Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00246703 Renewal 07/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's most recent physical completed on 11/10/23 did not document if the individual is current with their immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Director of Programs will meet with the Program Specialists to review the missing immunization documentation on the physical form. The Program Specialist will contact the family (by email or letter) for the individual's immunization dates to attach to the current physical form. The Program Specialists will review all physicals to ensure that the immunization information is current and documented on the physical form. 08/09/2024 Implemented
2380.111(c)(4)Individual #1 had a vision screening on 11/7/22 and not again since, outside of the annual timeframe. The vision section on Individual #3's physical examination form dated 4/4/24, was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Director of Programs will meet with the Program Specialists to review the missing vision screening documentation on the physical form. The Program Specialist will contact the family (by email or letter) to request that we receive documentation related to the individual's vision screening status. The Program Specialists will review all physicals to ensure that the vision screening information is documented on the physical form 08/09/2024 Implemented
2380.181(d)Individual #1's assessment is signed but is not dated.The program specialist shall sign and date the assessment.Director of Programs will review with the Program Specialists this regulation that the program specialist must sign and date the assessment completing it in its entirety. 08/09/2024 Implemented
2380.181(e)(11)Individual #1's most recent assessment does not document if they have had a Psychological. Individual #2's most recent assessment completed on 11/8/23 did not document if the individual had a psychological completed.The assessment must include the following information: Psychological evaluations, if applicable.Director of Programs will review with the Program Specialists this regulation that all assessments must include if the individual had any psychological evaluations completed. Program Specialist will review all assessments to check if psychological evaluations are documented, if applicable. The Program Specialist will contact the family (by email or letter) for the date of the evaluation and name of the evaluator. Program Specialist will add this information to the lifetime medical section of the assessment if applicable. 08/09/2024 Implemented
2380.26Staff #3 had a criminal history. As per OAPSA, the following criteria must be discussed and documented prior to being approved for hire: If a criminal history clearance and/or the criminal history record check identifies a criminal record, providers must make a case-by-case decision about whether to hire the person that includes consideration of the following factors: · · The nature of the crime, · · Facts surrounding the conviction, · · Time elapsed since the conviction, · · The evidence of the individual's rehabilitation; and · · The nature and requirements of the job. Documentation of the review must be maintained for any staff that were hired whose criminal history clearance results or criminal history check identified a criminal record. This did not occur.The facility shall comply with applicable Federal and State statutes and regulations and local ordinances.Director of Programs and Director of Human Resources will meet to review the federal & state regulations and local ordinances in order to develop guidelines that outlines how J&FC will handle criminal history clearances/record check that identifies a criminal record. Director of Human Resources will develop a form that will be used for documentation purposes covering the nature of the crime, facts surrounding the conviction, time elapsed since the conviction, evidence of the individual's rehabilitation and nature and requirements of the job. The form will also include the decision/conclusion for the hire. Once the guidelines and form are created the Director of Human Resources will implement the guidelines when needed. 08/09/2024 Implemented
2380.39(b)(1)Staff #1 only had 6 hours of training from 7/1/23 to 6/30/24.The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.Director of Human Resources and Director of Programs have developed a spreadsheet for employees who are required to complete 12 hours of training annually in order to track that the required training hours are completed within the required timeframe. 08/09/2024 Implemented
2380.39(c)(1)Staff #1 did not have training in Community Integration from 7/1/23 to 6/30/24. Staff #2 and #4 did not have training on Community Integration or Individual Choice/Supporting Individuals to Develop and maintain relationships from 7/1/23 to 6/30/24.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.Director of Programs and Human Resource Assistant will meet to review the trainings that are required annually for all employees who need 12 or 24 hours of training under the 2380 & 6100 regulations. Director of Programs will make sure that person centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships is included for the 24/25 training year. Director of Programs will review the training requirements with staff #1, #2 and #4. Director of Programs will ensure that staff #1, #2 and #4 completes the training within the next 30 days. 08/09/2024 Implemented
2380.39(c)(1)Staff #1 did not have training in Prevention/Detection/Reporting from 7/1/23 to 6/30/24.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.Director of Programs and Human Resource Assistant will meet to review the trainings that are required annually for all employees who need 12 hours of training under the 2380 & 6100 regulations. Director of Programs will make sure that abuse prevention/detection/reporting is included for the 24/25 training year. Director of Programs will review the training requirements with staff #1. Director of Programs will ensure that staff #1 completes the training within the next 30 days. 08/09/2024 Implemented
2380.39(c)(4)Staff #1 did not have training in Recognizing and Reporting Incidents from 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Director of Programs and Human Resource Assistant will meet to review the trainings that are required annually for all employees who need 12 hours of training under the 2380 & 6100 regulations. Director of Programs will make sure that recognizing and reporting incidents is included for the 24/25 training year. Director of Programs will review the training requirements with staff #1. Director of Programs will ensure that staff #1 completes the training within the next 30 days. 08/09/2024 Implemented
2380.39(c)(5)Staff #1 did not have training in Use of Behavior Supports from 7/1/23 to 6/30/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Director of Programs and Human Resource Assistant will meet to review the trainings that are required annually for all employees who need 12 hours of training under the 2380 & 6100 regulations. Director of Programs will make sure that use of behavior supports is included for the 24/25 training year. Director of Programs will review the training requirements with staff #1. Director of Programs will ensure that staff #1 completes the training within the next 30 days. 08/09/2024 Implemented
2380.127(a)(3)Individual #1 is prescribed Novolog to be administered before lunch. Additionally, there is a sliding scale for the Novolog. In January 2024, Individual #1 was to receive 4 units before lunch. If Individual #1's blood sugar is between 151-200, they are to receive 1 extra unit. On 1/5/24, Individual #1's blood sugar was 191. They did not receive an additional unit of Novolog.Medication errors include the following: Administration of the wrong dose of medication.Upon notification of the medication error, the Director of Programs had it entered into EIM/HCSIS by 7/29/24 under administration of the wrong dose of medication. The Director of Programs and/or J&FC Nurse will review with the staff responsible to administer the required medication (insulin) the protocol required to follow using the sliding scale. The Director of Programs will review with the staff the requirement of reporting medication errors within the proper timeframe allowed. 08/09/2024 Implemented
2380.186Individual #1's blood sugar is to be tested daily. If their blood sugar is 400 or above, their Endocrinologist is to be called. On 6/20/24 and 6/27/24, their blood sugar tested at 400 and 538 respectively. There is no documentation that Individual #1's Endocrinologist was called.The facility shall implement the individual plan, including revisions.Director of Programs will review with the staff the diabetic/insulin protocol outlined by the prescribing physician for the individual to ensure the individual is safe and healthy. Director of Programs will review with staff the proper documentation required showing that the protocol is being followed as written. Director of Programs will contact the residential program specialist to ensure that J&FC has the most current protocol. Revisions will be made to J&FC protocol (if needed) to be in alignment with the residential home and physician's orders. 08/09/2024 Implemented
SIN-00228470 Renewal 08/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.67(a)At the time of the inspection, the white cabinet sitting on the floor in the woman's bathroom had the paint peeling off of it. The cabinet doors were not on it correctly and it would not close correctly.Furniture and equipment shall be nonhazardous, clean and sturdy.The Director of Programs will contact the facility maintenance coordinator to have the cabinet removed from the restroom by 8/11/23. 08/11/2023 Implemented
2380.70(d)At the time of the inspection, the thermometer in the first aid kit was not operable.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Director of Programs replaced the thermometer with a new thermometer that is in working order. The thermometer was placed in the first aid kit which is kept in the first aid room, in a locked cabinet. 08/11/2023 Implemented
2380.87(a)During the fire drill held on 8/9/23, during the walk-through of the facility, the fire alarms in the back of the program did not sound. The alarms that did go off in the front part of the facility were not loud enough to be heard throughout the entire building. All of the strobes went off, but there was no sound coming from the actual alarms.There shall be an operable fire alarm system that is audible throughout the building.Director of Programs will contact the facility maintenance coordinator to ask that the alarm system be updated to include horn strobes in each program area. The facility maintenance coordinator will contact Advantage Security Inc. to have them replaced asap. 08/11/2023 Implemented
2380.89(f)Eleven fire drills for the year have been conducted on a Friday. Agency needs to vary the day of the week the fire drills are held.Fire drills shall be held on different days of the week and at different times of the day.The Director of Programs will develop a monthly fire drill schedule annually, specifying the following items: location of fire, day/date of the week, and time. Director of Programs will identify a designee that will also be responsible to assist with ensuring that the fire drills occur as stated on the schedule. 08/31/2023 Implemented
