Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282753 Renewal 01/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)According to the written fire drill record submitted from 3/28/25 to 12/4/25, the facility's drills conducted on 4/14/25 and 8/27/25 did not document whether the fire alarm was operative, as the corresponding field that read, "Was the fire alarm operative?," was unaddressed.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.fire safety coordinator went back to the fire drill records and marked the box on 'was fire alarm operative" for the fire drill records for 4/14/2025 and 8/27/2025 (this was just an oversight). 02/24/2026 Implemented
2380.111(c)(10)Individual #4's current physical examination, completed on 2/27/25, did not include medical information pertinent to diagnoses and treatment in case of an emergency, as the corresponding field was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.individual #4 has his next annual physical scheduled for 3/2/2026. family/caregiver will be made aware of the information that was missing from 2025 physical. 02/24/2026 Implemented
2380.181(e)(11)Individual #2's Service Plan, last updated 12/17/25, indicated that Individual #2 had a psychological evaluation completed on 11/2/09. However, Individual #2's content of records included neither such an applicable psychological evaluation, nor documentation of the agency's request to obtain one.The assessment must include the following information: Psychological evaluations, if applicable.program director emailed the request for psychological evaluation to individual #2's supports coordinator on 2/5/2026 02/25/2026 Implemented
2380.181(e)(12)Individual #1's current assessment, completed on 9/16/25, did not provide recommendations for specific areas of training, vocational programming, and competitive community-integrated employment to promote skill growth, as the assessment's corresponding field contained brief comments on Individual #1's current prompting levels across various domains and present maladaptive behavior. Individual #2's current assessment, completed on 9/16/25 and last updated on 11/24/25, did not provide recommendations for specific areas of training, vocational programming, and competitive community-integrated employment to promote skill growth, as the assessment's corresponding field contained brief comments on Individual #2's current prompting levels across various domains and present maladaptive behavior. Individual #3's current assessment, completed on 9/4/25, did not address recommendations for specific areas of training, vocational programming, and competitive community-integrated employment to promote skill growth. Individual #4's current assessment, completed on 10/31/25, did not address recommendations for specific areas of training, vocational programming, and competitive community-integrated employment to promote skill growth.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The program specialist had a meeting with the program director, 2/26/2026, about the assessments needing to include recommendations for specific areas of training. program specialist reviewed and updated the assessments for Individuals 1,2,3, and 4. to include areas for training. Individuals 1,2,3, and 4 do not wish to pursue community integrated employment at this time. 02/26/2026 Implemented
2380.36(a)Direct Service Woker #2's date-of-hire is 3/10/25, and their first day working with individuals occurred on 3/27/25. However, Direct Service Worker #2's initial fire safety training was completed between 4/24/25 and 4/25/25.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.direct service worker #2 did receive initial fire safety as part of their orientation process before working with individuals but did not include all of the information in their orientation summary. program director has developed a more specific form for new hire orientations that will be completed. 02/05/2026 Implemented
2380.38(b)(5)Direct Service Worker #1's date-of-hire is 9/22/25. Direct Service Worker #1's orientation, completed from 9/22/25 to 10/3/25, contained no documentation of completing training in the required content area of job-related knowledge and skills regarding individual specific reviews of service plans and behavior support plans. Direct Service Worker #2's date-of-hire is 3/10/25. Direct Service Worker #2's orientation, completed from 3/10/25 to 3/17/25, contained no documentation of completing training in the required content area of job-related knowledge and skills regarding individual specific reviews of service plans.The orientation must encompass the following areas: Job-related knowledge and skills.direct service worker #1 and #2 did receive training in job related skills but did not include this documentation in their orientation summary. the program director developed a new staff orientation check list that includes specific topics. 02/05/2026 Implemented
