Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274752 Renewal 10/21/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The fire safety inspection of the facility was not completed in 2024 per a letter from the Hanover Area Fire & Rescue saying they overlooked coming to inspect the facility. The inspection is to be completed annually. The Hanover Area Fire & Rescue did come and inspect the facility on 7/11/25.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.We have added the fire safety inspection date to the outlook calendar for the Program Specialist, the Program Supervisor, the Assistant Director of IDD, and the Director of IDD. A second date was added for May 1st each year to notify us to contact the Fire department to ensure that the fire safety inspection is scheduled within the regulated time frame. The outlook calendar will notify the PC, PS, ADOS, and DOS each May 1st to ensure that the annual inspection is scheduled to be completed on or before 7/11/2025. If it is not already scheduled, the Program Coordinator will call the fire company to get it scheduled. 10/31/2025 Implemented
2380.111(a)Individual #1 did not have an annual physical upon their admission date of 2/21/25. There are 2 physicals in the record; one is signed by the doctor 7/11/25 and one is signed by the doctor 7/21/25. There was no other physical available at the time of the inspection.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Prior to a new individual beginning day program and each new annual physical will be reviewed by the Program Specialist, and then will be forwarded to the DOS/ ADOS for a second review. A new signature sheet has been implemented of for the Program Specialist and DOS/ADOS to sign off verifying that all information was checked and is correct. A new individual may not start program until the physical has been checked and signed off on by two people when applicable. 10/31/2025 Implemented
2380.181(f)The initial assessment dated 4/22/25 for individual #1 was not sent to all ISP team members; specifically it was not sent to the individual's residential habilitation team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.60 day assessment was sent to the residential program on 10/31/25 to ensure they received a copy although late. we have collected email addresses for all family members who wished to provide them along with residential providers so that most assessments will be sent electronically to the plan team. Updated the letter sending assessment and trained the PC on how it should be filled out. Any person who requests a hard copy of an assessment will initial off on the original letter that the program specialist keeps in the individual's file. 10/31/2025 Implemented
SIN-00257417 Renewal 01/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)For individual #3, the physical exam form from 10/2/24 had a statement saying to refer to the annual assessment for complete medical history; however, the annual assessment was not attached to the physical exam and there was no indication if the physician had reviewed it.The physical examination shall include: A review of previous medical history.Individuals physical from their residential program has documentation that the physician reviewed the medical history, but we did send our form with the residential provider to have the physician document that they reviewed the lifetime medical history on our form as well. Physical form has been updated to include a space for the physician to acknowledge that they have reviewed the previous medical history. Program Specialist and LPN have been trained that the lifetime medical history section of the annual assessment must be copied and attached to the physical form. 01/22/2025 Implemented
2380.113(a)Staff #2 had a physical on 6/11/22 and not again until 7/5/24, which is outside of the required two-year time frame of needing to have a physical completed.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 Program Specialist was trained to ensure that all staff physicals are completed in compliance with regulations, and that staff may not work if their physical date passes without a new completed physical being submitted. IRQ Manager was placed in charge of tracking and ensuring that physical forms are sent to staff at least 2 months prior to the due date. Staff physical dates have been added to outlook calendars for both the Program Specialist and the IRQ Manager. 01/23/2025 Implemented
SIN-00240531 Renewal 03/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)On 3/12/24, while conducting the walk-through of the facility under the kitchen sink contained over 10 cleaning sprays, Clorox bleach, air fresheners, that were all poisonous. The cabinet doors only had white child locks- when the licensing rep pulled on the cabinet doors under the kitchen sink, the doors where easily opened. The doors opened approx. 2 inches and just pushing on the top of the lock opened the cabinet doors exposing all of the poisonous cleaning supplies.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All poisonous materials were moved to the locked utility closet at the time of inspection until magnetic locks were installed. Magnetic locks were installed on the kitchen cabinet and the magnet is stored in another area 03/18/2024 Implemented
2380.111(c)(3)Individual #2's Tetanus was administered late- 6/4/13 then 6/20/23.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Specialist was trained to ensure that all required vaccinations are completed on time, and that individuals cannot attend day program until requirements are up to date- including physicals, TB testing, and vaccinations 03/25/2024 Implemented
2380.173(1)(ii)Individual #2- person profile document listing Identifying Marks was left blank.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.Program Specialist was trained by the DOS that all sections of the personal profile page must be filled out with no blank spaces. Program Supervisor and staff were trained as well and told that if they find errors or are aware of changes that they need to inform the Program Specialist so that the form may be updated in a timely manner 03/25/2024 Implemented
2380.181(a)Individual #1's initial assessment was not completed within the 60 days after the admission date of 6/5/23. The initial assessment was completed 8/7/23, should have been completed by 8/4/23.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 DOS retrained the Program Specialist that initial 60-day assessments do not have a grace period and must be completed no later than the 60-day date 03/25/2024 Implemented
2380.181(d)Staff #2 did not sign Individual #2's initial assessment. This section was left blank on the initial assessment.The program specialist shall sign and date the assessment.Program Specialist was retrained on the regulation and the need for signing and dating all assessments. 03/25/2024 Implemented
SIN-00223409 Initial review 04/25/2023 Compliant - Finalized