2380.111(c)(5)Individual #1's annual physical completed on 12/20/22 did not contain the results from the TB test administered on 9/26/22 & read on 9/29/22. This section was left blank. Individual #1's TB was not administered within the 2-year time frame- it was completed late- 8/31/20 and then on 9/29/22.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 Program Specialist will contact the residential provider via phone or email, requesting documentation that the TB was administered on 9/26/22 and read on 9/29/22, and discuss having the individual's TB completed at the same time of annual physical moving forward. 08/31/2023 Implemented
2380.181(e)(3)(iv)Individual #1 is on a pureed level 1 dysphagia diet with thin liquids & drinks liquids from a cup & uses a straw, per the 7/6/23 ISP- the 7/17/23 assessment has that all food must be soft/pureed, chopped into small portions & should never drink out of a straw. All food that is brought into the program is prepared by the Individual's residential provider and is pureed.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others.The Program Specialist will review the individual's ISP and assessment in the specific area of "personal needs with or without assistance from others." Program Specialist will complete an assessment addendum to ensure that it's consistent with the individual's ISP. The assessment addendum will be sent to the individual's team informing them of the revisions, and the addendum will be printed and filed. 08/31/2023 Implemented
SIN-00208067 Renewal 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)Individuals #5 and #6 have hearing impairments and use hearing aids. During a test of the fire alarm system on 08/16/2022, the alarm was audible throughout the building, however, the strobe light system failed to function.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.The Executive Director of Operations will submit a work order to the Maintenance Director to install a lighting system that interfaces with the fire alarm system. The Quality Compliance Coordinator will revise the fire drill form, adding a checkbox to indicate whether the lighting system was functional during the fire drills. 08/30/2022 Implemented
2380.111(a)Individual #4 had an annual physical completed on 08/20/20 and not again until 11/19/21, outside of the annual timeframe.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialists will develop an annual calendar with each individual's annual physical due date. The Program Specialists will notify the family 30 days prior to the due date that the physical is coming due and notify the family 15 days prior to the due date to ensure that the physical is scheduled. 09/09/2022 Implemented
2380.111(c)(5)Individual #4 had a Tuberculosis test completed on 07/10/19 and not again until 08/14/22, outside of the bi-annual time frame.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 Program Specialists will develop an annual calendar with each individual's TB test due date. The Program Specialists will notify the family 30 days prior to the due date that the TB test is coming due and notify the family 15 days prior to the due date to ensure that the TB test is scheduled. 09/09/2022 Implemented
2380.21(u)(repeat from 09/23/21 Inspection) The provider reviewed the Individual rights with Individual #1 on 06/07/21 and not again until 06/24/22.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.The Program Specialists will review the Individual Rights Contract with all individuals who currently attend the day program by 9/9/2022. 09/09/2022 Implemented
2380.38(b)(1)Staff #3 was hired on 07/29/21. Their first day working with individuals was 10/12/21. They did not receive person-centered practices training or community integration training until 11/04/21 and 03/03/22.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 Training Coordinator will schedule all new employees within their first 2 weeks of employment to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees, in order for the training to be scheduled within the first 2 weeks of employment. 09/16/2022 Implemented
2380.38(b)(2)Staff #3 was hired on 07/29/21. Their first day working with individuals was 10/12/21. Staff #3 did not receive training on Prevention, Detection, Reporting Abuse until 10/26/21 and 11/23/21.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.The Training Coordinator will schedule all new employees within their first 2 weeks of employment to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees, in order for the training to be scheduled within the first 2 weeks of employment. 09/16/2022 Implemented
2380.38(b)(3)Staff #3 was hired on 07/29/21. Their first day working with individuals was 10/12/21. They did not receive training on individual rights until 11/09/21.The orientation must encompass the following areas: Individual rights.The Training Coordinator will schedule all new employees within their first 2 weeks of employment to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees, in order for the training to be scheduled within the first 2 weeks of employment. 09/16/2022 Implemented
2380.38(b)(4)Staff #3 was hired on 07/29/21. Their first day working with individuals was 10/12/21. Staff #3 did not receive training on recognizing and reporting incidents until 10/26/21 and 11/23/21.The orientation must encompass the following areas: Recognizing and reporting incident.The Training Coordinator will schedule all new employees within their first 2 weeks of employment to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees, in order for the training to be scheduled within the first 2 weeks of employment. 09/16/2022 Implemented
2380.129(d)The Medication Administration Training record that Staff #3 completed is not dated.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The Certified Med Trainer will ensure that all medication training admin forms are accurately and thoroughly completed, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. 09/09/2022 Implemented
2380.173(1)(i)Individual #3 gender is listed as male on their demographic sheet.The name, sex, admission date, birthdate and Social Security number.The Program Specialists will review and correct all individual's face sheets to ensure the information correctly identifies the individual. 09/09/2022 Implemented
2380.181(f)Individual #3 most recent assessment was provided to the team on 04/18/22. The team meeting was held on 05/17/22. The assessment was not provided 30 days prior to the team 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.The Program Specialists will develop an annual calendar with all annual ISP meeting dates for all individuals to ensure the assessment is completed 30 days prior to the ISP meeting. 09/09/2022 Implemented
2380.183(c)There is no record of persons who participated at Individual #2 06/09/2022 ISP meeting.The list of persons who participated in the individual plan meeting shall be kept.The Program Specialists will ask for a copy of the signature sheet during in person ISP Meetings and/or complete a Virtual Meeting Attendee Form. 09/09/2022 Implemented
SIN-00193460 Renewal 09/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The 5/21/21 Fire Drill Entry notes that the drill was conducted in "> 3 minutes" and "one individual did not exit" the building during the drill.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.One of the program specialists will be assigned the responsibility of making sure the fire drills are being run monthly and completed successfully. If a fire drill is unsuccessful, another fire drill will be held later in the month to maintain compliance. 10/04/2021 Implemented
2380.113(a)[Repeat violation from 10/06/20] Staff #6 had a physical completed on 1/4/18 and not again until 1/22/20.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.The HR department will develop an annual calendar with staffs physical due dates and will ensure multiple notifications go out to staff to ensure they are aware of when their upcoming physicals are due. Staff will inform the HR department of when their physical is scheduled and submit applicable paperwork to the HR department. 10/04/2021 Implemented
2380.113(c)(2)[Repeat violation from 10/06/20] Staff #4 had a TB test completed on 11/28/18 and not again until 12/28/20. Staff #6 had a TB test completed on 1/4/18 and not again until 1/22/20.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.The HR department will develop an annual calendar with staff's TB due dates and will ensure multiple notifications go out to staff to ensure they are aware of when their upcoming TB's are due. Staff will inform the HR department of when their TB is scheduled and submit applicable paperwork to the HR department. 10/04/2021 Implemented
2380.21(u)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 9/23/2021 annual inspection, Individuals #1, #3, and #4 were not informed of all of the individual rights as described in 2380.21.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.The rights form has been updated to include all of the rights in 2380.21. All individuals will be informed of these rights and be asked to sign off on the updated rights form by 10/8/21. It is the responsibility of the program specialists to notify the individuals of their rights upon admission and annually thereafter. 10/08/2021 Implemented
2380.126(a)(11)Individual #4 Medication Administration Record does not list the diagnosis or purpose of the prescribed medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The MAR has been updated to include the purpose for the medication. It is the responsibility of the agency nurse to ensure the purpose for the medication is on the MAR. 10/01/2021 Implemented
SIN-00177163 Renewal 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.65The seven steps located from the rear program room to the rear egress were not equipped with non-skid surfaces. The surfaces of the steps were constructed of a slippery, plastic, flooring material. Interior stairs and outside steps shall have a nonskid surface.On 10/9/20, the steps were equipped with non-skid tape by the maintenance supervisor. The program manager will be responsible for inspecting the building monthly using the monthly safety checklist and address any issues that do not meet regulations. Please see attachment #1. 10/09/2020 Implemented
2380.89(c)The fire drill records from August 2019-current, September 2020, do not record the exit route used during fire drills. The fire drill records listed numbers as the identifiers for where the individual's evacuated. However, the record did not indicate which doors/egress routes were associated with the numbers. Furthermore, the egress doors within the facility were not labeled.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.The fire drill form was revised to include a key on the form to clearly define what exit routes were used. A revised floor plan that has the same key is documented in the fire safety book with the fire drill forms. Forms were revised on 11/6/20 by the Quality Assurance and Compliance Coordinator. Please see attachments #2 and #3. 11/06/2020 Implemented
2380.111(c)(1)There is no evidence that Individual #1 medical history was reviewed at the 08/20/20 annual physical.The physical examination shall include: A review of previous medical history.The program specialists reviewed the lifetime medical history with the family and sent a lifetime medical history form to the doctor to sign off on. The program specialists reviewed all physicals to ensure all lifetime medical histories were properly filled out on the physical forms. Going forward, the program specialists will be responsible for attaching a previous medical history form with the physical form after reviewing the previous medical history with the family. Please see attachment #4. 11/10/2020 Implemented
