantoux tests. This system will streamline our record-keeping process and enhance accuracy. 2. **Appointment of Day Program Director**: We have hired a dedicated Day Program Director who will oversee all aspects of client records, including programming. This individual will be responsible for pulling weekly reports on physical and Mantoux dates for day program clients. 3. **Client Reminder System**: If a physical or Mantoux test is within three months of the due date, a reminder paper will be sent to the appropriate contact for the client. This proactive approach will help ensure timely compliance with testing requirements. 4. **Weekly Supervision Meetings**: The Program Director will conduct weekly supervision meetings to review reports and address any issues or discrepancies in client records. This regular review process will enable us to promptly address any compliance issues as they arise. 5. **Welcome Letter for New Clients**: A "Welcome Letter" will be sent to all new clients admitted to the Day Program, along with a copy of the physical form to be filled out by their physician before their start date. This will set clear expectations and facilitate compliance from the outset. 6. **Appointment of Assistant Director**: We have also hired an Assistant Director who will review client files every three months to ensure ongoing compliance. The findings will be reviewed with the Program Director to address any areas needing improvement. We are confident that these measures will help us achieve and maintain compliance with licensing requirements. We appreciate your feedback and oversight, and we are committed to continuously improving our practices to ensure the safety and well-being of our clients. 04/30/2024 Implemented
2380.113(a)Direct Service Worker #1, date of hire 8/26/19, had a physical examination completed 6/30/20 and then again 12/27/22.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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Staff records, including certifications and health-related information, will be maintained in the On-Target Platform. The system will automate reminders for staff certifications, physical examinations, and Mantoux tests. Failure to adhere to these requirements will result in suspension from scheduling until compliance is achieved, prioritizing the health and safety of all individuals involved. 1. **On-Target Platform Integration:** - All staff records, including certifications and health-related information, will be entered into the On-Target Platform. 2. **Reminder System Implementation:** - The On-Target Platform will be configured to send reminders to staff members at appropriate intervals: - 6 months before the due date - 3 months before the due date - 3 weeks before the due date - Reminders will include instructions for scheduling physical examinations and Mantoux tests. 3. **Scheduling Process:** - Upon receiving a reminder, staff members will be responsible for scheduling their physical examinations and Mantoux tests. - Staff may schedule appointments with their Primary Care Physician (PCP) or coordinate with the Training Coordinator to schedule an appointment at corporate health. 4. **Compliance Enforcement:** - If a staff member fails to complete the required certifications, physical examinations, or Mantoux tests within the specified timeframe, the On-Target Platform will enforce compliance measures: - The scheduler will not allow the staff member to be scheduled until compliance is achieved. - Staff members will be suspended from scheduling until they complete the necessary requirements. - Suspension from scheduling is crucial to maintaining the health and safety standards of licensing regulations. 5. **Documentation and Reporting:** - The On-Target Platform will maintain comprehensive documentation of staff records, certifications, reminders, and compliance status. - Regular reports will be generated to track compliance rates and identify any areas of improvement. 05/01/2024 Implemented
2380.113(c)(2)Direct Service Worker #2, date of hire 5/25/23, had Tuberculin skin testing administered 5/25/23. The results section of the physical examination form stated, "no show for results".The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.Staff records, including certifications and health-related information, will be maintained in the On-Target Platform. The system will automate reminders for staff certifications, physical examinations, and Mantoux tests. Failure to adhere to these requirements will result in suspension from scheduling until compliance is achieved, prioritizing the health and safety of all individuals involved. 1. **On-Target Platform Integration:** - All staff records, including certifications and health-related information, will be entered into the On-Target Platform. 2. **Reminder System Implementation:** - The On-Target Platform will be configured to send reminders to staff members at appropriate intervals: - 6 months before the due date - 3 months before the due date - 3 weeks before the due date - Reminders will include instructions for scheduling physical examinations and Mantoux tests. 