Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270527 Renewal 09/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)The Immunizations section of the physical exam completed 8/21/2025 for Individual #1 reads See Attached, however the attached document does not list Immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual's physical has been sent back to the doctor for completion. 09/12/2025 Implemented
2380.111(c)(4)The hearing screening on the physical exam completed 8/21/2025 for Individual #1 was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual's physical has been sent back to the doctor for completion 09/12/2025 Implemented
2380.39(c)(5)The annual training for Staff #2 does not include Use of Behavior Supports for training year 7/1/2024 -- 6/30/2025.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.An internal review of the agencies transfer process for training when an employee that works under one division and then transfers to a new division that has different training requirements. 09/12/2025 Implemented
2380.183(b)At the time of the inspection, it could not be determined if at least 3 members of the planning team and the Individual were present at the 2025 ISP meeting as there was no ISP signature sheet in the record.At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.Program Specialist has reached out to the Support Coordinator to request a copy of the sign in sheet. 09/12/2025 Implemented
2380.183(c)At the time of the inspection, the ISP signature sheet for Individual #1 was not in the record.The list of persons who participated in the individual plan meeting shall be kept.Program Specialist has reached out to the Supports Coordinator requesting the needed paperwork 09/12/2025 Implemented
SIN-00230320 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.171(b)(1)Individual #2's contact in case of an emergency did not have the phone number for the contact listed.Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.Individual Emergency form had a blank space where the designated person to be contacted in case of an emergencys number should be (Attachment #1). This has been corrected (Attachment #2). Please also see individual Emergency Contact form with no blank spaces and all the required information (Attachment #3). 09/14/2023 Implemented
2380.181(f)Individual #2's ISP meeting was held on 2/6/2023. The assessment was sent to the plan team on 1/08/2023, which was not the full 30 days prior as required by this regulation.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Individual had an assessment sent out to the team on 1/8/2022 (Attachment #4) and the team met for the ISP on 1/13/22 (attachment #5), the assessment was sent out less then 30 days prior to the ISP meeting. In 2023 Assessment was sent out 1/6/23 (attachment #6 and the meeting was held 2/6/2023 exactly 30 days after the assessment was sent (Attachment #7 and #8). 09/14/2023 Implemented
SIN-00201237 Renewal 10/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff # 3's physical was completed 2/19/2019 and not again until 3/5/2021.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.Attachments #1 - #4 are correct staff physicals that were completed timely. 11/02/2022 Implemented
2380.113(c)(2)Staff # 3's TB testing was completed 02/25/19 and not again until 03/08/21.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. 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.Attachments #1-4 shows compliant documentation that was completed. 11/01/2022 Implemented
2380.36(b)Staff # 3 did not have Emergency Training in 2021. Staff # 3 did not have emergency training in 2021.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Attachment #5 is an example of training documentation completed on time and in compliance. 11/01/2022 Implemented
2380.36(c)Staff # 3 had CPR training on 07/31/20 and not again until 08/19/22.There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.Attachments #6-9 are completed trainings of staff that are in compliance. 11/01/2022 Implemented
2380.173(1)(i)Individual # 1 does not have an admission date on the emergency information sheet. The space was left blank.The name, sex, admission date, birthdate and Social Security number.Attachment #10 and 11 show the document be corrected for compliance. 11/01/2022 Implemented
SIN-00197127 Renewal 12/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)Bathroom # 1 has a ceiling tile which is not secured to mounting rack. There are two holes in the drywall by the kitchen sink. The wall outside the cleaning closet has a 3 inch area in the drywall which is unpainted and dented.Floors, walls, ceilings and other surfaces shall be in good repair.All walls, ceilings and other services have been fixed and are currently in good repair. The ceiling tile was replaced, the holes were filled in and the wall painted. 12/23/2021 Implemented
2380.173(1)(ii)The identifying marks section on Individual # 2's demographic sheet only has a slash in the space. There is no comment for 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 individual's record has been corrected to indicate "None" for identifying marks. 12/23/2021 Implemented
SIN-00161519 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)Individual #1 assessment dated 7/25/19 and the lifetime medical history was not included.The assessment must include the following information: A lifetime medical history.The program specialist shall include a lifetime medical history with all assessments. The Program Specialist was retrained on the assessment regulation and understands the responsibility to include the Lifetime Medical History in every annual assessment. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. In an effort to ensure ongoing compliance UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audit will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days. Attached you will find individual #1¿s assessment (attachment #1) referred to in the citation as well as a second assessment for another individual that was completed since the onsite visit and citation (Attachment #3) Please see Attachment #1 and #3 09/30/2019 Implemented
