| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(a) | Fire drill records show drills were not held during the months of February 2024, August 2024 and September 2024. The fire drill reports for those months indicated that the "drills" were held at times that all individuals were in the community and there were no individuals in the building. | An unannounced fire drill shall be held at least once a month. | Via will ensure that fire drills are conducted when participants are receiving services. At this location there are often times that participants are not at the building, either due to a lower number of individuals receiving services or due to being in the community. That said, we will make sure that fire drills are scheduled with the Program Manager, in addition to the Maintenance Supervisor and Health and Safety lead so that we have a better idea of when participants will be in the building. |
01/06/2025
| Implemented |
| 2380.111(a) | Individual #1 had a physical examination on 5/12/2023, then not again until 6/05/2024 which exceeds the regulatory timeframe. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Via will ensure that the regulation and Via's Physical Exam Acknowledgement Process are followed- which requires that a physical form is required every 365 days with a 15-day grace period. |
01/08/2025
| Implemented |
| 2380.111(c)(3) | The physical examination completed on 6/05/2024 for Individual #1 did not include a tetanus and diphtheria immunization. Individual #1 had last received a tetanus and diphtheria booster on 10/19/2006 which is more than 10 years ago, which is the recommended frequency according to the Centers for Disease Control (CDC).
The physical examination completed on 1/17/2024 for Individual #2 did not include a tetanus and diphtheria immunization. Individual #2 had last received a tetanus booster on 10/11/2013, and a diphtheria booster on 8/31/2006, more than 10 years ago, which is the recommended frequency according to the Centers for Disease Control (CDC). | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Via will review all physical forms, as they come in, to ensure that immunizations are included as part of the physical examination and documented accordingly. |
01/08/2025
| Implemented |
| 2380.111(c)(10) | The current annual physical examination completed on 6/05/2024 for Individual #1 did not include documentation of medical information pertinent to the diagnosis and treatment in case of emergency. The area(s) on the VIA physical examination form where that information would be recorded was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Via will ensure, going forward, that the physical examination will include the required medical information related to emergencies for all individuals supported in the 2380 program. |
01/08/2025
| Implemented |
| 2380.21(u) | Individual #1 was informed of their individual rights, and signed to indicate that they were informed, on 11/14/2024. There was documentation to indicate that the individual was informed of their rights at time of their admission to the facility on 11/16/2023.
Individual #2 was informed of their rights on 5/19/2023, then not again until 6/17/2024 which exceeds the regulatory timeframe. | 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. | Via's Civil, Legal and Human Rights form will now be reviewed with participants upon admission to the agency, when transferring from one department to the 2380 program, and several times throughout the year, at the same time as fire safety training (which occurs minimally twice a year). The increased schedule will ensure this important document is covered at least one time annually. |
12/10/2024
| Implemented |
| 2380.125(f) | Individual #2 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness but did not have a written protocol as part of the individual plan to address the social, emotional and environmental needs (SEEN Plan) of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Via will review the ISP of each person supported in the 2380 program to determine if medications are prescribed to treat the symptoms of a diagnosed psychiatric illness. If so, a request will be emailed to the Supports Coordinator to add language that is appropriate for the social, emotional and environmental needs of the individuals that are being supported. |
01/03/2025
| Implemented |