Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229131 Renewal 08/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #3's Tdap vaccination was completed in 2012 and the again on 7/26/23. Individual # 4's Tdap vaccination completed on 6/1/12 and then again on 7/3/23.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.An admission checklist was implemented to ensure that vaccination dates are checked prior to admission to the program on 8/14/2023. Program supervisor will continue to track vaccination dates on a spreadsheet at least 1x monthly. A form letter was drafted on 8/14/2023 to ensure that documentation of requests to obtain the Tdap vaccination is provided to families and providers. This letter will be sent 1 month prior to Tdap due date. 08/25/2023 Implemented
2380.111(c)(4)Individual #1, physical examination completed 6/20/2023 did not address vision screening . This section was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physical examination form was updated to include the option to circle "yes" or "no" regarding an individuals vision falling within normal limits. A physical review checklist including all regulatory standards was created on 8/14/2023. 08/25/2023 Implemented
2380.111(c)(7)Individual #4's physical examination, completed 6/19/23, however current medication list was attached for the physician to review, however it was left blank. Per most recent individual plan that was last updated on 7/18/23, indicates that Individual #4 is prescribed the following medications: Atorvastatin, Fluoxetine, and Famotidine. [Repeat 8/26/22]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.A reviewed list of Individual #4's medications was received on 8/10/2023. 08/25/2023 Implemented
2380.113(a)Direct Service Worker #1's most recent physical examination was completed on 1/17/2020.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.Direct Service Worker's Physical was completed on 08/12/2023. 08/25/2023 Implemented
2380.113(c)(2)Direct Service Worker #1's most recent Tuberculin screening was completed on 1/19/20.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.Direct Service Worker's Tuberculin screening was completed on 08/12/2023. 08/25/2023 Implemented
2380.181(e)(12)The annual assessment completed for Individual #1 on 8/7/23 did not include recommendations. The initial assessment completed for Individual #2 on 6/1/23 did not include recommendations. The initial assessment completed for Individual #3 on 4/3/23 did not include recommendations. The annual assessment completed for Individual #4 on 1/17/23 did not include recommendations. [Repeat 8/26.22]The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Training on the completion of the recommendations section of the assessment and use of SMART goals will be completed on 8/25/2023 with program specialist. 08/25/2023 Implemented
2380.173(5)The most recent Individual Plan in Individual #1's record is from the fiscal year of 7/1/22 through 6/30/23. The most recent Individual Plan in Individual #2's record is from the fiscal year of 7/1/22 through 6/30/23. The most recent Individual Plan in Individual #3's record is from the fiscal year of 7/1/22 through 6/30/23. The most recent Individual Plan in Individual #4's record is from the fiscal year of 7/1/22 through 6/30/23.Individual plan documents as required by this chapter.The program specialist ensure that the most recent ISP has been printed and added to each individuals file by 8/16/2023. The program specialist will check HCSIS and the printed ISP at least once quarterly wile completing the quarterly review. 08/16/2023 Implemented
2380.182(c)In the need for Supervision section of the assessments completed for Individual #1 on 8/7/22 and 8/7/23, indicates Individual #1 can be left unsupervised for up to 15min. In the Supervision Care Needs section of the Individual Plan, updated 7/26/23, reads "[Individual #1] attends the Diversified Human Service, Therapeutic Activity Center three days a week, where he receives no less than line of sight supervision."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The individual's supports coordinator was emailed on 8/10/2023 regarding the necessary update of the ISP to match the assessment. The SC responded on 8/11/23 stating that the changes would be made. Program specialist will monitor HCSIS 1x weekly for updated ISP. 08/25/2023 Implemented
SIN-00210385 Renewal 08/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual#1's tuberculin skin test via Mantoux method was read with negative results on 5/27/22. However, the interpreter's medical credentials were not provided. [Repeat violation from 9/14/21].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, (.111d)...signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistantIndividual #1¿s TB test was read by a CRNP. We obtained the electronic record from the physician¿s office providing the credentials. The TB test results of all other individuals have been inspected for compliance. 09/08/2022 Implemented
2380.111(c)(7)Individual #2's 8/8/22 physical exam does not include an assessment of their health maintenance needs, medication regimen and the need for blood work at recommended intervals. This field was left blank.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 #2¿s physical exam was returned for completion of the blank fields and the medication list that was inadvertently not attached to the scan of her physical has been attached. All individuals¿ physicals have been examined for compliance. 09/08/2022 Implemented
2380.111(c)(10)Individual #2's 8/8/22 physical exam does not include medical information pertinent to diagnosis and treatment in case of an emergency. This field was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #2¿s physical exam was returned for completion of the blank fields. All individuals¿ physicals have been examined for compliance. 09/08/2022 Implemented
2380.181(e)(4)Individual #2's 1/17/22 assessment need for supervision is not addressed.The assessment must include the following information: The individual's need for supervision.Individual #2¿s assessment need for supervision was competed and all individuals¿ assessments were examined for completeness. 09/08/2022 Implemented
