Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285839 Renewal 03/26/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #2, date of admission 05/15/25, did not receive training 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, and smoking safety procedures if individuals smoke at the facility upon admission to the day program.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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, and smoking safety procedures if individuals smoke at the facility.A copy of Individual 2's Fire Safety training from their admission date to the day program was not completed. Only a copy of their Fire Safety training from their Residential start date was documented. As the anniversary of the admission date is coming up, the Fire Safety will be reviewed with the individual and documented by this date, May 15th, 2026. As this is a past date and it cannot be corrected, we will prevent this for future new individuals by requiring Program Specialists to complete a checklist that includes all required first day paperwork when an individual is admitted to the Day Program Facility. All paperwork will be documented and uploaded to OnTarget Clinical with the date completed and expiration date to ensure all records are completed and kept up to date. Program Specialists will run monthly reports for documents with upcoming expiration dates to guarantee all records are updated timely. This will also be reviewed on a monthly basis with the Program Director and Program Specialists one-on-one meetings. 05/15/2026 Implemented
2380.181(a)Individual #1, date of admission 10/22/25, had an initial functional assessment completed on 03/04/26. This exceeds 60 calendar days after admission. Individual #2, date of admission 05/15/25, did not have an initial functional assessment completed and provided for review during the inspection. This exceeds the 60 calendar days after admission.Each individual 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.ndividual 1 did not have the initial functional Assessment from their admission date (10/22/2025) completed until March 3, 2026, which is more than 60 days after admission. Individual 2 did not have a functional assessment completed on admission (5/15/2025). As these cannot be corrected due to being past dates, we will prevent this from happening in the future by having Program Specialists complete client paperwork on admission by following an admission-day checklist. Program Specialists will run monthly reports on OnTarget Clinical to ensure all records are completed and kept up to date. All assessments will be completed annually. This will also be reviewed monthly with the Program Director and Program Specialists one-on-one meetings. 05/15/2026 Implemented
2380.21(v)Individual #2, date of admission 05/15/25, did not have a signed statement that they were informed of individual rights upon admission to the program.The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.A copy of Individual 2's Individual Rights acknowledgment from the day of their admission (5/15/2025) to the day program was not completed. Only a copy of the Individual Rights from their Residential start date was documented. As the anniversary of the admission date is coming up, the Individual Rights through our Annual Consent Packet will be documented by this date, May 15th, 2026. As this is a past date and it cannot be corrected, we will prevent this for future new individuals by requiring Program Specialists to complete a checklist that includes all required first day paperwork when an individual is admitted to the Day Program Facility. All paperwork will be documented and uploaded to OnTarget Clinical with the date completed and expiration date to ensure all records are completed and kept up to date. Program Specialists will run monthly reports for documents with upcoming expiration dates to guarantee all records are updated in a timely manner. This will also be reviewed monthly with the Program Director and Program Specialists during one-on-one meetings. 05/15/2026 Implemented
2380.38(b)(2)Direct Service Worker #1, date of hire 07/14/25, did not complete the following training during the orientation training: Prevention, detection, and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Direct Service Worker 1 did not complete their Abuse Training during their new hire Orientation when they were rehired. This training will be completed by the individual in Quarter 4 (April 1, 2026- June 30, 2026), according to our Abound Health Training syllabus. The Onboarding team and Program Specialists will work together to ensure all training will be completed for new hires. A checklist has been created to track new hire paperwork once passed from onboarding to Program Specialist to ensure all aspects of new hire requirements are completed. Reports will be run monthly to track expiring certifications and trainings for employees so they can be completed on time. As well as reviewed with Program Directors and Program Specialists on a monthly basis. 04/29/2026 Implemented
2380.181(f)Individual #1 had assessment completed on 03/04/26 sent to the ISP Service Plan Team on 03/04/26 for an annual meeting that occurred on 03/17/26. This is not at least 30 calendar days prior to the individual meeting. Individual #2 did not have a functional assessment sent to the ISP Service Plan Team prior to the annual ISP meeting conducted on 01/30/26. Individual #3's functional assessment completed 04/02/25 did not record the date that the assessment was sent to the ISP Service Plan Team, therefore compliance with the regulation could not be measured.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Individual 3's Annual Assessment was signed but not dated by Program specialist. Program specialists will ensure assessments are completed, dated, signed, and sent to the individual's team annually and within the proper time frames (within 60 days of admission and distributed to the team 30 days prior to ISP meeting). Program Specialists will run monthly reports to ensure all records are completed correctly and kept up to date. This will also be reviewed monthly with the Program Director and Program Specialists one-on-one meetings. 05/01/2026 Implemented