2380.113(a)Staff #3 received a physical examination on 10/25/17 and not again until 1/22/2020, outside the regulatory time frame to be completed every two years.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 tracking system has now been established to notify the staff and staffs supervisor 30 days prior of their due dates for physicals and PPDs. The supervisor will work with the staff to ensure their physical is completed on time. 10/09/2020 Implemented
2380.113(c)(2)Staff #3 10/25/17 and 1/22/2020 physical examination records do not include the date or results of a previous chest x-ray that was completed due to a history of positive PPD results. The field on the physical examination records to include the results and dates of the chest x-rays were left blank and nothing was attached to the physical examination records.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.The paperwork received from the doctor stating that the chest x-ray was completed has been attached to their previous physical form and will be attached for all upcoming physicals for any staff who have had a chest x-ray. The Director of Programs will be responsible for ensuring this information is included on the physical forms. The names of other staff in the organization who have had a chest x-ray have been noted and their chest x-ray forms have been documented with their physicals. Please see attachment #5. 10/09/2020 Implemented
2380.173(1)(ii)Individual #2 record did not include identifying marks and stated that this regulation was not applicable. However, Individual #2 has numerous freckles on the face that are identifying characteristics.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The program specialists have updated the face sheet to include the identifying marks. The program specialists have reviewed all face sheets to ensure identifying marks are included for all individuals. The program specialists are responsible for ensuring all information on the face sheets are complete and accurate. Please see attachment #6. 11/05/2020 Implemented
2380.173(1)(v)The most recent photograph of Individual #1 in the record is dated 09/09/2019, it is not current. The most recent photograph of Individual #3 in the record is dated 05/22/2019, it is not current. The most recent photograph of Individual #4 in the record is dated 05/16/2019, it is not current.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Program Specialist took a photograph of individual #1 and placed it in their file. Program specialists and Quality Assurance and Compliance Coordinator have taken photographs for all other individuals currently in the program. Going forward, program specialists will be responsible for taking photographs of individuals upon admission to the facility and annually thereafter. Any individuals currently not in program due to Covid concerns will have their photos taken when they return to the facility. Please see attachment #7. 11/13/2020 Implemented
2380.21(u)Individual #1 was admitted to the facility on 9/09/2019. The regulatory rights described in 2380.21(a)-(t), effective 02/03/2020, were not reviewed with Individual #1. Individual #2 was admitted to the facility on 8/17/2020. The regulatory rights described in 2380.21(a)-(t), effective 02/03/2020, were not reviewed with Individual #2 upon admission. Individual #3 was admitted to the facility on 3/28/2012. The regulatory rights described in 2380.21(a)-(t), effective 02/03/2020 were not reviewed with Individual #3. Individual #4 was admitted to the facility on 7/26/2010. The regulatory rights described in 2380.21(a)-(t), effective 02/03/2020, were not reviewed with Individual #4.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.Individuals #1, 2, and 4 have had the Individual Rights contract reviewed with them by the Quality Assurance and Compliance Coordinator and the Program Specialists. Individual #3 has not returned to the program since choosing not to receive services at this time due to covid concerns, but the contract will be reviewed with them when they return. All individuals currently in the program have had the Individual Rights contract reviewed with them. All individuals currently not receiving services at this time due to Covid concerns will have it reviewed with them upon returning to services. Going forward it is the program specialists responsibility to review the individuals rights with them upon admission to the facility and annually thereafter. Please see attachment #8. 11/13/2020 Implemented
2380.36(a)There is no evidence that the content of the staff fire safety training reviewed with staff members included a review of the evacuation procedures, smoking safety if individuals or staff smoke, the use of fire extinguishers, smoke detectors and fire alarms, or notification of the fire department as soon as possible after a fire is discovered. The only content kept for staff fire safety training was a questionnaire form completed that did not describe the required content of 2380.36(a).Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.The Training Coordinator has developed site specific fire safety training and clearly documented training form to be completed annually with staff. This training will be completed upon initial hire and annually thereafter with staff. The Director of Programs will be responsible for ensuring all staff are trained. Please see attachment #9. 11/09/2020 Implemented
2380.126(b)Individual #5 was administered Carafate Suspension medication at 10AM on 12/11/2019. However, the staff person who administered the medication did not identify themselves via initials and signature or written name for the staff person who administered the medication. The individual's mediation administration record listed "SS" as administering the medication, but the staff key did not include a written confirmation of a staff with the initials SS or their corresponding name. This must be recorded at the time of administration.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All med trained staff were re-trained on legibly documenting their name and initials on the MAR¿s by the Quality Assurance and Compliance Coordinator. It is the responsibility of all med trained staff to ensure they are clearly documenting their names and initials. The Quality Assurance and Compliance Coordinator will be responsible for checking the MAR¿s to ensure documentation is legible. Please see attachment #10. 11/11/2020 Implemented
2380.129(a)Staff #4 has been administering medications to individuals at the program since 11/5/2019. However, Staff #4 did not pass the Department approved initial medication administration training course and it's requirements. Staff #5 recorded on 11/5/19 that Staff #5 passed the course on 11/5/19 but never met the course requirements of scoring a 90 or above collectively on the initial online examinations (multiple choice test and written documentation test) and skills demonstration. Scoring a 90 or above on the online examinations and skills demonstration is required prior to passing the exam. If a score of 90 or above is not met, the staff must retake the initial examination. There is no evidence that Staff #4 completed the initial examination requirements again with a passing score.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Staff #4 completed the modified med training course on 10/15/2020. The staff was trained on J&FC policy and procedures for administering meds and has performed their med passes with a certified trainer. The staff will retake the exam once appendix K is lifted. All certified med instructors have met with the director of programs to review the requirements of the med course for passing staff. Additionally, the training records of all med trained staff were checked to ensure that all staff are eligible to administer meds. It is the responsibility of the certified med trainers to ensure that all staff pass the course before administering meds. Please see attachment #11. 11/13/2020 Implemented
SIN-00161468 Renewal 08/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(a)There was no audible fire alarm system in the basement at time of the inspection.There shall be an operable fire alarm system that is audible throughout the building.Program Manager sent a work order to the Maintenance Supervisor, to hook up an audible alarm system connected to the main system in the basement on 9/9/19. This is to be completed as soon as possible. Program Manager has added to check the sound of the basement alarm to the Fire Drill Record as well as the Monthly Safety Checklist. A copy of the work order, fire drill record and safety checklist are included. 09/09/2019 Implemented
2380.87(b)Individual #5 is hearing impaired and he attends the ATF. The ATF is not equipped to alert him of a fire emergency due to lack of equipment.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Program Manager sent a work order to the Maintenance Supervisor on 9/16/19. Upon research from 9/2/19-9/13/19 the Program Manager cannot find a vibrating alarm system that is compatible with our current system. Upon a phone call with the Maintenance Supervisor on 9/11/19, the Program Manager was informed that the Maintenance Supervisor will be having a meeting with our Fire Alarm system company on 9/12/19 and will inquire about getting a compatible vibrating system. A copy of the work order is included. 09/16/2019 Implemented
2380.111(c)(9)Individual #2's physical dated 9/20/18 had NKDA for allergies and her Individual Support Plan dated 2/14/19 lists Poison Ivy as an allergy.The physical examination shall include: Allergies or contraindicated medication.Program Specialists reviewed the requirement that all sections of the physicals that need to be filled out including but not limited to allergies, with the Program Manager and the Executive Director on August 30, 2019. We created a physical checklist that outlines the important aspects of a physical that need to be filled out. The Program Manager and Executive Director will monitor for compliance. A copy of this checklist is included. 08/30/2019 Implemented
2380.181(e)(13)(i)Individual #2 assessment dated 7/26/19 did not include progress and current level in Health. Individual #3 assessment dated 5/29/19 did not include progress and current level in Health. Individual #4 assessment dated 1/10/19 did not include progress and current level in Health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Individual #2: Program Specialist created an addendum to the assessment on September 12, 2019. The Addendum was mailed out on September 12, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #3: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #4: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. 09/12/2019 Implemented
2380.181(e)(13)(ii)Individual #2 assessment dated 7/26/19 did not include progress and current level in Motor and Communications. Individual #3 assessment dated 5/29/19 did not include progress and current level in Motor and Communications. Individual #4 assessment dated 1/10/19 did not include progress and current level in Motor and Communications.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Individual #2: Program Specialist created an addendum to the assessment on September 12, 2019. The Addendum was mailed out on September 12, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #3: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #4: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. 09/12/2019 Implemented