2380.181(e)(6)Individual #1's 9/3/21 assessment does not address their ability to safely use or avoid poisonous substances.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Individual #1¿s assessment has been corrected to address their inability to safely use or avoid poisonous substances. All individuals¿ assessments have been examined for completeness. 09/08/2022 Implemented
2380.181(e)(7)Individual #1's 9/3/21 assessment does not address their knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F.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.Individual #1¿s assessment has been corrected to address their knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 F. All individuals¿ assessments have been examined for completeness. 09/08/2022 Implemented
2380.181(e)(12)Individual #1's 9/3/21 assessment does not include recommendations for specific areas of training, vocational programming, and competitive community-integrated employment. Individual #'2's 1/17/22 assessment does not include recommendations for specific areas of training, vocational programming, and competitive community-integrated employment. Individual #3's 12/27/21 assessment does not include recommendations for specific areas of training, vocational programming, and competitive community-integrated employment. Individual #4's 9/9/21 assessment does 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.Our assessments did not address recommendations for specific areas of training, vocational programming and competitive community-integrated employment. As a temporary remediation, each individual in the program had a statement addressing this requirement attached to their assessment. 09/08/2022 Implemented
2380.181(e)(13)(ii)Individual #2's 1/17/22 assessment does not address their progress over the last 365 calendar days and current level of functioning 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.Individual #2¿s assessment was corrected to complete the motor and communication skills sections. It is unknown why individual #2¿s assessment was not completed in its entirety. All individuals¿ assessments have been examined for completeness. 09/08/2022 Implemented
2380.181(e)(14)Individual #2's 1/17/22 assessment does not address their knowledge of water safety and ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Individual #2¿s assessment was corrected to address their knowledge of water safety and ability to swim. All individuals¿ assessments have been examined for completeness. 09/08/2022 Implemented
SIN-00192875 Renewal 09/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)The physical examination, completed 10/19/2020, for Individual #2 did not included the vision and hearing screening, these section read N/A. The physical examination, completed 6/9/2021, for Individual #3 indicated that a hearing screening was completed on 7/15/21, there was not documentation of the hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physician had marked the vision and hearing screenings as N/A, indicating that the individual sees vision and hearing specialists, but no visit information from the specialists was provided. This violation could not be immediately corrected, as the specialists on record state that they did not see the individual within the 12 months prior to the physical exam. This individual's next physical exam is due in October 2021. Information of hearing and vision screening has been provided to the family and will be provided to the physician at the time of the visit. A memo provided to all families and caregivers states the following information relevant to vision and hearing screenings: 2. Absent or incomplete Vision and Hearing screenings. Solution: If the individual is seen annually by a vision and/or hearing specialist, attach the information from the most recent visit(s) to the health appraisal form. The attached form ¿Medical Information Update¿ can be completed by the caregiver to summarize the specialist visit in lieu of the complete visit record. The specialist needs only to review the information for accuracy and sign. The physician completing the annual physical exam can then verify and document that there is no need for additional screening. If the individual does NOT see a vision and/or hearing specialist, the physician (or other professional as defined at the top of the health appraisal form) must either complete a screening or respond as to why a screening is not recommended. If the individual refuses, it must be documented. 09/23/2021 Implemented
2380.111(c)(5)Individual #1's tuberculin skin testing completed, 6/10/20 did not include a signature or credentials of health care provider reading the results.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.Documentation of the person reading this individual's TB test on 6/10/20 was obtained. The following information specific to this violation was provided to all families and caregivers responsible for the physical exams: 5. TB Test not signed by the person reading the test OR read and signed by a person who is not qualified. Solution: Please be aware of the criteria printed on the health appraisal form. All parts of the health appraisal can be completed by a licensed physician, certified nurse practitioner, or licensed physician assistant. In addition, immunizations, vision and hearing screening, and TB tests may be completed and documented by a registered nurse or licensed practical nurse. No one other than those specified can perform or sign any part of the health appraisal. When returning to have a TB test read, please be aware of who is reading it to ensure they meet the qualifications. 09/23/2021 Implemented
2380.113(a)Direct Service Worker #1, date of hire 8/1/21 had an initial physical examination completed 8/11/21.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 violation was a "fluke" due to an internal staff transfer and misunderstanding between supervisors about the requirements and documentation between programs. On the staff person's first day working with individuals, it was determined that she did not have a physical exam within the last 12 months and went immediately to get her physical and TB test. She did not return to work until both were complete. 09/23/2021 Implemented