2380.182(c)Individual #1's Service Plan, last updated 12/16/25, contained the following discrepancies between their current assessment, completed on 9/16/25, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Service Plan, last updated 12/16/25, stated that, "[Individual #1] may not understand the concept of poisonous substances," that, "Should [Individual #1] use any cleaning products, staff will be within arm's length to assist [them]," and that, "To ensure [Individual #1's] safety, all cleaning supplies are kept locked." In contrast, Individual #1's assessment, completed on 9/16/25, informed, "Yes," meaning that Individual #1 recognizes poisonous materials and relative items; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 12/16/25, explained that, " [Individual #1] is unaware of heat sources or how to protect [oneself] from them" and that, "[Individual #1] should be supervised at all times when in the presence of heat sources." However, Individual #1's assessment, completed on 9/16/25, indicated, "Yes," denoting that Individual #1 independently can avoid dangerous heat sources; regarding water safety, Individual #1's Service Plan, last updated, 12/16/25, did not address their knowledge of water safety or ability to swim. However, Individual #1's current assessment, completed on 9/16/25, indicated that Individual #1 does not understand basic water safety rules and cannot swim; regarding facility supervision, Individual #1's Service Plan, last updated 12/16/25, explained that Individual #1 requires a 1:4 to 1:6 staffing ratio with visual range monitoring and that "[Individual #1] has unsupervised time for [their] daily walking program (inside the building) with staff being in auditory range." However, Individual #1's assessment, completed on 9/16/25, provided no staffing ratios, supervision lengths, or types of monitoring in general while Individual #1 is at the facility, informing only that Individual #1 can utilize the restroom independently; and regarding community supervision, Individual #1's Service Plan, last updated 12/16/25, explained that Individual #1 requires a 1:1 staffing ratio at all times while staff must always be within arm's length. In contrast, Individual #1's assessment, completed on 9/16/25, provided no staffing ratios, supervision lengths, or types of monitoring in general while Individual #1 is out in the community, informing that, "[Individual #1] requires complete supervision when encountering strangers." Individual #2's Service Plan, last updated 12/17/25, contained the following discrepancies between their current assessment, completed on 9/16/25 and last updated 11/24/25, in the following health and safety skill domains: regarding poisonous materials, Individual #2's Service Plan, last updated 12/17/25, stated that, "[Individual #2] [is] unable to safely handle poisonous materials [and] household cleaners." However, Individual #2's assessment, completed on 9/16/25 and last updated 11/24/25, informed, "Yes," meaning that Individual #2 recognizes poisonous materials and relative items; regarding facility supervision, Individual #2's Service Plan, last updated 12/17/25, explained that Individual #2 requires a 1:4 to 1:6 staffing ratio and has unsupervised time (up to five minutes) while using the bathroom. In contrast, Individual #2's assessment, completed on 9/16/25 and last updated 11/24/25, provided no staffing ratios, supervision lengths, or types of monitoring in general while Individual #2 is at the facility; and regarding community supervision, Individual #2's Service Plan, last updated 12/17/25, explained that Individual #2 requires a 1:1 staffing ratio at all times while staff must always be within visual range. In contrast, Individual #2's assessment, completed on 9/16/25 and last updated 11/24/25, provided no staffing ratios, supervision lengths, or types of monitoring in general while Individual #2 is out in the community, informing that, "[Individual #1] requires complete supervision when encountering strangers." Individual #3's Service Plan, last updated 12/15/25, contained the following discrepancies between their current assessment, completed on 9/4/25, in the following health and safety skill domain: regarding water safety, Individual #3's Service Plan, last updated 12/15/25, explained that. "[Individual #3] needs physical assistance with tempering [their] water...to ensure it is not too hot." In contrast, Individual #3's current assessment, completed on 9/4/25, indicated that Individual #3 can safely temper their own water temperature. Individual #4's Service Plan, last updated 1/6/26, contained the following discrepancies between their current assessment, completed on 10/31/25, in the following health and safety skill domains: regarding fire evacuation, Individual #4's Service Plan, last updated 1/6/26, stated that, "During fire drills, [Individual #4] can exit a building/ home with prompting/ reminders to 'exit quickly.'" In contrast, Individual #4's assessment, completed on 10/31/25, indicated that Individual #4 can evacuate the building independently without prompting; and regarding water safety, Individual #4's Service Plan, last updated 1/6/26, informed that Individual #4 is able to temper their own water temperature and can "recognize what would be hot [versus] cold." However, individual #4's assessment, completed on 10/31/25, indicated that Individual #4 cannot safely temper their own water temperature.