2380.36(b)Staff #2 had fire safety training on 7/25/18. There was no documentation that she had it again.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program specialists and Direct Support Professionals shall be trained annually by a fire safety expert in the training areas specified in subsection (a). An annual training will take place during fire safety month in April each year and a follow-up training will be conducted in the same month for anyone who is unable to attend the first training. Attached you will find the original documentation cited for Staff #2 (attachment #4 )and the new training from Staff #2 (attachment #5) who was trained during the retraining session since the onsite visit and citation, Please see attachment #4 and #5 10/02/2019 Implemented
2380.181(f)Individual #1's assessment dated 7/25/19 did not include documentation that it was sent to the team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The Program Specialist was retrained on the corresponding regulation. It is the Program Specialists responsibility to create and email/mail out documentation to the SC and all team members following the completion of an assessment and are required to keep a copy of that documentation. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. In an effort to ensure ongoing compliance UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program management. Documentation of the audit will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within 10 days. Attached you will find individual #1¿s assessment (attachment #1) referred to in the citation. A second attachment has been included to show the correspondence from the program Specialist in sending out another individual¿s assessment to the team (Attachment #2). Please see Attachments #1 and #2 09/30/2019 Implemented
SIN-00143456 Renewal 10/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(a)Fire alarm system- The fire alarm system was not working properly when tested on 10/12/18. Only 1 of the alarms went off when tested.There shall be an operable fire alarm system that is audible throughout the building.PERSON(S) RESPONSIBLE Program Specialist Program Manager CORRECTIVE ACTION(S) TAKEN As per inspection completed on 10/18/18, all systems were in fact operational. It should be noted that, as per Tyco technician, the facility contains two bell alarms. Only one bell alarm sounds while the system is activated in `test¿ mode. The second bell alarm sounds only when the system is activated outside of `test¿ mode and is connected to each suite in the plaza of the facility¿s location. This regulation is important because it ensures that during monthly drills and on-site fire safety training, individuals are provided the same visual and auditory alarm cues that would be heard during an event in case of emergency. It is also critical that every person inside the facility (in all areas of the facility) is able to hear the alarm immediately in order to respond and evacuate immediately. ¿ An immediate action taken was a phone call to notify Tyco. During the phone call on 10/12/18 a work order was requested for as soon as possible. Tyco provided a date of 10/18/18 for job #85729254. ¿ A representative of Tyco visited the facility as requested on 10/18/18 and inspected all of the smoke detectors, bells, and etc. As best practice to ensure alarms are extremely loud, one of the devices in the back of the building that is currently a strobe and will be replaced with a strobe that has a bell alarm. The bell alarm will be installed when the part arrives to Tyco after being ordered. PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ Program staff will inspect each smoke detector, bell alarm, strobe light etc. during/after each monthly fire drill to ensure that all are in working order and sound loudly in all program areas. If any issues are observed, the information will be reported immediately to Tyco and the agency¿s Program Manager. ¿ Tyco will continue to complete site inspections at the facility twice annually. ¿ Bell alarms are scheduled to be installed in designated locations agreed upon by Tyco, the director of day programs, and program specialist. ¿ Within the agency, audits of on-site fire safety will occur quarterly within the program through use of approved audit worksheets to ensure compliance in this area. (attachment 1: refer to page 5 for fire safety section) 10/18/2018 Implemented
2380.111(c)(10)Physical- Individual 1- 8/10/18 annual physical did not contain information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.This regulation is important because it is a proactive measure in which day program staff are provided with information on individual needs and/or treatment pertinent to individual diagnosis at time of emergencies prior to possibility of an emergency occurring. PERSON(S) RESPONSIBLE Program Specialist CORRECTIVE ACTION(S) TAKEN ¿ As an immediate correction, Program Specialist has ensured all required information on the physical examination form. (attachment#2) ¿ Program Specialist has provided recent physical exam for BF, another individual, to evidence recent compliance across records that medical information pertinent to diagnosis and treatment in case of emergency is adequately and accurately answers on physical report. (attachment 3) PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ Ongoing, letters to individuals that are mailed to inform 60 days¿ notice to complete an annual physical exam will include directive to ensure that all areas of the physical exam report are completed in their entirety. (attachment 4) ¿ A blank copy of the annual physical exam report will be provided to each individual accompanying the 60 day notice letter. All lines of necessary completion will be highlighted to encourage compliance. (attachment 4) ¿ When the program specialist receives a copy of an individual¿s annual physical exam, the program specialist will compare the information recorded on the physical to the information documented in the individual¿s ISP and assessment to ensure content is consistent across all records. (attachment 5) ¿ Within the agency, audits of individual records will occur quarterly within the program through use of approved audit worksheets to ensure compliance in this area. (attachment 1) 10/18/2018 Implemented