2380.113(c)(2)Direct Service Worker #2 had a tuberculin skin test completed on 2/14/20 which was read by a certified medical assistant.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.We were unable to immediately correct this specific violation, as we can not change who read the test. We did inspect all other individual's physical exams to ensure that no other tests were read by an unqualified healthcare professional. All families and caregivers responsible for physical exams were issued memos pertaining to annual physical exams. Specific to this violation, the following information was provided: 5. TB Test not signed by the person reading the test OR read and signed by a person who is not qualified. Solution: Please be aware of the criteria printed on the health appraisal form. All parts of the health appraisal can be completed by a licensed physician, certified nurse practitioner, or licensed physician assistant. In addition, immunizations, vision and hearing screening, and TB tests may be completed and documented by a registered nurse or licensed practical nurse. No one other than those specified can perform or sign any part of the health appraisal. When returning to have a TB test read, please be aware of who is reading it to ensure they meet the qualifications. 09/23/2021 Implemented
SIN-00155175 Renewal 05/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility had an fire safety inspection on 2/22/18 and then again on 4/26/19.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.It was not realized until the inspection was due that the fire inspector who came annually for fire inspections was no longer with the fire department. His replacement did not know about the previously scheduled inspection, and was not able to come until 4/26/19. In retrospect, we should have then contacted an alternative inspection source to try getting it done sooner. Fire inspections dates are tracked and scheduled by the program supervisor, and will be monitored by the Developmental Services Director. 06/07/2019 Implemented
2380.111(c)(5)Individual #2 had tuberculin skin testing 7/29/16 and then again on 8/24/18.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 #2 gets very upset about medical visits. Instead of taking her for a separate appointment to get her TB test and later her physical (insurance would not pay for physical earlier than 8/15/18), her mother chose to only take her for one appointment. The earliest she was able to schedule the appointment was 8/22/18, at which time the TB test was administered and it was read on 8/24/18. Will will advise families to try to schedule annual appointments on the very first date that insurance allows so that the time between TB tests falls within the 15 day grace period. 06/07/2019 Implemented
2380.111(c)(6)Individual #2's physical examination, completed 8/28/18 does not address communicable diseases.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.It is current policy to return a physical assessment to the caregiver if there is an incomplete field to be corrected by the physician. The program supervisor missed this omission. Developmental Services Director will begin reviewing and initialing all physical assessments for completeness. 06/07/2019 Implemented
2380.181(f)The program specialist completed Individual #1's assessment on 8/8/18. Individual #1's annual ISP meeting was held on 8/7/18.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).In error, the program supervisor recorded an incorrect ISP date on the spreadsheet he was using to track ISP dates, assessments, and assessment distribution. The error was corrected and the accuracy of dates for all other individuals was verified. Assessment and distribution dates are being tracked and are in compliance. 06/07/2019 Implemented
SIN-00134715 Renewal 05/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's most recent immunization was on 3-6-2008.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Documentation of immunization was located for individual #1 dated 2/12/18. During the week of 5/21/18 - 5/25/18, program specialists recorded most recent immunization dates for all program individuals. Director created a spreadsheet so upcoming due dates for immunizations would be easily accessible. The next immunization due for any individual in the program is in November 2020. Reminders will be sent home by the program specialist two months prior to next immunization being due. [Upon completion and submission to the facility, a designated staff person trained in the requirements of individuals' physical examinations shall audit all individual physical examinations to ensure all required information is included and immunizations are completed timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/13/18)] 06/05/2018 Implemented
2380.111(c)(4)Individual #3's physical examination completed 6-13-17 did not include a hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Because Individual #3 was due for her annual physical, correction of the prior year's examination in violation was not requested. The annual exam dated 6/26/18 has all fields, including hearing screening, completed. The Program Supervisor met with all staff responsible for reviewing individuals¿ physical examinations of the required information as per 2380.111(c)(4) on 5/21/18. During the week on 5/21/18 - 5/25/18, program specialists audited individuals¿ physical examinations to ensure all required information is included and there are not any required areas incomplete and individuals are provided health care as ordered. Immediately and moving forward, physical examinations will be thoroughly examined by program specialists upon receipt. If any information is missing from a physical examination, program staff will keep documentation of efforts to work with the individual¿s caregiver to correct. [Documentation of audits of physical examinations by the program specialist shall be kept. (DPOC by AES, HSLS on 9/13/18)] 05/25/2018 Implemented