2380.181(e)(13)(iii)Individual #2 assessment dated 7/26/19 did not include progress and current level in Personal Adjustment. Individual #3 assessment dated 5/29/19 did not include progress and current level in Personal Adjustment. Individual #4 assessment dated 1/10/19 did not include progress and current level in Personal Adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Individual #2: Program Specialist created an addendum to the assessment on September 12, 2019. The Addendum was mailed out on September 12, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #3: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #4: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. 09/06/2019 Implemented
2380.181(e)(13)(iv)Individual #2 assessment dated 7/26/19 did not include progress and current level in Socialization. Individual #3 assessment dated 5/29/19 did not include progress and current level in Socialization. Individual #4 assessment dated 1/10/19 did not include progress and current level in Socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Individual #2: Program Specialist created an addendum to the assessment on September 12, 2019. The Addendum was mailed out on September 12, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #3: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #4: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. 09/12/2019 Implemented
2380.181(e)(13)(v)Individual #2 assessment dated 7/26/19 did not include progress and current level in Recreation. Individual #3 assessment dated 5/29/19 did not include progress and current level in Recreation. Individual #4 assessment dated 1/10/19 did not include progress and current level in Recreation.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Individual #2: Program Specialist created an addendum to the assessment on September 12, 2019. The Addendum was mailed out on September 12, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #3: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. Individual #4: Program Specialist created an addendum to the assessment on September 5, 2019. The Addendum was mailed out on September 6, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. 09/12/2019 Implemented
2380.181(e)(13)(vi)Individual #2 assessment dated 7/26/19 did not include progress and current level in Community Integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Program Specialist created an addendum to the assessment on September 12, 2019. The Addendum was mailed out on September 12, 2019. Specialist have been informed and trained on the expectation of what is acceptable for Assessments on new individuals to the program. Quarterly file checks will take place by the Program Specialists to ensure all sections are completed in the Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on August 30, 2019. The Program Manager and Executive Director will monitor for compliance. 09/12/2019 Implemented
SIN-00139092 Renewal 09/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.67(a)Baseball sized amount of dryer lint was observed in the dryer lint trap.Furniture and equipment shall be nonhazardous, clean and sturdy.All staff were reminded to check the dry lint trap before and after use. There has been a posting added by the dryer to remind staff of this as well. It will be added as part of the daily cleaning routines and monthly safety checklists as well. 10/02/2018 Implemented
2380.111(c)(5)Individual #1 had a TB test read on 10/8/14 and not again until 11/2/16.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 program specialists have created a spreadsheet which contains all due dates. They will be responsible for sending notifications out when physicals and immunizations are due. These will be sent out with the ISP reviews previous to the due dates in order for caregivers to have adequate notice to schedule appointments. The program specialists will review this spreadsheet at least quarterly and add due dates to their calendar to track these. The program specialists will also provide notification to caregivers that the individual will not be able to attend program if there physical and other requirements are not completed within required time frames. 10/02/2018 Implemented
2380.173(9)Individual #4's current physical indicated no diet recommendations. Individual's current assessment indicated calorie controlled, high fiber diet, and the current ISP indicated a regular diet.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The program specialist updated the assessment to reflect diet information from the physical and ISP which contained the correct information. An addendum was sent out to all team members to inform them of this change. 10/02/2018 Implemented
2380.181(a)Individual #4's assessment was completed on 12/21/16 and not again until 2/5/18 and 6/19/18.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.The program specialists have a spreadsheet of due dates which include the date of the assessments. This spreadsheet will be reviewed and updated at least quarterly in order to maintain compliance with due dates of paperwork. 10/09/2018 Implemented
2380.181(e)(4)Individual #3's assessment completed on 1/15/18 did not include community supervision needs.The assessment must include the following information: The individual¿s need for supervision.The program specialist has completed an addendum to the assessment to include the community supervision needs for the individual. This will be added to the checklist for all assessments that are completed. 10/01/2018 Implemented
2380.181(e)(7)Individual #4's assessment dated 6/19/18 did not include individual's ability to move away from heat sources.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The program specialist has added this information for the individual in an addendum to the assessment. It will also be added to the checklist for all assessments to include both components of awareness of heat sources. 10/02/2018 Implemented
2380.181(f)Individual #3's 1/15/18 assessment was sent to team members on 1/15/18 for a 2/8/18 ISP meeting. Individual #4's 2/5/18 assessment was sent to team members on 2/5/18 for a 2/8/18 ISP meeting.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).The program specialist has updated the format of the assessment cover letter to include the requirement to schedule the ISP meeting 30 days after the date of the assessment. Program Specialists will also inform the Supports Coordinators of this requirement when scheduling ISP meetings. 10/02/2018 Implemented
SIN-00110686 Renewal 06/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(1)There was no documentation of a degree or experience available for Staff #1.A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with persons with disabilities.A copy of staff #1¿s college graduation transcript was received on 7/11/17 and placed in the personnel file. The HR Director added a line on the Applicant Checklist that states ¿Copy of diploma (if applicable)¿ as a reminder at time of new staff orientation to request a copy of educational documents if required for the position hired for. The HR Director will monitor for compliance. 07/11/2017 Implemented
2380.53(a)Five tubes of toothpaste were unlocked underneath laundry room/bathroom sink.Tubes indicated poison control should be contacted if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The toothpaste tubes were separated on 6/22/17 into Ziploc bags so they were contained in one bag per individual.. All toothpaste tubes was locked up in a cabinet. They will be distributed for use as needed and relocked up as soon as the individuals are done with them. The Program Manager and Executive Director will monitor for compliance. 06/22/2017 Implemented
2380.55(a)Several individuals' toothbrushes were stored in the same plastic cup underneath the laundry room/bathroom sink. One toothbrush did not have a toothbrush cover over the brush head. Clean and sanitary conditions shall be maintained in the facility.The toothbrushes were separated on 6/22/17 into Ziploc bags so they were contained in one bag per individual and the top of the toothbrush was not exposed to other brushes. All toothbrushes were locked up in a cabinet. They will be distributed for use as needed and relocked up as soon as the individuals are done with them. The Program Manager and Executive Director will monitor for compliance. 06/22/2017 Implemented
2380.58(a)Red/brown couch in tv area in main room has approximately 5-6 pieces of duct tape covering several rips/tears.Floors, walls, ceilings and other surfaces shall be in good repair.The couch was removed on 7/7/17 and put into the garbage dumpster. A new couch will be purchased and added to the main program area. The Program Manager will check the furniture on a monthly basis to ensure that there are no concerns. Should there be concerns, the Program Manager will immediately contact the Facilities and Maintenance Manager to discuss possible repairs or disposal of the item, depending on the issue presented. 07/07/2017 Implemented
2380.69(e)No toilet paper was available in the men's bathroom across the hall from the laundry room. Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.There is already a daily checklist that is completed by staff who are to check the restrooms and ensure toilet paper and other supplies are adequately stocked. A training was conducted with staff on 7/6/15 at the monthly staff meeting to remind staff to be sure extra toilet paper is in the bathrooms. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.91(a)Individual #1 was not instructed in the individual's primary language or mode of communication, upon initial admission on 11/21/2016, iin 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.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.This correction is unable to be made since her date of admission is past. Fire safety training was added to the Intake/Interview Summary that is completed on day of admission for all individuals. This will serve as a reminder to complete the fire safety training at the time intake occurs. Program Specialists reviewed the requirement that fire safety training needs to take place with individuals on their day of admission, with the Program Manager and the Executive Director on June 30, 2017. The Program Manager and Executive Director will monitor for compliance. 06/30/2017 Implemented
2380.111(c)(5)Individual #3 had a TB test completed on 7/15/2013 and not again until 2/25/2016.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.Correction can not be be made since the date due is already past. Program Specialists will begin adding due dates to the Quarterly Reviews effective immediately as a reminder to all team members. A reminder letter is already mailed out a month in advance to the parents/guardians regarding the need for TB tests to be completed before the deadline. The Program Manager, Program Specialists and Executive Director will monitor for compliance. 07/07/2017 Implemented