2380.125Medication error- On 9/11/18 Individual 3-was to receive the medication Clanodine at 12pm. The is medication was omitted and no EIM report was filed.Documentation of medication errors and follow-up action taken shall be kept.This regulation is important because it provides documentation that supports proper care was provided to an individual, following a medication error, to ensure the individual¿s health, safety, and welfare. Omission of a medication is an incident that must be reported to ODP within 24 hours of the omission occurring. Point Person (Program Specialist) Incident Reporter (Director of Day Programs) Initial Reporter(s) staff other than the program specialist who are trained and certified in medication administration and/or identify an incident to report immediately CORRECTIVE ACTION(S) TAKEN ¿ The individual¿s designated contact within his residential provider was called and informed. This phone call was made on 9/19 upon discovery. ¿ As an immediate corrective action, an medication error incident was entered into EIM for 9/11/18 and linked to EIM incident filed on 9/20/18 for reference. ¿ Program Specialist attended EIM Point Person Training provided by the agency on 10/29/2018 (2.0 training hours; attachment 6) ¿ Program Specialist re-trained all program staff on reportable incidents as outlined by ODP. (attachment 7) ¿ Program Specialist/Point Person will note specifics for each date that omission may have occurred. PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ A bright yellow index card labeled ¿12 PM¿ has been taped to the locked filing cabinet that contains the medication lock box to serve as a visual reminder to the program specialist. ¿ The individual who takes medication is currently working on time management skills and increasing his independence to support his ISP outcome for program service. Program staff are working with the individual to tell time and to recognize when it is time to take medications by using an analog clock as a resource. Given a verbal reminder within the hour before administration, the individual has shown progress in recognizing the correct time on the clock and approaching staff. ¿ Within the agency, audits of individual records will occur quarterly within the program through use of approved audit worksheets to ensure compliance in this area. (attachment 1: refer to page 3 for medications) 11/02/2018 Implemented
2380.186(a)ISP review- Individual 1-ISP review dated 5/1/18 was completed late. It should have been completed by 4/26/18.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.This regulation is important to ensure that services by a provider are reviewed regarding participation and progress towards outcomes, as well as information in the ISP pertaining to and relevant for the specific service. This information is vital to determine changes needed to services including discontinuing, revising, or implementing a new service. This occurred due to oversight on part of previous Program Specialist and lack of quality monitoring by Program Manager role. PERSON(S) RESPONSIBLE Program Specialist CORRECTIVE ACTION(S) TAKEN ¿ Although the quarterly was completed late there was no gap in the time period reviewed, rather the ISP review was written late. All team members have comprehensive information regarding individual¿s progress and participation and services for the full year. PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ Program Specialist will ensure the next quarterly for Individual #1 is completed within 15 days of the quarter having ended or earlier if necessary to stay within 3-month period. ¿ Program Specialist has ensured that quarterly reviews are completed every 3 months and written within 15 days of the time period covered for all individuals as evidenced by Individual #1's quarterly completed on 10/1/18; meeting held 10/9/18. (Attachment 8) ¿ As a preventative measure to ensure perpetual readiness and ongoing compliance, quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment 1) 10/18/2018 Implemented
SIN-00123101 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Repeat Violation 11/08/16 - Individual # 2's Individual Support Plan (ISP) states that he/she has a shunt and was hospitalized April 2004 for a shunt revision. Physical dated 04/20/17 does not indicate a shunt nor provide information pertinent to emergencies related to shunt. N/A was in space for information pertinent to emergencies. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.PERSON(S) RESPONSIBLE Shasta Stine, Program Supervisor CORRECTIVE ACTION(S) TAKEN ¿ Immediate correction was made by Program Supervisor to Individual #2¿s most recent physical to add shunt surgery completed in April 2004 based on information in the ISP (Attachment #5) - Individual physical submitted to indicate compliance across programs (Attachment #6) PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ All physicals for individuals will be closely examined and compared to ISP and other medical documentation provided to be sure information is complete and accurate. ¿ If information is missing or inaccurate, Program Supervisor will contact Individual and supportive team members to resubmit to PCP ¿ If physical is unable to be revised by PCP direct, Program Supervisor will revise physical, initial, sign and date to match all appropriate information needed. - All staff were inserviced on all citations received and this plan of correction. See attachment #9 - Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. See attachment #10 01/31/2018 Implemented