2380.181(f)The program specialist provided Individual #1's assessment completed 9-15-17 to the plan team members on 11-27-17 for the annual ISP meeting on 12-12-17.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).A policy memo was issued on 5/23/18 by Director to the Program Supervisor and Program Specialists with the direction that assessments should be submitted to the Supports Coordinator and plan team members approximately 120 days prior to the Annual Review Update date. At least quarterly for one year, the Program Supervisor shall audit correspondence documentation to ensure the program specialist provided the individual's assessments to all individuals' plan team members as required. Documentation of audits shall be kept. 05/23/2018 Implemented
2380.186(e)The program specialist did not notify Individual #1's plan team members of the option to decline ISP review documentation. The program specialist did not notify Individual #2's plan team members of the option to decline ISP review documentation. The program specialist did not notify Individual #3's plan team members of the option to decline ISP review documentation..The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Throughout the week of 5/21/18 - 5/25/18, program specialists inspected the charts of all program individuals to locate declination forms. The declination form for Individual #3 was located in the record dated 3/15/16. A declination form was sent home with Individual #1 and was returned dated 6/29/18. A declination form for Individual #2, who no longer attends the program, was sent home and not returned. At the time of each annual ISP, the program specialist will ensure that documentation is present ensuring that all plan members have been notified of the option to decline the ISP review documentation. 05/25/2018 Implemented
SIN-00116002 Renewal 06/02/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #3's physical examination, completed 6/2/16 did not include a review of previous medical history. This section was blank. The physical examination shall include: A review of previous medical history.Physical examinations will be reviewed upon receipt by the Program Specialist for all required information including a review of previous medical history. If required information is missing, it will be documented and returned for completion. A memo to physicians stressing the importance of completing all sections has been attached to the health appraisal forms. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [Individual #3 had a physical examination completed on 6/13/17 to include previous medical history. Immediately, upon completion and at least biannually, the program specialist shall review all current individual physical examinations to ensure all required information is included and there are not any areas of required information left blank. Documentation of reviews shall be kept. (AS 7/18/17)] 06/27/2017 Implemented
2380.111(c)(4)Individual #3's physical examination completed 6/2/16 and Individual #4's physical examination completed 4/25/17 did not include a vision and hearing screening. This section was blank. The physical examination shall include: Vision and hearing screening, as recommended by the physician.Physical examinations will be reviewed upon receipt by the Program Specialist for all required information including a review of previous medical history. If required information is missing, it will be documented and returned for completion. A memo to physicians stressing the importance of completing all sections has been attached to the health appraisal forms. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [Individual #3 had a physical examination on 6/13/17 to address vision and hearing screening to be completed by specialists. Individual #4's physical examination was updated on 7/14/17. Immediately, upon completion and at least biannually, the program specialist shall review all current individual physical examinations to ensure all required information is included and there are not any areas of required information left blank. Documentation of reviews shall be kept. (AS 7/18/17)] 06/27/2017 Implemented
2380.111(c)(5)Individual #2's two most recent Tuberculin skin testing were completed on 2/13/15 and 3/22/17. (Repeated Violation-6/3/16, et al)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.An Outlook calendar has been created and is shared by the Program Supervisor, Program Specialists, and Program Director. Due dates and completion dates are tracked and documented on this calendar for medical appraisals, assessments, and ISP-related tasks. Color coding is utilized so that incomplete tasks are easily recognized. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [At least monthly for 6 months and then continuing quarterly, a designated management staff person shall review tracking system to ensure timely completion of Tuberculin skin testing for all individuals. At least quarterly for 1 year, a designated staff person shall review a 25% sample of current physical examination to ensure timely completion with all required information and that there is not any areas of required information left blank. Documentation of tracking system reviews shall be kept. (AS 7/6/17)] 07/01/2017 Implemented
2380.111(c)(7)Individual #1's physical examination completed 7/27/16 did not include an assessment the individual's health maintenance needs, medication regimen and the need for bloodwork at recommended intervals. This section was blank. 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.Physical examinations will be reviewed upon receipt by the Program Specialist for all required information including a review of previous medical history. If required information is missing, it will be documented and returned for completion. A memo to physicians stressing the importance of completing all sections has been attached to the health appraisal forms. Pre-licensing self-inspections will be conducted twice per year to monitor compliance.[Individual #1 will have an updated annual physical examination by 8/11/2017 to include individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Immediately, upon completion and at least biannually, the program specialist shall review all current individual physical examinations to ensure all required information is included and there are not any areas of required information left blank. Documentation of reviews shall be kept. (AS 7/18/17)] 06/27/2017 Implemented