SIN-00263804 Renewal 04/02/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility had an annual fire safety inspection completed on 06/13/23 and then again on 06/18/24. This exceeds the annual requirement.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 Annual Fire Safety Inspection will be scheduled prior to 6/18/2025 to ensure compliance for this year. 06/18/2025 Implemented
2380.111(c)(6)Individual #2's physical examination, completed 1/15/2025, indicated that the individual was not free of communicable disease; however, the physician did not indicate the specific precautions that should be taken to prevent the spread of disease. This section was left blank.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.The Information on the Individual¿s Physical exam has been updated to reflect the correct information. Sent in an attached email. All client physical details have to be reviewed by the Program Specialist initially and the Program Director or Assistant Program Director upon completion to ensure compliance. If the physical is not compliant the physical will be sent back to the doctor to update for compliance, then reviewed by the PS and Program Director or assistant Program Director for s second time. This process will be repeated until compliance is achieved. The Physical will then be uploaded to OTC and the reminder date set 3 months in advance. 06/30/2025 Implemented
2380.111(c)(10)Individual #2's physical examination, completed 1/15/2025 did not include medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Information on the Individual¿s Physical exam has been updated to reflect the correct information. S(ent in an attached email). All client physical details have to be reviewed by the Program Specialist initially and the Program Director or Assistant Program Director upon completion to ensure compliance. If the physical is not compliant the physical will be sent back to the doctor to update for compliance, then reviewed by the PS and Program Director or assistant Program Director for s second time. This process will be repeated until compliance is achieved. The Physical will then be uploaded to OTC and the reminder date set 3 months in advance. 06/30/2025 Implemented
2380.113(a)Program Specialist #2, date of hire 11/26/18, had their physical examinations completed on 3/20/2023 and 3/24/2025. [Repeated violation: 4/3/2024]. Direct Service Worker #3, date of hire 9/30/2024, had their initial physical examination completed on 10/4/2024. [Repeated violation: 4/3/2024] Direct Service Worker #4, date of hire 02/25/21, had their biennial physical examinations completed on 3/14/2023 and 3/27/2025. [Repeated violation: 4/3/2024]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.The Personal Records Specialist will send a reminder to the DSP/PS and their Supervisor to complete their Biennial Physical a month in advance. Once received the Supervisor and DSP/PS will connect to ensure the physical exam is scheduled within the appropriate timeframe and updated in on target Clinical. Once complete the physical will be updated in On target and reminder date set to one month prior for reminder to be sent. Program Director and/or assistant Director will pull a report in OTC to ensure Physical dates are compliant and being completed monthly. On boarding will ensure that a physical and Mantoux are competed prior to starting orientation training. It was discovered upon this investigation that on boarding was not scheduling Physical and Mantoux¿s required prior to training. The regulations related to this have been shared with On boarding and they have changed their process which include a Pre employment physical prior to date of hire. The Program Director and or Assistant Program Director will run a report each month to ensure compliance. 06/30/2025 Implemented
2380.113(c)(2)Direct Service Worker #3, date of hire 9/30/2024, had their initial tuberculin skin testing completed via Mantoux method on 10/7/2024. [Repeated violation: 4/3/2024]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.On boarding will ensure that a physical and Mantoux are competed prior to starting orientation training. It was discovered upon this investigation that on boarding was not scheduling Physical and Mantoux¿s required prior to training. The regulations related to this have been shared with On boarding and they have changed their process which include a Pre employment physical prior to date of hire. The Program Director and or Assistant Program Director will run a report each month to ensure compliance. 06/30/2025 Implemented
2380.21(u)Individual #1, date of admission 03/20/24, was most recently informed of their individual rights and the process to report a rights violation on 03/20/24. This exceeds the annual requirement. Individual #3, date of admission 01/31/22, was informed of their individual rights and the process to report a rights violation on 12/5/2023 and again on 12/6/2024. This exceeds the annual requirement.The 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.Upon admission and annually thereafter, all individuals will be provided with a clear and accessible statement of rights in the Abound Annual Consent Packet. This Packet can either be sent electronically to the individual/family member to sign or completed signed and uploaded to On Target Clinical. The Program Specialist assigned to the day program will be responsible for completing this information in a timely manner. The On-target line will be updated to reflect a reminder date of 2 months prior to the date the Annual Consent Packet Expires. An Audit of all client profiles is in the process of being completed and all Annual Consent Packets that were not completed or not completed within the appropriate time frame are being completed now. The Assistant Program Director will also conduct audits every month to ensure compliance. 05/01/2025 Implemented
