Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263405 Renewal 03/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility had an annual fire safety inspection completed on 01/29/24 and then again on 02/19/25. This exceeds the annual requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.A Fire Safety Inspection for the MCAR Facility was completed on February 19, 2025. 02/19/2025 Implemented
SIN-00204563 Renewal 05/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's physical examination conducted on 03/28/22 did not include a hearing screening. This section of the form was blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #1 did have a hearing screening completed on 3/28/22 during the initial physical. The physician did not check the box. Hearing is normal with the box checked, signed and dated 5/24/22 by individual #1 physician. The Program Specialist has been retrained on 2380 physical regulations and requirements on 5/23/22. The Program Specialist will review all physicals on the caseload prior to 6/15/22. [Updated physical exam for Individual #1 that includes hearing screening, dated 5/24/22, received 6/17/22 and reviewed on 6/23/22. Training for Program Specialist, dated 5/24/22, received 6/17/22 and reviewed on 6/23/22. DPOC by HDKP, HSLS, on 6/23/22]. 05/24/2022 Implemented
2380.111(c)(5)Individual #1's physical examination conducted 03/28/22 had a Tuberculin skin test completed on 03/31/22; however, the results of the test were not signed or initialed and did not indicate the credentials of the person completing the reading, therefore compliance could not be measured.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 for individual #1 has followed up with the physician in regards to the TB reading. The physician did read the negative result on 3/31/22. He has signed and dated this correction on 5/24/22. The Program Specialist has been retrained on 2380 physical regulations and requirements on 5/23/22. The Program Specialist will review and correct all physicals on the caseload prior to 6/15/22. [Updated physical exam for Individual #1 that includes a review of the Tuberculin evaluation, dated 5/24/22, received 6/17/22 and reviewed on 6/23/22. Training for Program Specialist, dated 5/24/22, received 6/17/22 and reviewed on 6/23/22. DPOC by HDKP, HSLS, on 6/23/22]. 05/24/2022 Implemented
2380.113(c)(2)Program Specialist #1's physical examination conducted 02/22/22 had a Tuberculin skin test completed on 02/24/22; however, the results of the test were not signed or initialed and did not indicate the credentials of the person completing the reading, therefore compliance could not be measured.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.Program Specialist #1 did have the negative Tuberculin test read by the providers Nursing Director on 2/24/22. This has been signed and noted on the physical by the Nursing Director. All employee physicals have been reviewed for completeness. [Updated physical exam for Program Specialist #1 that includes an initialed tuberculin evaluation, dated 2/24/22, received 6/17/22 and reviewed on 6/23/22. Training for Program Specialist, dated 5/24/22, received 6/17/22 and reviewed on 6/23/22. DPOC by HDKP, HSLS, on 6/23/22]. 05/24/2022 Implemented
SIN-00187544 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's record did not contain a Tetanus immunization. Tetanus booster shots are recommended by the Unites States Public Health Service, Center for Disease Control every 10 years.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 will have a new physical and tetanus immunization completed prior to returning to the 2380 licensed facility and will be compliant with 2380.111(c) (3). Requiring a tetanus immunization every 10years. [Individual #1 Tetanus immunization verified on 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. 05/27/2021 Implemented
2380.111(c)(5)Individual #1 had a Tuberculin skin test by Mantoux method on 12/14/17 and then again on 03/12/20. Individual #2 had a Tuberculin skin test by Mantoux method on 02/16/18 and then again on 03/05/20.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.Individual #1 will have a new annual physical and Tuberculin Skin Test this year prior to resuming service in the 2380 Facility. this will bring him compliant with 2380. 111 (c) (5). Individual #2 will have a tuberculin skin test completed prior to the annual physical and read during the annual physical keeping both on the same date and compliant with 2380. 111 (c) (5) [Individual #1 and Individual #2 tuberculin evaluations verified 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. 05/27/2021 Implemented
2380.111(c)(7)Individual #1's physical examination, dated 01/14/20, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section of the physical examination was left blank. Individual #1's physical examination, dated 01/14/21, did not include an assessment of the individual's medication regimen. This section of the physical examination states "see attached;" however, no medication list was attached to the examination form.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.Individual #1 will have a new physical this year prior to services resuming in the 2380 facility. This physical will be completed and compliant to 2380. 111 (c) (7) showing an assessment of the individual's health maintenance needs along with needed blood work times. A life time medical history showing will be attached to the physical form prior to the physical and returned to the program specialist. [Individual #1's health maintenance needs and needed bloodwork at recommended intervals verified 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. 05/27/2021 Implemented
2380.111(c)(8)Individual #1's physical examination, dated 01/14/20, did not include physical limitations. This section of the physical was left blank.The physical examination shall include: Physical limitations of the individual.Individual #1 will have a new physical completed prior to resuming services this year. All areas will be completed by the medical professional including physical limitations. [Individual #1's physical limitation were verified on 7/15/21. DPOC by HSKP, HSLS, on 7/16/21]. 05/27/2021 Implemented
2380.111(c)(10)Individual #1's physical examination, dated 01/14/20, did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1 will have a new physical completed prior to resuming services this year. All areas will be completed by the medical professional including all medical information related to diagnosis and treatment in case of an emergency situation. [Individual #1's physical verified on 7/15/21. All required information was obtained. DPOC by HDKP, HSLS, on 7/16/21]. 05/27/2021 Implemented
SIN-00241747 Renewal 03/27/2024 Compliant - Finalized
SIN-00223009 Renewal 04/18/2023 Compliant - Finalized
SIN-00165523 Renewal 11/05/2019 Compliant - Finalized