2380.111(c)(10)Individual #1's physical examination completed 7/27/16 and Individual #4's physical examination completed 4/25/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. (Repeated Violation-6/3/16, et al) The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Physical examinations will be reviewed upon receipt by the Program Specialist for all required information including a review of previous medical history. If required information is missing, it will be documented and returned for completion. A memo to physicians stressing the importance of completing all sections has been attached to the health appraisal forms. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [Individual #1 will have an updated annual physical examination by 8/11/2017 to include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #4s' physical examinations was updated on 7/14/17. Immediately, upon completion and at least biannually, the program specialist shall review all current individual physical examinations to ensure all required information is included and there are not any areas of required information left blank. Documentation of reviews shall be kept. (AS 7/18/17)] 07/01/2017 Implemented
2380.173(1)(ii)The records for Individual #1 and Individual #2 did not include race and color of hair. The records for Individual #1, Individual #2 and Individual #4 did not include identifying marks. 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 records of Individual #2, Individual #3, and Individual #4 have been corrected to include the missing information. A document containing personal information including the race, height, weight, color of hair, color of eyes and identifying marks has been printed and included in each individual¿s record. This document will be reviewed and updated at least annually. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [On June 5, 2017, the records for Individual #1 and #2 were updated by the program specialist to include race and color of hair. On June 5, 2017, the records for Individual #1, Individual #2 and Individual #4 were updated by the program specialist to include identifying marks. Immediately and at least biannually, the CEO or designee shall review all individual records to ensure all required personal information is included as per 2380.173(1)-(11). Documentation of reviews shall be kept. (AS 7/6/17)] 06/27/2017 Implemented
2380.173(1)(iv)The record for Individual #3 did not include religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.A document containing personal information including religious affiliation has been printed and included in each individual's record. This document will be reviewed and updated at least annually. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [On June 5, 2017, Individual #1's record was updated by the program specialist to include religious affiliation. Immediately and at least biannually, the CEO or designee shall review all individual records to ensure all required personal information is included as per 2380.173(1)-(11). Documentation of reviews shall be kept. (AS 7/6/17)] 06/27/2017 Implemented
2380.181(a)Individual #1's most recent assessment was completed 5/18/16.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.An Outlook calendar has been created and is shared by the Program Supervisor, Program Specialists, and Program Director. Due dates and completion dates are tracked and documented on this calendar for medical appraisals, assessments, and ISP-related tasks. Color coding is utilized so that incomplete tasks are easily recognized. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [On 6/6/17, the program specialist completed an annual assessment for Individual #1. Immediately, all individuals' assessments shall be reviewed to ensure timely completion. Documentation of biannual reviews of tracking and assessments shall be kept. (AS 7/18/17)] 07/01/2017 Implemented
2380.181(e)(7)Individual #3's assessment completed 1/25/17 did not include knowledge of heat sources. This section was blank.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.Individual #3¿s assessment was corrected to include this information. All assessments have been reviewed to ensure no blank sections. Staff was re-trained on the completion of assessments to ensure that all fields are completed. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [On 6/6/17, the program specialist completed an annual assessment for Individual #1. Immediately, all individuals' assessments shall be reviewed to ensure timely completion. Documentation of biannual reviews of tracking and assessments shall be kept. (AS 7/18/17)] 07/01/2017 Implemented
2380.181(e)(8)Individual #3's assessment completed 1/25/17 did not include ability to evacuate in the event of a fire. This section was blank.The assessment must include the following information: The individual's ability to evacuate in the event of a fire.Individual #3¿s assessment was corrected to include this information. All assessments have been reviewed to ensure no blank sections. Staff was re-trained on the completion of assessments to ensure that all fields are completed. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [On 6/5/17, Individual #1's assessment was updated to include the individual's ability to evacuate in the event of a fire. Immediately and continuing at least quarterly, for 1 year a designated management staff person shall review completed assessments to ensure all required information is included. Documentation of reviews shall be kept. (AS 7/6/17)] 06/27/2017 Implemented
2380.181(f)The program specialist did not provide Individual #2's assessment, completed 8/1/16 to the plan team members for the annual ISP meeting on 8/1/16. The program specialist provided Individual #3's assessment completed 1/25/17 to the plan team members on 3/15/17 for the annual ISP meeting on 3/15/17.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).An Outlook calendar has been created and is shared by the Program Supervisor, Program Specialists, and Program Director. Due dates and completion dates are tracked and documented on this calendar for medical appraisals, assessments, and ISP-related tasks. Color coding is utilized so that incomplete tasks are easily recognized. Pre-licensing self-inspections will be conducted twice per year to monitor compliance. [At least monthly for 6 months and then continuing quarterly, designated management staff person shall review tracking system to ensure completion and that the program specialist provides all individuals' assessments to all plan team members, timely and documentation of the correspondence is kept. Documentation of tracking system review shall be kept. (AS 7/6/17)] 07/01/2017 Implemented