3. **Scheduling Process:** - Upon receiving a reminder, staff members will be responsible for scheduling their physical examinations and Mantoux tests. - Staff may schedule appointments with their Primary Care Physician (PCP) or coordinate with the Training Coordinator to schedule an appointment at corporate health. 4. **Compliance Enforcement:** - If a staff member fails to complete the required certifications, physical examinations, or Mantoux tests within the specified timeframe, the On-Target Platform will enforce compliance measures: - The scheduler will not allow the staff member to be scheduled until compliance is achieved. - Staff members will be suspended from scheduling until they complete the necessary requirements. - Suspension from scheduling is crucial to maintaining the health and safety standards of licensing regulations. 5. **Documentation and Reporting:** - The On-Target Platform will maintain comprehensive documentation of staff records, certifications, reminders, and compliance status. - Regular reports will be generated to track compliance rates and identify any areas of improvement. 05/01/2024 Implemented
2380.181(f)Individual #2's assessment completed 4/27/23 was provided to individual plan team members 4/27/23 for an annual ISP meeting held 5/22/23. [Repeat Violation 4/20/23]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.All client assessments will be uploaded into the On-Target system, with dates entered to track completion. Weekly reports will be generated and reviewed by the Day Program Director in supervision meetings with the Program Director to ensure assessments are completed promptly and forwarded to the Service Coordinator (SC) within 30 days of the client's Individual Service Plan (ISP) meeting. Additionally, the Assistant Director will conduct quarterly reviews of client records, reporting findings to the Program Director for further action. 1. **Assessment Upload and Documentation:** - All client assessments will be completed and uploaded into the On-Target system promptly. - Dates of assessment completion will be entered into the system for tracking purposes. 2. **Weekly Reporting and Supervision Meetings:** - The Day Program Director will run a weekly report from the On-Target system to track assessment completion. - During weekly supervision meetings with the Program Director, the Day Program Director will review the report to ensure assessments are completed in a timely manner. - Any delays or issues with assessment completion will be addressed and appropriate actions will be taken to rectify the situation. 3. **Timely Submission to Service Coordinator (SC):** - All assessments must be forwarded to the SC within 30 days of the client's ISP meeting date. - The Day Program Director will monitor the submission timeline closely and take corrective action if assessments are not sent within the specified timeframe. 4. **Assistant Director Quarterly Reviews:** - The Assistant Director will conduct quarterly reviews of client records to ensure completeness, accuracy, and compliance with regulatory standards. - Findings from the quarterly reviews will be documented and reported to the Program Director for further action. 05/01/2024 Implemented
SIN-00223155 Renewal 04/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2 had a physical examination completed on 10/21/21 and then again on 11/22/22. This exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Provider will continue to send letters to families reminding them of needing a physical completed with in the annual timeframe (knowing there is a 15 day grace period). If the family/individual does not meet the requirement the individuals services will be suspended until physical is completed. [Documentation of training, dated 4/25/23, related to individual physical examination requirements was received on 6/22/23 and reviewed 6/23/23. DPOC by HDKP, HSLS, on 6/23/23]. 05/30/2023 Implemented
2380.36(b)Program Specialist #1 was trained in general fire safety on 07/14/21 and then again on 09/02/22. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).PHS will do an audit to ensure compliance in the area of Fire Safety of all staff with in a licensed setting. Training will be held with all Program specialists to ensure they understand the regulation and the meaning of annually according to regulations definition. [Documentation of training, dated 4/25/23, related to fire safety training requirements was received on 6/22/23 and reviewed 6/23/23. Documentation of monthly fire safety training audits by Director, dated 5/31/23 and 6/20/23, were received on 6/22/23 and reviewed 6/23/23. Documentation of quarterly review of fire safety training audit by Compliance Director, dated 6/20/23, was received on 6/22/23 and reviewed 6/23/23. DPOC by HDKP, HSLS, on 6/23/23]. 05/30/2023 Implemented