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Program director and program specialist meet (2/25/2026) to discuss plan of correction for violations. Program specialist changed Individual 1's assessment to state that individual 1 does not recognize poisonous material and needs physical, verbal, gestural prompts. Individual 1 assessment was revised to state individual1 does not avoid heat sources and needs physical, verbal and gestural prompts. Regarding water safety for individual 1 an ISP plan of correction will be sent to the supports coordinator to add Individual 1 does not know how to swim and has no knowledge of basic water safety rules. Plan of correction also has a change in unsupervised time to change unsupervised time for walking program to unsupervised time for bathroom breaks. Program specialist revised the unsupervised form to included supervision for facility, community and restroom. Individual 2 regarding poisonous materials the assessment was changed to state Individual 2 does not recognize poisonous materials and needs physical, verbal prompts. Individual 2's unsupervised time sheet was revised and includes all staffing rations and supervision lengths. Individual 3 assessment was revised to include Individual 3 does not adjust water temperature and needs physical verbal prompts. Individual 4 assessment was revised to included individual 4 needs verbal and gestural prompts to exit during a fire drill. Individual 4's service plan request for a change was sent to the supports coordinator to state that Individual 4 needs Family/caregiver to physically temper his bath/shower water. 03/03/2026 Implemented
2380.183(c)An Invitation Letter, dated 9/15/25, informed that Individual #1's last Annual Review Service Plan Meeting was scheduled for 10/22/25 at 10:00 AM. Agency interviews conducted on 1/30/26 corroborated that such a meeting had occurred on 10/22/25. However, Individual #1's content of records included neither the list of persons who participated in this meeting, nor documentation of the agency's request to obtain a meeting attendance record from the Supports Coordinator.The list of persons who participated in the individual plan meeting shall be kept.program specialist developed a form to document those in attendance at any meeting that they are present. program specialist used the new form to document those in attendance at individual #1's annual review meeting to be part of his record. 02/05/2026 Implemented
SIN-00241504 Renewal 03/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.86At 12:46PM, an operable portable space heater was in the staff office conference room which contained the locked individual records.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices.The portable space heater was immediately removed from the building by director, . 03/25/2024 Implemented
2380.111(c)(4)The most recent vision and hearing screening for Individual #1 was completed on 7/11/2022.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Director,, contacted individual #1's guardian and informed them of the missing information on the recent physical. Director asked the guardian to contact the doctor that completed the physical and ask about the vision and hearing screening. Doctor was contacted and form faxed to the facility stating the vision and hearing screening were completed. 03/25/2024 Implemented
2380.21(u)Individual #1 was informed and explain individual rights on 6/2/22 and then again on 6/6/23.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.Program specialist was informed of the violation and stated that she thought she had a 15-day grace period when a requirement is annually. program specialist was made aware that this was not the case for this violation. Program specialist was told that there is no 15-day grace period and that the information need to be distributed and explained every 365 days or sooner. 03/28/2024 Implemented
2380.39(c)(1)Direct Service Worker #1's annual training hours for 2023 calendar training year did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.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.direct service worker #1's training record was reviewed and director, , believed that some of the areas of noncompliance were trained. direct service worker #1 completed additional training on building and maintaining relationship on my ODP website. Building relationships with deaf/blind individuals and building relationships to strengthen a person's support system. i am enclosing certificates that verify the training areas that were completed previously. 03/25/2024 Implemented
2380.39(c)(3)Direct Service Worker #2's annual training hours for 2023 calendar training year did not encompass Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Direct service worker #2 completed training on Individual rights. 03/26/2024 Implemented