2380.186(d)The program specialist did not provide Individual #4's ISP review documentation completed 6/9/16 to the plan team members. (Repeated Violation-6/3/16, et al)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.An Outlook calendar has been created and is shared by the Program Supervisor, Program Specialists, and Program Director. Due dates and completion are tracked and documented on this calendar for medical appraisals, assessments, and ISP-related tasks including distribution. Color coding is utilized so that incomplete tasks are easily recognized. Pre-licensing self-inspections will be conducted twice per year to monitor compliance.[At least monthly for 6 months and then continuing quarterly, designated management staff person shall review tracking system to ensure completion and that the program specialist provides all individuals' ISP review documentation, to plan team members, timely, as required and documentation of the correspondence is kept. Documentation of tracking system review shall be kept. (AS 7/6/17)] 06/27/2017 Implemented
SIN-00095677 Renewal 06/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)Individual #1's monthly documentation of individual's participation and progress towards outcomes, dated 6/2015, 7/2015, 8/2015, 9/2015, 11/2015, 12/2015, 1/2016, 2/2016, and 3/2016, were not signed and dated by Program Specialist #1 or Program Specialist #2. Individual #2's monthly documentation of individual's participation and progress towards outcomes, dated 7/2015, 8/2015, 9/2015, 10/2015, 11/2015, 12/2015, 1/2016, 2/2016, and 3/2016, were not signed and dated by Program Specialist #1 or Program Specialist #2.The program specialist shall be responsible for the following:  Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.Agency began utilizing ODP's monthly progress report template in April 2016 and monthly progress reports are completed by the program specialists, thus ensuring their signatures on all documentation. All agency staff has been trained on the new form/template on 5/18/16 and 5/23/16. Program supervisor or designee responsible for reviewing monthly report and ensuring program specialists signed reports. [Individual #1's monthly documentation of individual's participation and progress towards outcomes, dated 6/2015, 7/2015, 8/2015, 9/2015, 11/2015, 12/2015, 1/2016, 2/2016, and 3/2016, were signed and dated by the Program Specialist on 6/16/16. Individual #2's monthly documentation of individual's participation and progress towards outcomes, dated 7/2015, 8/2015, 9/2015, 10/2015, 11/2015, 12/2015, 1/2016, 2/2016, and 3/2016, were signed and dated by the Program Specialist on 6/16/16. Immediately, the CEO will review with all program specialists the responsibilities of the position and sign and date upon review. Within 30 days of receipt of the plan of correction, the program specialist will review all individuals monthly documentation for the past year to ensure all documentation has been reviewed, signed and dated and will address as needed. At least quarterly the CEO/Director will review a 25% sample of all individuals' monthly documentation to ensure the program specialist review, sign and date as required. Documentation of all reviews shall be kept. (AS 8/2/15)] 07/23/2016 Implemented
2380.89(c)Written fire drill record, dated 11/30/2015, did not include the time of day the fire drill was completed. Written fire drill record, dated 5/31/2016, did not indicate whether the fire alarm was operative.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 drill record revised in a manner to lessen risk of missing information. All staff has been trained on completing the new form. Program supervisor and program specialist both responsible for thorough check of fire drill record to ensure completion and signing as verification. Fire drill records will be reviewed by supervisor or designee at least every 6 months. [Training sign-in sheet, dated with 13 signatures for training "New fire drill record" was submitted to the Department. Documentation of reviews of fire drill records shall be kept. (AS 8/2/16)] 07/23/2016 Implemented
2380.111(c)(5)Individual #2, date of admission 7/9/2015, had Tuberculin skin testing completed 10/29/2015.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.Admission checklist has been developed for all new individuals. Individuals will not be able to start program until all admission requirements are met. TB testing included in the checklist. Program specialist and supervisor responsible for ensuring all required information is received prior to admission to the program. [Immediately and prior to admission and after completion of an annual physical, the Program Specialist and supervisor will review all individuals' physical examinations to ensure all required information is present and there are not areas left blank and will obtain missing information prior to entering in to the individuals record. At least quarterly the CEO or director will review a 25% sample of current physical examinations to ensure all required information is present. Documentation of all reviews shall be kept. (AS 8/3/16)] 07/23/2016 Implemented