2380.111(c)(8)Individual #2's physical dated 6/10/2016 indicated no physical limitations. However his record indicates depth perception issues, unsteady gait, and that he uses a walker.The physical examination shall include: Physical limitations of the individual.The Program Specialist added the additional physical limitations to the physical exam form and signed and dated it on 7/6/17 Program Specialists will review all physical exams as they are received to ensure all pertinent information is completed. They will contact the parents/legal guardians, or group home staff to have them assist in getting the physical exam form completed properly prior to placing the document in the file. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.111(c)(10)Individual #1's physical dated 4/10/2017 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. Individual #2's physical dated 6/10/2016 stated York Hospital. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Program Specialist added individual #1¿s missing medical information on 7/3/17 and to individual #2¿s physical form on 7/6/17. Program Specialists will review all physical exams as they are received to ensure all pertinent information is completed. They will contact the parents/legal guardians, or group home staff to have them assist in getting the physical exam form completed properly prior to placing the document in the file. The Program Manager and Executive Director will monitor for compliance. 07/03/2017 Implemented
2380.113(a)Staff #2 had a physical completed on 4/17/2014 and not again until 6/1/2016. 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.This is unable to be corrected since the date due is already past. The reminder system for staff members to obtain their physical exams has been changed. The HR Admin Assistant will now be sending out a reminder email to staff members at least a month in advance instead of 2 weeks as we have been doing. The due date will be placed on the Admin Assistants calendar as a reminder to follow up with the staff member if the physical exam was not yet received. The HR Director will be responsible for overseeing that the physical exams are completed on time. A new electronic monitoring system will be purchased this fiscal year 2017/2018 as part of our time attendance system. This will give the agency electronic reminder capability for physical exam due dates. 07/11/2017 Implemented
2380.113(c)(2)Staff #2 had a TB test read on 4/19/2014 and not again until 6/3/2016.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.This is unable to be corrected since the date due is already past. The reminder system for staff members to obtain their TB tests has been changed. The HR Admin Assistant will now be sending out a reminder email to staff members at least a month in advance instead of 2 weeks as we have been doing. The due date will be placed on the Admin Assistant¿s calendar as a reminder to follow up with the staff member if the results of the TB test were not yet received. The HR Director will be responsible for overseeing that TB tests are completed on time. A new electronic monitoring system will be purchased this fiscal year 2017/2018 as part of our time attendance system. This will give the agency electronic reminder capability for TB test due dates. 07/11/2017 Implemented
2380.127(a)(1)Individual #1 received medications administered via g-tube from staff at program beginning on 11/28/2016. No training was completed by individual's physician until 1/12/2017. One staff member received this training on 1/12/2017 (this specific staff person no longer works at facility), then this staff member trained other program staff memembers. Training was not completed by a medical professional. Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: A licensed physician, licensed dentist, certified physician¿s assistant, registered nurse or licensed practical nurse.We looked into medical provider options for training but have not been able to locate a medical professional at this time who is able to provide the training. Since it is not logistically possible for us to have staff trained, we will cease providing medication by Gtube. Her mother is going to continue giving her medication by Gtube at alternative times outside of day program hours since the mother determined this to be acceptable. 6/22/17 was the last day staff gave meds to Individual #1. Her mother removed all medication from the day program. The Program Manager and Executive Director will monitor for compliance. 06/22/2017 Implemented
2380.128(d)Staff #2 completed the Medication Administration Course on 11/21/2014 and 12/22/2015, and none since, yet she has been passing medications.A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.Staff member #2 was scheduled for the July 2017 Medication Training session so she can be certified again to administer meds. She was also instructed not to give medications until after she passes the Medication Training course. On 6/29/17, Sarah Ronk, Medication Administration Trainer for the agency, emailed all managers and the Executive Director to alert them that she had created a spreadsheet that listed all medication trained staff. The spreadsheet contains all staff certification dates. This spreadsheet was shared with all managers and the Executive Director as a reminder system for both the managers and the Executive Director as to when staff are due for recertification. This will ensure that certifications occur prior to the deadlines. The Program Managers, Medication Trainers, and Executive Director will all be responsible for monitoring for compliance. 06/29/2017 Implemented
2380.172(b)Individual #2's physical dated 6/10/2016 had information crossed out in the diet section, and somone wrote in regular. No date was present. Initials were present, but not legible.Entries in an individual¿s record shall be legible, dated and signed by the person making the entry.Correction can not be be made since it appears the initials next to the crossout were added by the previous Program Manager who no longer works at J & F. Program Specialists were informed by the Executive Director on 7/5/17 that any cross outs require one line through the word, a legible signature of the person crossing out a word, and the date the cross out occurred. The Program Manager and Executive Director will monitor for compliance. 07/05/2017 Implemented
2380.173(7)ISP in Individual #2's record did not contain the most current ISP.Each individual¿s record must include the following information:  A copy of the current ISP.The Program Specialist printed out the most recent ISP on 7/6/17 and placed a copy in the file. Quarterly file checks will take place by the Program Specialists to ensure the most recent ISP has been printed out and filed in the individual file. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.173(9)Individual #2's ISP indicated individual can be unsupervised up to 15 minutes before staff need to check on him. Individual's current assessment indicates individual can be unsupervised at day program for up to 15 minutes with periodic checks. ISP reviews state individual is unsupervised up to 15 minutes followed by periodic checks. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Specialist updated the Assessment and Review on 7/6/2017 and mailed to team members on 7/7/2017. Program Specialist will use the same wording in all Assessments and Reviews so it matches the ISP. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.181(a)Individual #1's initial assessment dated 2/7/2017 was not completed within 1 year prior to or 60 calendar days after admission to the facility. Individual #2's assessment was completed on 12/11/2015 and not again until 3/15/2017. 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.This correction is unable to be made since the required date is already past. An entry was added to the Intake Interview Summary that indicates the date the Initial Assessment is due. Both Program Specialists and the Program Manager will place the due date on their calendars as a reminder as well. Program Specialists reviewed the new procedure of adding the Initial Assessment due date to the Intake Interview Summary and adding the date to calendars as a reminder, with the Program Manager and the Executive Director on June 30, 2017. The Program Manager and Executive Director will monitor for compliance. 06/30/2017 Implemented
2380.181(e)(12)Individual #1's assessment dated 2/7/2017 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program Specialist created an addendum to the assessment with recommendations on June 22, 2017. The Addendum was mailed out on July 3, 2017. Quarterly file checks will take place by the Program Specialists to ensure all sections of the sections are completed in Assessments. Program Specialists reviewed the requirement that all sections of Assessments need to be filled out, with the Program Manager and the Executive Director on June 30, 2017. The Program Manager and Executive Director will monitor for compliance. 06/22/2017 Implemented
2380.181(e)(13)(i)Individual #3's assessment dated 12/12/2016 did not include progress and growth in the area of health. Information was verbatim of 12/2/2015 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The Program Specialist completed the addendum on 7/6/2017 for the Health section of the 12/16/16 Assessment and mailed it out on 7/7/2107. In the future, Program Specialists will read the previous year¿s Assessment and physical exams prior to completing a new Assessment in order to gather all updated data and provide the annual updates for all sections of the assessment. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.181(e)(13)(ii)Individual #2's assessment dated 3/15/2017 did not include progress and growth in the area of motor and communication skills. Information was verbatim of previous year's assessment. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Program Specialist completed an addendum on 7/6/2017 for the Motor & Communication section of the Assessment dated 3/15/17 and mailed it out on 7/7/2017. In the future, the Program Specialist will read the previous year¿s Assessment and the current ISP prior to completing a new Assessment in order to gather all updated data to provide the annual updates on Motor & Communication Skills. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.181(e)(13)(iii)Individual #2's assessment dated 12/12/2016 and Individual #3's assessment dated 3/15/2017 did not include progress and growth in the area of personal adjustment. Information was verbatim of previous year's assessments. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Personal Adjustment Sections for Individual #2 (ISP Review dated 3/15/17) and Individual #3 (ISP Review dated 12/12/16) were updated through addendums and mailed to all team members. The Program Specialist completed the addendums on 7/6/2017 and mailed them on 7/7/2017. In the future, the Program Specialists will read the previous year¿s Assessment and the current ISP prior to completing a new Assessment in order to gather all updated data to provide the annual updates on Personal Adjustment. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.181(e)(13)(iv)Individual #2's assessment dated 12/12/2016 and Individual #3's assessment dated 3/15/2017 did not include progress and growth in the area of socialization. Information was verbatim of previous year's assessments. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Socialization Sections for Individual #2 (ISP Review dated 3/15/17) and Individual #3 (ISP Review dated 12/12/16) were updated through addendums and mailed to all team members. The Program Specialist completed the addendums on 7/6/2017 and mailed them on 7/7/2017. In the future, the Program Specialists will read the previous year¿s Assessment and the current ISP prior to completing a new Assessment in order to gather all updated data to provide the annual updates on Socialization. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.181(e)(13)(v)Individual #2's assessment dated 12/12/2016 and Individual #3's assessment dated 3/15/2017 did not include progress and growth in the area of recreation. Information was verbatim of previous year's assessments. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Recreation Sections for Individual #2 (ISP Review dated 3/15/17) and Individual #3 (ISP Review dated 12/12/16) were updated through addendums and mailed to all team members. The Program Specialist completed the addendums on 7/6/2017 and mailed them on 7/7/2017. In the future, the Program Specialists will read the previous year¿s Assessment and the current ISP prior to completing a new Assessment in order to gather all updated data to provide the annual updates on Recreation. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.181(e)(13)(vi)Individual #2's assessment dated 12/12/2016 did not include progress and growth in the area of community integration. Information was verbatim of previous year's assessment. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The Community Integration Section for Individual #2 (ISP Review dated 3/15/17) was updated by the Program Specialist through an addendum on 7/6/17 and mailed to all team members on 7/7/17. In the future, the Program Specialists will read the previous year¿s Assessment and the current ISP prior to completing a new Assessment in order to gather all updated data to provide the annual updates on Community Integration. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.183(3)Individual #2's outcome in his current ISP dated 6/13/2017 did not indicate how day programming staff would monitor progress.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.Program Specialist emailed Supports Coordinator on July 7, 2017 to request the information be added to the ISP that Program Specialist will provide details in Quarterly reports. Quarterly file checks will take place by the Program Specialists to ensure that the Supports Coordinator entered required data. If not, an additional email will be sent to the Supports Coordinator requesting the information be added and a copy of the email will be placed in the individual¿s file.The Program Manager and Executive Director will monitor for compliance. 07/07/2017 Implemented
2380.183(5)Individual #2's ISP did not include a SEEN plan that includes diagnosis, medications, symptoms, behaviors, and how staff are to provide assistance.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The psychotropic medication and psychiatric diagnosis information for the SEEN plan was added to his current behavior plan by the Program Specialist on 7/6/2017. A Special Plan Review will be held quarterly with the Program Specialists and Program Manager to review special plans which include SEEN/Behavior plans to review for psychiatric medication/diagnosis and behavioral updates. The Program Manager and Executive Director reviewed the new procedure on July 5, 2017 with the Program Specialists to implement quarterly meetings. The first Special Plans Review is scheduled for 9/6/17. The Program Manager and Executive Director will monitor for compliance. 07/06/2017 Implemented
2380.185(b)Individual #1's ISP dated 5/8/2017 indicated a seizure protocol is in place at the facility. However, no seizure protocol is present in the record.The ISP shall be implemented as written.The mother of the individual completed and submitted the seizure protocol to the Program Specialist on 6/22/17. The form was added to the file. On July 3, 2017, the Program Specialist added the seizure protocol requirement to the Forms Checklist for Intake to include name of form and date it was received by Jessica & Friends. The Program Manager and Executive Director reviewed the updated form with the Program Specialist on July 5, 2017 to ensure Seizure Protocol was added to the checklist. The Program Manager and Executive Director will monitor for compliance. 06/22/2017 Implemented
2380.186(b)Individual #2's ISP review dated 4/7/2017 was not dated by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.On 7/7/17, the Program Specialist reviewed the ISP Review and dated it. All ISP Reviews will be checked for all individuals in the program to ensure everything is dated. The Program Specialists will complete these reviews no later than September 1, 2017. Thereafter, Quarterly File Reviews will take place by the Program Specialists to ensure all forms are dated properly. The Program Manager and Executive Director will monitor for compliance. 07/07/2017 Implemented
2380.186(c)(1)Individual #2's ISP reviews discuss progress and participation regarding outcomes for hygiene/toothbrushing, phone number, and program participation. Individual's ISP indicates outcomes for independence and sorting, cutting, and organizing. Not able to determine what outcomes this individual is currently working on. The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Program Specialist emailed the York County Supports Coordinator on 7/7/17 asking her to remove the sorting, cutting and organizing outcome phrase from the ISP. The Supports Coordinator responded that she made the change requested. Quarterly file checks will take place by the Programs Specialists to ensure all goals match the Outcomes in the ISP. Program Specialists reviewed the ISP Outcomes and Goal requirements with the Program Manager and the Executive Director on June 30, 2017. The Program Manager and Executive Director will provide oversight to ensure the outcomes and goals match in the ISPs for all individuals in the program. 07/07/2017 Implemented
2380.186(c)(2)Individual #2 has 15 minutes of unsupervised time and a behavior support plan. Neither are reviewed in the ISP reviews. ISP reviews state there is no need for a behavior support plan.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialist clarified the "Need for Supervision" section of the Quarterly Review that was due 4/7/17. Quarterly file checks will be utilized in the future by the Program Specialists to ensure all aspects of the ISP and Support Plans are reviewed in ISP Reviews. Program Specialists reviewed the ISP Review requirements for updating unsupervised time and behavior support plan details with the Program Manager and Executive Director on 6/30/17. The Program Manager and Executive Director will monitor for compliance. 07/07/2017 Implemented
2380.186(d)Individual #2's ISP review dated 10/14/2016 was sent to team members on 10/7/2016, prior to ISP review being completed. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Due to the length of time that has passed since the ISP Review was completed and the previous Program Manager who signed it is no longer employed at Jessica & Friends, a correction is unable to be made to change the discrepancy. Program Specialists reviewed the requirement that date of ISP Reviews and signature with dates needs to match, with the Program Manager and the Executive Director on June 30, 2017. Quarterly file checks will take place by the Program Specialists to ensure all dates for ISP Reviews do not occur prior to the review. The Program Manager and Executive Director will provide oversight to ensure that mailings are completed within appropriate time frames and not prior to ISP Reviews. 06/30/2017 Implemented
Article X.1007Staff #4's criminal history check dated 7/21/2016 stated under review for control, and no final report was present in the record.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.A copy of staff member #2¿s criminal clearance was received on 6/29/17 and placed in her personnel file. The Executive Director reminded the HR Director on 7/10/17 to check that any criminal clearances received that indicate they are ¿under review¿ need to be followed up on within 2 weeks to ensure a final document is received and filed in personnel files. The HR Director will monitor for compliance. 06/29/2017 Implemented
SIN-00094889 Renewal 05/31/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)A cup of laundry detergent, that contained a lable to contact poison control center if ingested, was found unlocked and accessible to individuals in the laundry room. Many individuals, including Individuals #1 and #2, in the program were assessed to be unsafe around poisonous materials. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Arianna McClane, Program Manager immediately locked up detergent cup. Arianna will continue to ensure that all poisons are properly secured in a locked area or made inaccessible. This will be done through routine walk throughs and monthly safety checks. Direct support staff have been reminded to keep all poisons, and any utensil or container used to disperse them, in locked cabinets in their perspective rooms. Direct support staff were also reminded that any item which states poison control needs to be locked up as well as any item that would be in contact with the poison through its use. 05/31/2016 Implemented
2380.58(b)A 3 foot diameter chunk of floor was missing from the entryway into the main program area. Individual #5's Individual Support Plan indiciated that he has an unsteady gait due to depth perception, may have difficulty walking, and has a walker to use at program when he's walking. The missing piece of flooring created a tripping hazard. There was also a small square of carpet placed over the hole, creating a second tripping hazard for those individuals using walking devices at the program. Floors, walls, ceilings and other surfaces shall be free of hazards.Arianna McClane, Program Manager, contacted a contractor to repair the floor. The area of the floor which was in need of repair has been filled in and is no longer a tripping hazard. Arianna will check all areas of all floors to ensure they are free from hazards while doing monthly safety checks. Direct support staff have also been reminded to report any safety issues or hazards immediately to the Program Manager. 07/08/2016 Implemented
2380.82The exit door in the lunch room was locked. The locked door contained a lock that needed to be opened with a key from the inside. Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Arianna McClane, Program Manager immediately unlocked door. Manager has only key to lock this door and it will remain unlocked interiorly. Arianna met with all direct support staff to remind them of the importance of maintaining unlocked doors due to their use as fire exits. She and staff will maintain regular checks of doors during program hours to ensure that they are unlocked. 05/31/2016 Implemented
2380.111(c)(4)Individual #1's physical exam completed on 2/18/16 did not include a vision and hearing screening. This field was left blank on the exam form.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Arianna McClane, Program Manager filled in unmarked sections of physical using data from previous physicals, personal encounters, and the ISP. Arianna also contacted the house manager for Individual #1 to receive further confirmation of the information. Going forward, when physicals are turned into the Program Manager/Program Specialist, they will be reviewed thoroughly for completeness. If any information is found to be missing from the physical then the family/provider/doctor will be contacted in order to obtain the missing information. Sandy Myers, CEO, will implement routine checks of random samples of physicals to ensure they have all required information completed. This will include checking for any information related to hearing and vision screenings as well as other regulatory required information. There will also be checks to ensure all blanks are filled in with information. Any findings of missing sections or missing information will be relayed to the Program Specialist to ensure completion. 05/31/2016 Implemented