SIN-00186567 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)Program Specialist #1, Direct Service Worker #2 and Direct Service Worker #3 were most recently trained in fire safety training on 2/7/20.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).DUE TO THE COVID 19 PANDEMIC, THE CENTER BEING CLOSED, BULLETIN STATING THAT TRAININGS DUE COULD BE EXTENTED UNTIL 6/30/2021, I BELIEVED THIS TO INCLUDED INDIVIDUALS AND STAFF ONLY TO FIND OUT THAT IT ONLY INCLUDED INDIVIDUALS. WE MISSED OUR ANNUAL DUE DATE FOR FIRE SAFETY. ON 4/26/2021 PROGRAM SPECIALIST #1, DIRECT SERVICE WORKER #2, AND DIRECT SERVICE WORKER #3 COMPLETED THE TRAINING ALONG WITH ALL THE OTHER STAFF AND INDIVIDUALS. INCLUDED THE TWO SAFETY TRAINING VIDEOS FROM THE GREENSBURG FIRE DEPARTMENT TAPE LIBRARY AND DISCUSSION. 04/26/2021 Implemented
SIN-00147138 Renewal 12/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(a)The program specialist completed an ISP review from 4/1/18 to 6/30/18 for Individual #1 on 7/23/18. The program specialist completed an ISP review from 7/1/18 to 9/30/18 for Individual #1 on 10/25/18. The program specialist completed an ISP review from 4/1/18 to 6/30/18 for Individual #2 on 7/23/18. The program specialist completed an ISP review from 1/1/18 to 3/31/18 for Individual #2 on 4/23/18. The program specialist completed an ISP review from 7/1/18 to 9/30/18 for Individual #3 on 10/25/18. The program specialist completed an ISP review from 4/1/18 to 6/30/18 for Individual #3 on 7/23/18. The program specialist completed an ISP review from 7/1/18 to 9/30/18 for Individual #4 on 10/25/18. The program specialist completed an ISP review from 4/1/18 to 6/31/18 for Individual #4 on 7/23/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Moving forward, Program specialist will conduct quarterly ISP reviews with 15 days of the end of the review period for individuals 1,2,3,4, as well as all ISP quarterly for all participants of the YMCA ATF. Due to the nature of the violation this change will be implemented in the next ISP quarterly review that is expected to be January 2019. The program specialist was informed of the time frame change and will make a chart of the expected due dates for all ISP quarterly reviews to be within 15 days of the end of the quarter. Program director will follow up with program specialist to guarantee compliance. [At least quarterly for 1 year, the program director shall audit a 25% sample of ISP reviews to ensure completion, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/2/19)] 01/14/2019 Implemented
SIN-00105390 Renewal 12/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.85There were two aerosol cans of disinfectant deodorant spray approximately one foot from the furnace. The labels on the cans read "extremely flammable, store away from heat and flames".Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.On 1/10/2017 the storage area was rearranged by program supervisor and a staff person. The cleaning supplies and combustibles that were located on the shelves near the furnace were relocated across the room approximately 10 feet away from the furnace, in the locked room. A sign was placed on the shelves near the furnace the states "Do not place flammables or combustibles items on these shelves" Informational training was held on 1/17/2017 by program supervisor to inform all ATF staff of the relocation of the flammable and combustible supplies and equipment. All staff were reminded to monitor the storage area for compliance. The job training supervisor will monitor the storage area daily for one month. Then the job training supervisor will check the area weekly for two months, after the initial month, to maintain compliance. The program supervisor will check the area weekly for a period of one year to maintain compliance. 01/27/2017 Implemented
2380.128(e)Practicum Observer #1 had an initial examination completed on 11/18/10; no additional practicums were completed. Practicum Observer #1 completed the annual medication practicum for Program Specialist #2 dated 4/16/16. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.Medication administration trainer located the information from the medication practicums for the practicum observer in another file that were completed 11/08/2013 and 11/08/2016. Medication trainer developed an excel document that lists the due dates for the practicum observer and the necessary paper work needed for recertification-the practicum observer MAR audits and supervised medication observations, practicum observer examination data summary sheet. Medication administration trainer is to review the medication administration excel documentation monthly to determine if any requirements are need for the month. Program supervisor completed a training with the medication administration trainer on 1/25/2017 to review the medication administration requirements. Program director will review the medication administration process for one year to determine that all the practicum observer requirements are met. 01/27/2017 Implemented