2380.111(c)(10)Individual #4's physical examination, dated 6/2/2015, 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.Agency physical form revised to have all regulation requirements highlighted in color to ensure proper completion. Program supervisor or delegate responsible for thorough review of physical form and retuning to individual/family if information missing or incomplete. Program supervisor or designee responsible for checking the entire physical form to ensure all requirements met prior to filing.[Facility obtained a physical examination dated 6/15/15 for Individual #4's that included medical information pertinent to diagnosis and treatment in case of an emergency. Individual #4' physical examination completed 6/2/16 includes medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and prior to admission and after completion of an annual physical, the Program Specialist and supervisor will review all individuals' physical examinations to ensure all required information is present and there are not areas left blank and will obtain missing information prior to entering the physical examination into the individuals' records. At least quarterly the CEO or director will review a 25% sample of current physical examinations to ensure all required information is present. Documentation of all reviews shall be kept. (AS 8/3/16)] 07/23/2016 Implemented
2380.186(b)Individual #3's ISP review, dated 3/4/2016, was not signed and dated by Program Specialist #1, Program Specialist #2, or Individual #3. Individual #1's ISP review, dated 8/20/2015, was not signed and dated by Individual #1.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #3 goes to Florida usually every November through April; program will request a letter from family stating he will be gone for that specific period for his record. Program specialist will create an alert on Outlook for individual's return to review quarterlies and obtain signatures upon his return. Program supervisor is responsible for checking all quarterlies to ensure all signatures obtained prior to filing in the individuals' records. Program specialists responsible for reviewing assigned charts at a minimum of every six (6) months to ensure all reviews are signed by the individual and program specialist. [On 6/6/16, Individual #3 signed a signature page for meeting reading "Quarterly review which was held on 3/4/16 but [s/he] was in Florida but was reviewed upon arrival back to program." On 6/6/16, Individual #3 signed signature page "quarterly review for 8/20/16." Within 30 days of receipt of the plan of correction, CEO or Director will review the responsibilities referring to (2380.33(b)(1)-(19) of the program specialist with the program specialists and will sign and date upon review. Within 60 days or receipt of the plan of correction and at least semi-annually, the program specialist will review all individuals' ISP review for the past 6 months to ensure the program specialist and individual signed and dated the ISP reviews upon review. At least quarterly, the CEO/Director will review a 25% sample of individuals' ISP reviews to ensure the program specialist and individual sign and date as required. Documentation of reviews shall be kept. (AS 8/3/16)] 07/23/2016 Implemented
2380.186(d)Individual #2's ISP review documentation, dated 10/10/2015, 1/12/2016, and 4/12/2016, was not sent to the plan team members including Supports Coordinator, Behavioral Support Consultant, or Home and Community Habilitation provider. Individual #1's ISP review documentation, dated 8/20/2015, 2/18/2016, 5/18/2016 was not sent to the Supports Coordinator.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.Program implementing and recording the following means of transmittal of ISP review documentation to team members and SCs: 1) ISP review documentation will be scanned and emailed to plan team members by the program specialist; the email will be printed and filed with the quarterly as verification; 2) a quarterly review cover letter has been developed to send with documentation to the individual; letter lists and copies plan team members receiving documentation and letter to be filed with quarterly in individual's record; and 3) meeting signature sheet revised to add area for plan team members to initial if report received at meeting; signature sheet to be filed with quarterly in individual's record. Program supervisor or designee responsible for ensuring all plan team members receive copies of ISP reviews prior to filing documents in the individual charts.[On 6/7/16, Individual #2's ISP review documentation, dated 10/10/2015, 1/12/2016, and 4/12/2016, was sent to the plan team members including Supports Coordinator, Behavioral Support Consultant, or Home and Community Habilitation provider. On 6/7/16, Individual #1's ISP review documentation, dated 8/20/2015, 2/18/2016, 5/18/2016 was sent to the Supports Coordinator and Residential Program Specialist. Within 30 days of receipt of the plan of correction, CEO or Director will review the responsibilities referring to (2380.33(b)(1)-(19) of the program specialist with the program specialists and will sign and date upon review. Within 60 days or receipt of the plan of correction and at least semi-annually, the program specialist will review all individuals' correspondence documentation for the past 6 months to ensure the program specialist has provided all individual's ISP review documentation to all plan team members as required and will provide to all team members as required. At least quarterly, the CEO/Director will review a 25% sample of correspondence documentation to ensure the program specialist provides all individual's ISP review documentation to all plan team members as required. Documentation of reviews shall be kept.(AS 8/3/16)] 07/23/2016 Implemented
SIN-00091230 Unannounced Monitoring 12/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.156(d)Individual #1, who has a restrictive procedure plan last reviewed on 8/11/15, was physically restrained by Program Specialist #1 on 12-11-15. Documentation of the training program provided, the dates of the training, description of the training and the training source, for Program Specialist #1 was not kept. Documentation of the training program provided, including the staff persons trained, dates of the training, description of the training and the training source, shall be kept.Policy statement on Restraints and Restrictive Procedures has been updated to include training and maintenance of thorough documentation/training records as a requirement. Policy statement requires all staff responsible for the implementation of the plan to be trained prior to implementation and documentation of training be maintained. [Within 1 month of receipt of the plan of correction, all staff persons providing care to individuals who have a restrictive procedure plan will be retrained/trained on the individuals restrictive procedure plan as required in 2380.156(a)to(c). Documentation of the training provided shall be kept as specified in 156(d). If the Restrictive procedure plans for the individuals were developed and/or monitored by a behavior specialist or other professionals then those involved should be involved in the training of staff persons to ensure restrictive procedures are implemented utilizing the alternate positive approaches, specific techniques or procedures as written. (AS 5/23/16)] 04/07/2016 Implemented