2380.111(c)(5)Individual #3 had a tuberculin skin test completed on 9/13/13. There was no documentation that he had another tuberculin test with negaitve results completed since then. 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.Davan Chance, Program Specialist, obtained an updated form with the TB testing and result from the physician. This was placed in Individual #3¿s file the day of inspection. Going forward, when physicals are turned into the Program Specialists, they will be reviewed thoroughly for completeness. If any information is found to be missing from the physical then the family/provider/doctor will be contacted in order to obtain the missing information. In an occurrence when the TB test is not completed by the due date, the individual will be suspended from programming until it is completed and turned in. Sandy Myers, CEO, will implement routine checks of random samples of physicals to ensure they have all required information completed. This will include checking for any information related to tuberculin skin testing with negative results or a chest x-ray with results as well as other regulatory required information. There will also be checks to ensure all blanks are filled in with information. Any findings of missing sections or missing information will be relayed to the Program Specialist to ensure completion. 05/31/2016 Implemented
2380.122aIndividual #2 had a seizure disorder and was prescribed Diastat. Diastat available for Individual #2 at the program, did not contain a medication label. The Diastat was stored in a clear, plastic continer with his name written on the container in black marker. Prescriptions for medications may be written by a certified registered nurse practitioner as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners). The label on the original container must include the name of the prescribing practitioner.Arianna McClane, Program Manager, will ensure all medications have proper pharmacy labels which contain all necessary information. The protocol will be that when medication is brought into the program, it will be checked for a label that includes all information required by regulation. This check will be done again when new medication administration records are completed monthly. Sandy Myers, CEO, will implement a system to complete routine checks of random samples of medication labels. These checks will occur to ensure that all regulatory required information is contained on all medication labels. Any missing information will be made known to the Program Specialist in ordered to be corrected. 07/08/2016 Implemented
2380.124(a)Individual #4 was prescribed Nateglinide 120mg, take 1 tablet by mouth 3 times per day, half an hour before meals. The medication logs for Individual #4 did not indicate that the medication was to be taken 3 times per day. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.Arianna McClane, Program Manager will ensure that medication administration records have included as part of the dosage information the strength/amount of the medication and the frequency of the medication. When medications are brought into day program, the labels will be first checked to ensure that all the proper information is on the label. If the information is not there, the family/provider will be contacted to correct this situation. The information on the label will be used to complete the medication administration record. Every month when medication administration records are updated, the information on the label and on the MAR will be checked again. Sandy Myers, CEO, will implement a system to complete routine checks of random samples of medication administration records. These checks will occur to ensure that all regulatory required information is contained on all MARs. Any missing information will be made known to the Program Specialist in ordered to be corrected. 07/01/2016 Implemented
2380.173(1)(iv)Individual #3's record did not include his religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.Davan Chance, Program Specialist, has corrected the record of individual #3 to indicate religious affiliation. As part of the intake process, Program Specialists will ensure to ask this question of the individual, family, or provider to have information related to religious affiliation. When the individual, family, or provider indicates no religious affiliation or prefers not to discuss this, then the individual¿s record will indicate this by being marked not applicable or none. Sandy Myers, CEO, will implement a procedure to routinely complete checks of random samples of individuals records to make sure all necessary information for compliance is included in the record. If there is content missing in the individual record, this shall be communicated to the Program Specialist in order to have it corrected. 05/31/2016 Implemented
2380.173(1)(v)Individual #2's record did not include a dated photograph. Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Arianna McClane, Program Manager, corrected this non-compliance by returning the current, dated photograph into Individual #2¿s record as it had fallen out of the file and was in the locked cabinet. Sandy Myers, CEO, will implement a procedure to routinely complete checks of random individual records to ensure proper content is in each record. Any missing content will be reported immediately to the Program Specialist to be corrected 05/31/2016 Implemented
2380.173(7)The most current copy of Individuals #2 and #3's Individual Support Plan (ISP) was not in their record. Each individual¿s record must include the following information:  A copy of the current ISP.Arianna McClane and Davan Chance, Program Specialists, will ensure the most current ISP is in each individual file. At critical revision meetings, Program Specialists will collect information from the ISP which is not current or relevant as well as information which needs to be added or collected and provide this information to the SC in a written format. A copy of this information with be added to the individual record with the Program Specialists¿ signature and date attached to support the updating of the ISP until the corrections, deletions, or additions are updated and approved by the SCO. Sandy Myers, CEO, will conduct routine reviews of random samples of individual records. During these reviews, ISP¿s will be checked to ensure they are current. 05/31/2016 Implemented
2380.173(9)-Individual #1's 3/28/16 assessment indicated that she required line of sight supervision at all times at day program. Her Individual Support Plan (ISP) indicated that she only required line of sight supervision at day program when she was using the bathroom and out on community outings. Her ISP indicated that she did not have any allergies. Her physical indicated that she had seasonal allergies. -Individual #2's physical completed on 8/10/15 indicated that Benadryl has caused seizures in the past. The allergy section of his ISP only indicated that he had seasonal allergies. -Individual #5's ISP indicated that he is unsteady at times and has a walker that he has when he is walking at day program. His assessment indicated that he uses a walker when outside of the building or unfamiliar settings. He rarely uses it in the program area. His assessment also indicated that he is visually supervised in the day program and staff check on him every 15 minutes. It also says he can be left alone for 15 minutes at a time. His ISP indicated that his supervision is a 1:6, staff to individual, ratio. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Arianna McClane, day program manager, emailed SC for Individual #1 on 7/6/2016 with noted discrepancies and information to be added/changed in ISP. Copy of email printed and filed behind ISP in her record. Arianna McClane, day program manager, emailed SC for Individual #2 on 7/6/2016 with noted discrepancy and information to be added/changed in ISP. Copy of email printed and filed behind ISP in his record. Arianna McClane, day program manager, emailed SC for Individual #5 on 7/6/2016 with noted discrepancies and information to be added/changed in ISP. Copy of email printed and filed behind ISP in his record. Sandy Myers, CEO, will conduct routine checks of random samples of individual records to review content in ISP to ensure there are no discrepancies. Any issues or concerns found in ISP¿s of an individual will be reported to the Program Specialist and to the Supports Coordinator. The SC will be notified via email. The email will be printed out and placed in the individual record to show the discrepancy was noted and asked to be corrected. This will also be done in conjunction with assessment completion and once the approved ISP is available by the Program Specialist. 07/06/2016 Implemented
2380.181(d)The program specialist did not sign or date any individual's assessments. The signature and date was prepopulated by a non-secure network. The program specialist shall sign and date the assessment.Arianna McClane and Davan Chance, program specialists, will date each assessment at time of signing by individual and program specialist. Sandy Myers, CEO will conduct routine examinations of random samples of assessments to ensure the Program Specialist sign and date the assessments. Any non-compliance will be reported to the Program Specialists for correction. 07/07/2016 Implemented
2380.181(e)(13)(ii)Individual #1's 3/28/16 assessment did not include progress and growth in motor and communication skills. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Arianna McClane and Davan Chance, program specialists, will seek to add more detail to this section of the assessment to better encompass the individual¿s performance in each area. Program Specialist will be thorough in the assessment of the individual¿s progress in each of the noted areas including details throughout the past year. Sandy Myers, CEO, will conduct random, routine checks of individual¿s assessments to ensure that areas that must include progress are fully explained. When progress is not fully noted or explained, the Program Specialist will be notified to ensure completeness in these sections. 07/07/2016 Implemented
2380.181(e)(13)(iv)Individual #1's 3/28/16 assessment did not include progress and growth in socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Arianna McClane and Davan Chance, program specialists, will seek to add more detail to this section of the assessment to better encompass the individual¿s performance in each area. Program Specialist will be thorough in the assessment of the individual¿s progress in each of the noted areas including details throughout the past year. Sandy Myers, CEO, will conduct random, routine checks of individual¿s assessments to ensure that areas that must include progress are fully explained. When progress is not fully noted or explained, the Program Specialist will be notified to ensure completeness in these sections. 07/07/2016 Implemented