2380.36(b)Program Specialist #2, date of hire 11/26/18, participated in training to encompass general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility 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 of the local fire department as soon as possible after a fire is discovered on 08/01/2023 and again on 08/30/2024. This exceeds the annual requirement. Direct Service Worker #4, date of hire 02/25/21, participated in training to encompass general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility 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 of the local fire department as soon as possible after a fire is discovered on 09/6/2023 and again on 09/30/2024. This exceeds the annual requirement. Direct Service Worker #5, date of hire 11/29/22, participated in training to encompass general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility 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 of the local fire department as soon as possible after a fire is discovered on 08/14/2023 and again on 08/29/2024. 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).All dates for staff¿s Annual Fire Safety Training have been added to our Training Tracker and certifications are uploaded into On Target. The program specialist is responsible for ensuring staff complete Fire Safety within the annual training year. On or prior to the date of the previous training year. An Audit is in the process of being completed to ensure all Fire Safety dates for 2024 are complete and will be completed on or before 2025. The Assistant Program Director will conduct an audit every month to ensure compliance. 05/01/2025 Implemented
2380.38(b)(1)Chief Executive Officer #1, date of hire 04/22/24, did not participate in training to encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during orientation.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The CEO completed the training on PCP once it was discovered that it was not completed initially in Orientation. He completed it on 10/30/2025. The CEO completes required annual trainings and they are tracked on the training tracker as well as uploaded in On Target Clinical. 05/01/2025 Implemented
2380.38(b)(4)Chief Executive Officer #1, date of hire 04/22/24, did not participate in training to encompass recognizing and reporting incidents during orientation.The orientation must encompass the following areas: Recognizing and reporting incident.The CEO completed the training on Recognizing and Reporting once it was discovered that it was not completed initially in Orientation. He completed it on 10/30/2025. The CEO completes the required annual trainings and they are tracked on the training tracker as well as uploaded in On Target Clinical. 05/01/2025 Implemented
2380.39(c)(1)Direct Service Worker #5, date of hire 11/29/22, did not participate in training to encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 7/1/2023 -- 6/30/2024 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.A Training Tracker has been implemented to ensure staff complete all required trainings for the 24-25 Fiscal year. This is reviewed on a daily basis by Abound health Personal Records specialist. She notifies the Program Specialist if staff have not completed their required training for the quarter. We have broken the 24-hour training requirement into 4 quarters to ensure that the 24-hour requirement is met along with the required 6100 Trainings. The certifications are then uploaded into OTC to ensure compliance by all Direct Support Professionals. The Program Director and /or Assistant Director review this information weekly in their 1 on 1 meeting with Program Specialists. 05/01/2025 Implemented
2380.39(c)(3)Direct Service Worker #5, date of hire 11/29/22, did not participate in training to encompass individual rights during the 7/1/2023 -- 6/30/2024 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.A Training Tracker has been implemented to ensure staff complete all required trainings for the 24-25 Fiscal year. This is reviewed on a daily basis by Abound health Personal Records specialist. She notifies the Program Specialist if staff have not completed their required training for the quarter. We have broken the 24-hour training requirement into 4 quarters to ensure that the 24-hour requirement is met along with the required 6100 Trainings. The certifications are then uploaded into OTC to ensure compliance by all Direct Support Professionals. The Program Director and /or Assistant Director review this information weekly in their 1 on 1 meeting with Program Specialists. 05/01/2025 Implemented
2380.39(c)(4)Direct Service Worker #5, date of hire 11/29/22, did not participate in training to encompass recognizing and reporting incidents during the 7/1/2023 -- 6/30/2024 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.A Training Tracker has been implemented to ensure staff complete all required trainings for the 24-25 Fiscal year. This is reviewed on a daily basis by Abound health Personal Records specialist. She notifies the Program Specialist if staff have not completed their required training for the quarter. We have broken the 24-hour training requirement into 4 quarters to ensure that the 24-hour requirement is met along with the required 6100 Trainings. The certifications are then uploaded into OTC to ensure compliance by all Direct Support Professionals. The Program Director and /or Assistant Director review this information weekly in their 1 on 1 meeting with Program Specialists. 05/01/2025 Implemented
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