2380.181(f)Program Specialist #1 sent Individual #1's assessment completed on 07/08/22 to the individual plan team on 07/08/22 for an individual plan meeting held on 07/15/22. This is less than the 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Training will be held with all Program Specialists to ensure they understand the regulation. A rolodex will be maintained to ensure correct dates of assessments being completed as well as when they should be sent 30 days prior to the ISP Meeting. [Documentation of training, dated 4/25/23, related to individual assessment requirements was received on 6/22/23 and reviewed 6/23/23. Documentation of monthly individual assessment audits by Director, dated 5/31/23 and 6/20/23, were received on 6/22/23 and reviewed 6/23/23. Documentation of quarterly review of individual assessment audit by Compliance Director, dated 6/20/23, was received on 6/22/23 and reviewed 6/23/23. DPOC by HDKP, HSLS, on 6/23/23]. 05/30/2023 Implemented
SIN-00204913 Renewal 05/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)Program Specialist #1's 2/4/22 Tuberculin skin testing with negative results and Direct Service Worker #2's 12/16/20 Tuberculin skin testing with negative results were completed and certified by a Certified Medical Assistant.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.A form has been created to staple to the Physical Form (which also was updated) to request that a RN or a LPN, licensed physician, or CNP or CPA are the only people qualified through our regulations who is able to read and sign off on Tuberculin skin testing. 05/25/2022 Implemented
SIN-00187546 Renewal 05/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility did not have an annual onsite fire safety inspection by a fire safety expert.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The facility made several attempts to local fire Departments throughout the year but were unsuccessful. After initial discussion with inspector, the facility contacted Code Officer Jeff Richardson who is a Fire Code Enforcement Inspector. He also inspected the building with new renovations completed on 4.29.21. Jeff is scheduled in the process of finishing the fire inspection form and will return it to PHS upon completion. [Fire safety inspection completed 5/26/21. Verified 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. 06/30/2021 Implemented
2380.111(c)(10)Individual #1's physical examination, dated 04/07/21, did not include medical information pertinent to diagnosis and treatment in case of emergency. This section of the physical examination was left blank. Individual #3's physical examination, dated 03/02/20, did not include medical information pertinent to diagnosis and treatment in case of emergency. This section of the physical examination was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program specialist will review all ATF individuals physicals and ensure all are up to date with all areas being filled out. If the PS finds that an area was not filled out they will reach out to the physician for clarification and documentation will be kept. [Individual #1's complete physical examination verified on 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. 05/30/2021 Implemented
2380.113(a)Direct Service Worker #1, date of hire 01/13/20, did not have an initial physical examination completed until 10/19/20.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.PHS administrator will schedule a pre-employment physical and Mantoux prior to DSP hire date when planned to work in a licensed setting. [3 staff physical examination were reviewed and verified to contain all required information on 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. 05/30/2021 Implemented
2380.21(u)Individual #1 was informed and explained individual rights on 01/07/21. Individual #2 was informed and explained individual rights on 06/23/20. Individual #3 was informed and explained individual rights on 07/21/20. Individual #4 was informed and explained individual rights on 06/22/20. The rights document did not include the following rights: 2800.21(b) The facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; 2800.21(c) An individual may not be reprimanded, punished or retaliated against for exercising the individual's rights; 2800.21(d) A court's written order that restricts an individual's rights shall be followed; 2800.21(e) A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 2800.21(f) An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 2800.21(g) An individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual; 2800.21(h) An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 2800.21(k) An individual shall be treated with dignity and respect; 2800.21(l) An individual has the right to make choices and accept risks; 2800.21(m) An individual has the right to refuse to participate in activities and services; 2800.21(n) An individual has the right to privacy of person and possessions; 2800.21(o) An individual has the right of access to and security of the individual's possessions; 2800.21(p) An individual has the right to voice concerns about the services the individual receives; 2800.2 (q) An individual has the right to participate in the development and implementation of the individual planThe facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Individuals Rights Form was updated immediately upon discussion of the violation on 5.13.21. [Updated Individual Right form verified 7/15/21. Updated forms signed by individuals by 5/19/21. DPOC by HDKP, HSLS, on 7/16/21]. 07/01/2021 Implemented
SIN-00167472 Renewal 12/11/2019 Compliant - Finalized
SIN-00147655 Initial review 12/28/2018 Compliant - Finalized