2380.181(e)(13)(v)Individual #1's 3/28/16 assessment did not include progress and growth in recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Arianna McClane and Davan Chance, program specialists, will seek to add more detail to this section of the assessment to better encompass the individual¿s performance in each area. Program Specialist will be thorough in the assessment of the individual¿s progress in each of the noted areas including details throughout the past year. Sandy Myers, CEO, will conduct random, routine checks of individual¿s assessments to ensure that areas that must include progress are fully explained. When progress is not fully noted or explained, the Program Specialist will be notified to ensure completeness in these sections. 07/07/2016 Implemented
2380.183(5)Individual #1's Individual Support Plan (ISP) did not include a protocol to address her social, emotional and enviornmental needs. She was prescribed Carbmazepine, Seroquel, Fluvoxamine, Lamotrigine, and Impramine for Mood Disorder, Bipolar Disorder, and Obessive Compulsive Disorder. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Arianna McClane, program manager, has emailed the complete SEEN plan for Individual #1 to SC for inclusion in her plan on 7/6/2016. This email has been printed and added to her file. Program Specialists will review ISP¿s for content of SEEN plans when completing assessments and once they have received the approved ISP. Any information that is missing or incorrect in the ISP related to the SEEN plan will be reported to the SC through an email. The email will be printed and placed in the individual record to indicate that this information was given to the SC by the Program Specialist. Sandy Myers, CEO, will conduct routine checks of random samples of individual¿s records specific to content in the ISP and the SEEN plans. If there are any discrepancies noted or missing information related to the SEEN plan, the Program Specialists will be notified and asked to send corrections or information to the SC. 07/06/2016 Implemented
2380.183(7)(i)Individual #2's Individual Support Plan (ISP) did not include his potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.Arianna McClane, Program Manager has contacted the SC to update the information related to potential to advance in vocational programming and competitive community-integrated employment. Individuals #2¿s updated ISP was received 6/15/2016 and included an excerpt addressing his potential to advance in vocational programming and competitive community-integrated employment. An email was sent on 7/7/2016 as well to improve the wording of this excerpt. This email has been printed and added to his file. Sandy Myers, CEO, will conduct routine examinations of random individual records to ensure compliance with content in the ISP related to potential to advance as well as other content. Any discrepancies or missing information will be relayed to the program specialist to be communicated to the supports coordinator. 07/07/2016 Implemented
2380.183(7)(iii)Individual #2's Individual Support Plan (ISP) did not include his potential to advance in competitive community-integrated employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.Arianna McClane, Program Manager has contacted the SC to update the information related to potential to advance in vocational programming and competitive community-integrated employment. Individuals #2¿s updated ISP was received 6/15/2016 and included an excerpt addressing his potential to advance in vocational programming and competitive community-integrated employment. An email was sent on 7/7/2016 as well to improve the wording of this excerpt. This email has been printed and added to his file. Sandy Myers, CEO, will conduct routine examinations of random individual records to ensure compliance with content in the ISP related to potential to advance as well as other content. Any discrepancies or missing information will be relayed to the program specialist to be communicated to the supports coordinator. 07/07/2016 Implemented
2380.185(b)Individuals #2, #3, and #6's Individual Support Plan (ISP) indicated that they were not safe around sharp objects and they they should be locked. There was two pairs of scissors in an unlocked and accessible drawer in the program area and exercise area. The ISP shall be implemented as written.Arianna McClane, Program Manager, immediately collected the scissors in the program area and has them in an inaccessible, locked area. All sharps, including knives, scissors, and gardening shears have been secured in cabinets with keyed locks. This has been added to the monthly safety checklist to ensure compliance. All staff were re-trained on compliance with this regulation and reminded to be aware of where sharps are located and to ensure they are kept locked away. 05/31/2016 Implemented
2380.186(c)(2)The Individual Support Plan (ISP) reviews for Individual #1 did not review her behavior support plan or her protocol to address her social, emotional, and environmental needs. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Arianna McClane, Program Specialist, will be responsible for reviewing each section of the ISP in the ISP review including information related to the SEEN Plan. An addendum was made to Individual #1¿s ISP review to further review her SEEN plan. This addendum was printed and added to her file. Program Specialist will ensure complete review of each section of the ISP is included in each ISP Review. Sandy Myers, CEO, will complete routine reviews of random samples of individual ISP reviews to ensure that all areas of the ISP are reviewed in completion and thoroughly. 07/07/2016 Implemented
2380.186(c)(4)(iii)The Individual Support Plan (ISP) review for Individual #1 that was completed on 1/26/16 indicated that her outcomes of safety skills, exercise, and personal informtional were discontinued. Another outcome was not recommended by the program specialist. The ISP review must include the following: The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made.Upon discontinuation of a goal, Arianna McClane and Davan Chance, program specialists, will promptly provide written documentation to SC¿s and include recommendations for modification of the outcome or revision of the goal to promote progress in the future. Sandy Myers, CEO, will complete routine reviews of random individual records to ensure progress is being made on outcomes or if progress is not being made to ensure that Program Specialists are addressing this and communicating the decision made regarding the modification of the outcome to the Supports Coordinator. 06/30/2016 Implemented
SIN-00073741 Renewal 03/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Staff #1 did not have 24 hours of training in human services. The training year was August 2013 to July 2014. 12.75 Hours were a repeat training of policy and procedures and orientation. Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.Program manager will review training files with human resources department to verify 24 hours of relevant human services training has been completed. They will work together to ensure that repeated and ineligible training (such as policies) are not counted. Also, orientation and shadowing will no longer be counted as training hours. 03/20/2015 Implemented
2380.62There were no emergency numbers by the phone near the first desk located next to the filing cabinet. 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 telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were posted by the phone near the first desk located next to the filing cabinet. The program specialist has added the safety checklist to the monthly calendar as a reminder to check for this. The safety checklist had an additional item added which is to check each phone for posting of required emergency numbers. 03/20/2015 Implemented
2380.187Individual #1's ISP was not to team members within 30 calendar days after the ISP annual update. The meeting was held on 10/14/14 and the ISP was sent on 1/5/15. A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP annual update and ISP revision meetings.Following an individual's ISP meeting (annual updates, revision meetings), the program specialist will send a compulsory email or written correspondence to remind the supports coordinator that documentation must be received within 30 days of the meeting in order to remain in compliance. If the program specialist does not receive the documentation following the meeting, these attempts will continue to be made to obtain the necessary documentation. Copies of these attempts (email, written correspondence, case notes of phone calls) will be documented, printed, and filed in the individual's file. 03/23/2015 Implemented
SIN-00063054 Renewal 04/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(e)Staff #2 and Staff #4 were not trained in fire safety before working with the Individuals. Staff #2 was trained on 3/14/14 and began working with Individuals on 3/11/14. Staff #4 was trained on 11/7/2013 and began working with Individuals on 10/4/2013.Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Plan of Action: HR compliance officer will change the ordering of the orientation packet to execute fire safety training following reading of paper handouts and prior to tour of program area. HR compliance officer will include a note at the top of the orientation packet to remind managers that general orientation and program training must be completed prior to working directly with clients. Managers will ensure all parts of general orientation and program training are completed prior to directly working with clients. 06/01/2014 Implemented
2380.36(f)Staff #1 did not complete fire safety training in the regulatory timeframe. She was trained on 6/7/2012 and not again until 6/21/2013.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Plan of Action: HR compliance officer will change the ordering of the orientation packet to execute fire safety training following reading of paper handouts and prior to tour of program area. HR compliance officer will include a note at the top of the orientation packet to remind managers that general orientation and program training must be completed prior to working directly with clients. Managers will ensure all parts of general orientation and program training are completed prior to directly working with clients. 06/01/2014 Implemented
2380.181(e)(13)(iii)REPEAT. The assessment for Individual #1 did not include progress and growth in the areas of personal adjustment, socialization, recreation, and community-integration. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. (iii) Personal adjustment. (iv) Socialization. (v) Recreation. (vi) Community-integration. Plan of Action: Program director has created a modified progress and growth section (see attachment A) to model subsequent entries after and shared this document electronically with the program manager and program specialist. Program director modified the progress and growth section for the individual¿s assessment that was reviewed during licensing (see attachment B). Both program manager and program specialist will use the created outline as a basis for subsequent assessments. 06/01/2014 Implemented
2380.183(5)The ISP for Individual #2 did not include his behavior support plan. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Plan of Action: Program director created an ISP checklist (see attachment D), which has been shared electronically with program manager and program specialist. Program manager and program specialist will use checklist to review ISP. Program manager and program specialist will email any omissions or incorrect data to the client¿s support coordinator. Program manager and program specialist will print email and include it in ISP section of the client¿s binder. 06/01/2014 Implemented
SIN-00079201 Change in Location Capacity 05/28/2015 Compliant - Finalized