SIN-00079290 Renewal 05/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(d)Direct Service Worker #1 was hired on 11/3/14 and did not receive training in the areas of services for people with disabilities and program planning and implementation.Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.New employee orientation schedule revised to include training on services for people with disabilities and program planning and implementation. [A blank copy of the above mentioned document was submitted and received by the department on 7/24/15.(AS 7/24/15)] 07/06/2015 Implemented
2380.111(a)Individual #1, admitted on 6/6/14 did not have a physical examination completed until 6/20/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Information added to intake packet stating physical required prior to enrollment and annually thereafter; physical form sent to family/caregiver with packet.[A blank copy of the above mentioned document was submitted and received by the department on 7/24/15.(AS 7/24/15)] 07/06/2015 Implemented
2380.173(1)(ii)Individual #3's record did not include identifying marks.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.Procedure developed to ensure all pertinent information is obtained from family/caregiver. Program specialist responsible for reviewing the intake/personal information sent in by family/caregiver and contacting them if any information is left incomplete to obtain all required information. Area added for PS signature & date as verification of information being reviewed. [As per conversation with the Director on 7/24/15, the Director and Supervisor will immediately review all individual records for required personal information and will address as needed. (AS 7/24/15)] 07/06/2015 Implemented
2380.173(1)(v)Photographs in Individual #1 and individual # 4's records are not dated.Each individual's record must include the following information: Personal information including: A current, dated photograph."Current dated photograph" added to intake/personal information to ensure photo taken and dated by PS upon enrollment. [A blank copy of the above mentioned document was submitted and received by the department on 7/24/15.(AS 7/24/15)][As per conversation with the Director on 7/24/15, the Director and Supervisor will immediately review all individual records for required personal information and will address as needed. (AS 7/24/15)] 07/06/2015 Implemented
2380.186(a)The ISP reviews for Individual #1 were completed on 12/5/14 and then again on 4/8/15.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.Program developed ISP review chart to ensure all reviews are completed at least every 3 months. A meeting form has also been developed that has an area for the "Next Meeting Date"; this allows the team to schedule the next meeting to ensure timeliness.[A blank copy of the above mentioned document was submitted and received by the department on 7/24/15.(AS 7/24/15)][As per conversation with the Director on 7/24/15, the Director and Supervisor will immediately review all individual records for required personal information and will address as needed. (AS 7/24/15)] 07/06/2015 Implemented
2380.186(b)ISP reviews for Individual #2 dated 7/22/14 and 1/22/15 were not signed by the individual. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Procedure developed utilizing new meeting form. When individual is not present, area for individual signature will be highlighted on the meeting form and attached to the review report. Each program specialist will maintain a folder for reports needing signatures and will have the individual sign upon return to the program. 07/06/2015 Implemented
SIN-00063651 Renewal 06/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2's physical exam was on 4-9-14, but the prior physical exam was completed on 3-19-13, which exceeds the annual time frame. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Effective immediately the program supervisor will assure that requests and/or notices of requests of annual physical examinations will be sent to responsible sources relevant to the particular individual in a timely manner, approximately two months before the due date of the physical. Follow up will be done by Program Coordinator and Program Specialist at routine intervals to remind of the requirement of the physical. Supervisor will train Coordinator and Specialist to assure that physicals are requested in the required time frame. 06/06/2014 Implemented
2380.111(c)(5)Individual #1 had a mantoux test completed on 1-18-12 and 2-21-14. Individual #2 was admitted to the program on 1-13-14, however a mantoux test was not completed until 4-9-14.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.Program Supervisor will assure that physical examinations and TB tests are done within required time frame including prior to admission. Program Coordinator and Program Specialist will be trained in and follow timetable chart to request and follow up for required medical information. 06/06/2014 Implemented
2380.181(f)The results of Individual #1's assessment,dated 2-14-14, were not sent to the supports coordinator. 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).Assessments will be sent to the Supports Coordinator and plan team members 30 days prior to development or annual ISP meeting date by the Program Coordinator or Program Specialist in accordance with timetable chart. 06/06/2014 Implemented
SIN-00247945 Renewal 07/16/2024 Compliant - Finalized
SIN-00177459 Renewal 10/08/2020 Compliant - Finalized
SIN-00107526 Unannounced Monitoring 12/22/2016 Compliant - Finalized
SIN-00043602 Initial review 01/18/2013 Compliant - Finalized