2380.152The restrictive procedure policy did not include a process for the individual and family to review the use of restrictive procedures.A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the facility.Upon implementation of a restrictive procedure the program specialist will document the plan was shared with the individual and/or family. On 1/25/2017 restrictive procedure policy was updated by program supervisor to include. "The individual and family may request to review the restrictive procedure at any time by contacting the program specialist or restrictive procedure committee member by phone or in person." Program specialist will document any time the plan was shared with the individual or family. The program supervisor or program specialist will be responsible to inform the individual or family member of the process to obtain a copy of or to review the restrictive procedure upon implementation of a restrictive procedure. [Program Supervisor will review the restrictive procedure policy to ensure all aforementioned procedures are add and implemented as needed. (AS 1/26/17) 01/27/2017 Implemented
2380.181(e)(1)The assessment dated 3/20/16 for Individual # 3 did not include functional strengths, needs and preferences of the individual. The assessment must include the following information: Functional strengths, needs and preferences of the individual.On 1/24/2017 program specialist updated the assessment of individual #3 to include functional strengths, needs and preferences. On 1/25/2017 program supervisor had a training with the program specialist as to what is required in an assessment: functional strengths, needs, preferences, likes dislikes and interests, functional performance and progress, communication progress and performance, personal adjustment, personal needs, supervision needs, self administration of medications, use of poisonous materials, understanding of heat sources, fire safety, lifetime medical history, psychological evaluation, recommendations for specific areas of training, progress and growth in the following areas: health, motor and communication skills, personal adjustment, socialization, recreation, community integration, knowledge of water safety and ability to swim. Program specialist to review all individual charts to make sure all assessments are complete by 1/27/2017. Program director will review a 25% sample of individuals files quarterly for 1 year to make sure all individuals have a complete assessment. 01/27/2017 Implemented
2380.181(e)(10)The assessment dated 3/20/16 for Individual #3 did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.On 1/24/2017 the program specialist updated individual #3 assessment to include a lifetime medical history. On 1/25/2017 program supervisor had a training with the program specialist as to what is required in an assessment: functional strengths, needs, preferences, likes dislikes and interests, functional performance and progress, communication progress and performance, personal adjustment, personal needs, supervision needs, self administration of medications, use of poisonous materials, understanding of heat sources, fire safety, lifetime medical history, psychological evaluation, recommendations for specific areas of training, progress and growth in the following areas: health, motor and communication skills, personal adjustment, socialization, recreation, community integration, knowledge of water safety and ability to swim. Program specialist to review all charts to make sure all assessments are complete by 1/27/2017. Program director will review a 25% sample of individuals files quarterly for 1 year to make sure all individuals have a complete assessment. 01/27/2017 Implemented
2380.186(b)The ISP reviews dated 9/30/16, 6/30/16, and 3/31/16 for Individual #1 were not signed and dated by the individual. The ISP reviews dated 9/30/16, 6/30/16, and 3/31/16 for Individual #2 were not signed and dated by the individual. The ISP reviews dated 9/30/16 and 6/30/16 for Individual #3 were not signed and dated by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.On 1/25/2017 program specialist had Individual #1, #2, #3 reviewed quarterlies dated 9/30/16, 6/31/16, 3/31/16 and signed and dated the quarterly reviews (along with the rest of the ATF individuals). On 1/10/2017 program specialist revised the quarterly review sheet to include the signature of the individual (previously the signature of the individual was on a verification cover letter-I disagree with this violation) On 1/25/2017 program supervisor reviewed the quarterly review procedure with the program specialist. Information reviewed included the new quarterly review sheet and the need for the individual to sign the quarterly along with the program specialist when it is reviewed. Senior program director will review a 25% sample of individual files quarterly for compliance for a period of 1 year. 01/27/2017 Implemented
2380.186(d)The program specialist did not provided the ISP reviews dated 6/30/16 and 3/31/16 for Individual #1 to the SC. The program specialist did not provided the ISP review dated 3/31/16 for Individual #3 to the SC. 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.On 1/25/2017, program specialist sent quarterlies from 6/30/16 and 3/31/16 for Individual #1, #2, #3 (along with all ATF consumers most recent quarterly) to their SC. On 1/10/2017 program specialist revised the cover letter for the quarterly reviews to include the supports coordinator. On 1/25/17 program supervisor completed training with the program specialist to included who is to receive the quarterly reviews (SC or plan lead and all team member unless they have a signed declination of quarterly reviews in their file). Senior program director will review a 25% sample of individual files for cover letter documentation that the quarterly was sent to team members including the SC for a period of 1 year. 01/27/2017 Implemented
SIN-00087837 Renewal 01/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.57The outside light at the south exit doorway was not operable. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.The outside light was examined by the maintenance director and determined that the light bulb was burnt out. This was replaced 1/15/2016 and a picture will be forwarded. The light switch for the outside light will be labeled, monthly checks will be completed by program director.[Program director will document aforementioned monthly checks and the CEO or designee will review the documentation of check at least quarterly. CEO will develop a policy and procedure for completing needed maintenance and will train staff, maintenance director and program director as to the policy and procedures for maintaining areas that are lighted to assure safety as well as maintaining hazard free conditions. (AS 1/21/16)] 01/24/2016 Implemented
2380.111(c)(7)The physical examination for Individual #1 dated 2/5/15 did not include an assessment of the individual's health maintenance needs.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The program specialist has revised the Annual physical to include a section to document the individuals health maintenance needs, medication regimen, blood work intervals. This was completed on 1/15/2015 and will be forwarded. This will not occur in the future because of the revised form and continued monitoring of the state bulletins by Director and program specialist.[Immediately, Program specialist will review all current physical examinations to ensure required information is present and obtain as need including the information not included in Individual #1's current physical examination. Program specialist will review all new and annual individual physical examinations within 1 week of being submitted to the agency to ensure all required information is documented and will obtain information as needed. CEO will review a 25% sample of physical examinations at least quarterly for 1 year to ensure all required information is present. (AS 1/21/16) 01/24/2016 Implemented
2380.111(c)(10)The physical examination for Individual #1 dated 2/5/15 did not include medical information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The program specialist has revised the Annual physical to include a section to document the medical information pertinent to diagnosis and treatment in case of an emergency. This was completed on 1/15/2015 and will be forwarded. This will not occur in the future because of the revised form and continued monitoring of the state bulletins by Director and program specialist.[Immediately Program specialist will review all current physical examinations to ensure required information is present and obtain as need including the information not included in Individual #1's current physical examination. Program specialist will review all new and annual individual physical examinations within 1 week of being submitted to the agency to ensure all required information is documented and will obtain information as needed. CEO will review a 25% sample of physical examinations at least quarterly for 1 year to ensure all required information is present. (AS 1/21/16) 01/24/2016 Implemented
2380.181(f)The Program Specialist #1 did not provide the assessment for Individual #2 dated 9/5/15 to the SC and plan team members for the annual ISP review meeting on 11/10/15.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 will provide the annual assessment to the supports coordinator or plan lead and plan team members at least 30 calendar days prior to an ISP meeting. Program Specialist has created a chart documenting the annual plan date and a submit assessment date by column.[Program Specialist will maintain correspondence documentation as to when assessments are provided to the SC and plan team for all individuals. The CEO or designee will review tracking chart and correspondence documentation at least quarterly for the next year to ensure PS are providing assessments to SC and plan team as required. (AS 1/21/16)] 01/24/2016 Implemented
SIN-00071544 Renewal 01/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The facility does not have a letter from a fire safety expert within the past year specifying a maximum safe evacuation time. Individuals evacuated the building on January 10, 2014 in 2 minutes and 43 seconds; July 31, 2014 in 2 minutes and 50 seconds and August 27, 2014 in 2 minutes and 45 seconds.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.The Program Senior Director will contact the City of Greensburg fire prevention officer/Director of Code Enforcement Department- Leslie Harvey to evaluate the YMCA ATF Fire Drills and make recommendations. This will be completed by February 27, 2015. In the future, if evacuation time for drills exceeds either 2 and 1/2 minutes or the time specified in writing by the fire safety expert then additional staff will be added to ensure evacuation can be completed within the allotted timeframe. (CHG 2/4/15)] 01/25/2015 Implemented
2380.111(a)Individual #1 had a physical examination completed on February 15, 2013 and March 7, 2014.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The program supervisor will continue to notify the parents/ guardians of upcoming physical exams due date six weeks before they are due by telephone. Another reminder is sent out three weeks before the due date when the form is sent home. If physical not received by the due date then the consumer will be given a suspension notice and be unable to attend program until physical is obtained. Completed 1/22/2015 01/25/2015 Implemented
2380.181(a)Individual #1, date of admission March 18, 2013, had an initial assessment on February 15, 2013 and subsequent annual assessment on April 28, 2014.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 Specialist will develop a chart that is based on the individual consumers ISP Annual Review Update Date. There will be a column that this calculated to be 90 days before the annual review update date. Assessments will be distributed at this time to be completed within 15 days. Program specialist will then review and forward assessment to the casemanager 30 days before the meeting date. This chart will be developed by February 10, 2015. 01/25/2015 Implemented
2380.181(f)Individual #2's ISP meeting was held on June 16, 2014; however, the corresponding assessment was provided to the SC on May 27, 2014.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 will develop a chart that is based on the individual consumers ISP Annual Review Update Date. There will be a column that this calculated to be 90 days before the annual review update date. Assessments will be distributed at this time to be completed within 15 days. Program specialist will then review and forward assessment to the casemanager 30 days before the meeting date. This chart will be developed by February 10, 2015. 01/25/2015 Implemented
SIN-00072192 Unannounced Monitoring 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(17)Individual #1 has an implanted Vagus Nerve Stimulation (VNS) device. According to staff interviews, a magnet used in conjunction with the VNS device at the time of seizure activity may reduce the intensity of a seizure or stop a seizure. Information regarding the use of the magnet with the VNS implant during a seizure was not included in the individual's assessment completed on 10-28-13. On 7-3-14, Individual #1 had a seizure while on an outing with the staff persons of the adult training facility; however, staff person #1 did not bring the magnet with them on the outing. The program specialist did not coordinate the services provided to Individual #1.The program specialist shall be responsible for the following: Coordinating the services provided to an individual.On 12/17/2014 program specialist will review with all staff any special medical needs for the individuals and will develop a master sheet to have available to review when individuals are going on outings. [An individual's special circumstances for community form has been created and implemented. Training on the use of the forms that document special circumstances occurred on 12/17/14. Individual #1 no longer attends the program. (CHG 1/6/15)] 12/18/2014 Implemented
2380.181(e)(9)Individual #1 has an implanted Vagus Nerve Stimulation (VNS) device. According to staff interviews, a magnet used in conjunction with the VNS device at the time of seizure activity may reduce the intensity of a seizure or stop a seizure. Information regarding the use of the magnet with the VNS implant during a seizure was not included in the individual's assessment completed on 10-28-13. On 7-3-14, Individual #1 had a seizure while on an outing with the staff persons of the adult training facility; however, staff person #1 did not bring the magnet with them on the outing. The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.The assessment's part I was revised to include the individual's disability, functional and medical limitations. form updated by the program specialist on 12/15/2014. [An individual's special circumstances for community form has been created and implemented. Training on the use of the forms that document special circumstances occurred on 12/17/14. Individual #1 no longer attends the program. (CHG 1/6/15)] 12/18/2014 Implemented
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SIN-00221656 Renewal 03/30/2023 Compliant - Finalized
SIN-00203825 Renewal 04/20/2022 Compliant - Finalized
SIN-00167328 Renewal 12/10/2019 Compliant - Finalized
SIN-00126894 Renewal 12/27/2017 Compliant - Finalized
SIN-00057900 Renewal 12/20/2013 Compliant - Finalized