2380.113(a)Staff # 1 had a physical exam on 01/19/15 and not again until 10/27/17.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.PERSON(S) RESPONSIBLE Deirdre Frey, Program Specialist & Shasta Stine, Program Supervisor CORRECTIVE ACTION(S) TAKEN ¿ Immediate correction for Staff #1 exam completed 10/27/17 (attachment #4) ¿ Staff physical on 11/8/17 submitted to indicate compliance across programs (attachment #8) PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ Program Manager will monitor annual physical due dates and inform Program Supervisors and appropriate staff members of upcoming due dates at least 30 days prior to expiration with a letter or email. A copy letter or email will be kept in employee file. ¿ Physicals are due within a 2 year timeframe ¿ Program Supervisor will ensure that a physical is submitted by the required due date. If physical is not submitted by date specified, the staff member will be unable to return to work until the updated physical is complete and submitted. - All staff were inserviced on all citations received and this plan of correction. See attachment #9 - Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. See attachment #10 01/31/2018 Implemented
2380.113(c)(2)Staff # 1 had a TB test on 01/22/15 and not again until 10/30/17. 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.PERSON(S) RESPONSIBLE Deirdre Frey, Program Specialist & Shasta Stine, Program Supervisor CORRECTIVE ACTION(S) TAKEN ¿ Immediate correction for Staff #1 completed 10/27/17 (attachment #3) ¿ Staff TB test on 10/27/17 submitted to indicate compliance across programs (attachment #7) PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ Program Manager will monitor PPD due dates and inform Program Supervisors and appropriate staff members of upcoming due dates at least 30 days prior to expiration with a letter or email. A copy letter or email will be kept in employee file. ¿ PPD test results are due within a 2 year timeframe ¿ Program Supervisor will ensure that a PPD test result is submitted by the required due date. If physical is not submitted by date specified, the staff member will be unable to return to work until the PPD test had been administered and read. - All staff were inserviced on all citations received and this plan of correction. See attachment #9 - Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. See attachment #10 01/31/2018 Implemented
2380.173(9)Repeat Violation - 11/08/16 - Individual # 2's ISP dated 07/06/17 states that he/she can self medicate. Assessment dated 06/02/17 states that he/she is not self medicating. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.PERSON(S) RESPONSIBLE Shasta Stine, Program Supervisor CORRECTIVE ACTION(S) TAKEN - Upon review of citation, Supervisor was unable to determine where it was stated in the assessment reviewed by Licensor that individual #2 is not self-medicating. Question as to whether citation was in error. As best practice, corrective action and preventative measures have still been implemented. ¿ A Quarterly Meeting was held for Individual #2 on 11/2/17. The team confirmed he/she is self-medicating. ¿ An addendum to Individuals #2¿s previous assessment was made 11/3/17 to reflect he/she is self-medicating, as stated in the ISP. (Attachment #11) PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ Program Supervisor and audit teams will ensure that assessment and ISP matches for all individuals. ¿ If there is a discrepancy with the assessor and the information on the ISP, a team meeting will be held to resolve the inconsistency. ¿ If a change needs to be made to ISP, a letter or email will be sent to SC requesting that additional information be added to ISP regarding the needed changes for individual. - All staff were inserviced on all citations received and this plan of correction. See attachment #9 - Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. See attachment #10 01/31/2018 Implemented
2380.181(e)(10)Individual # 2's 06/02/17 initial assessment states "see attached" lifetime medical history. Lifetime medical history not attached nor located in record. The assessment must include the following information: A lifetime medical history.PERSON(S) RESPONSIBLE Shasta Stine, Program Supervisor CORRECTIVE ACTION(S) TAKEN ¿ Psychological Evaluation with Medical History information missing key piece of shunt surgery from 2004 to be considered an acceptable LMH. Shunt surgery was added to Medical History section of Psychological Evaluation by Program Supervisor based on information from ISP. (Attachment #2) PREVENTATIVE MEASURE(S) IMPLEMENTED ¿ All individuals' assessments will have a Lifetime Medical History attached. ¿ If an acceptable LMH cannot be obtained from Consumer, family, or Doctor, one will be created by the Program Supervisor from information provided by the ISP, annual physical, and any relevant information obtained by additional medical documentation. - All staff were inserviced on all citations received and this plan of correction. See attachment #9 - Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. See attachment #10 01/31/2018 Implemented
2380.186(c)(2)Individual # 2's 07/06/17 quarterly review did not provide information on SEEN plan utilization or effectiveness. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.PERSON(S) RESPONSIBLE Shasta Stine, Program Supervisor CORRECTIVE ACTION(S) TAKEN - An amendment to Individual # 2's Quarterly review was completed on 11/1/17 to include SEEN Plan specifics and its effectiveness. Revised Quarterly was distributed to all members of the team at the Quarterly Meeting 11/2/17. (Attachment #1) - All consumers with a SEEN Plan will have an added section in their Quarterly reviews to include specifics of the SEEN Plan and will note the effectiveness of the plan at Program. - All staff were inserviced on all citations received and this plan of correction. See attachment #9 - Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. See attachment #10 01/31/2018 Implemented
SIN-00104034 Renewal 11/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)Individual #1's ISP reviews dated 9/15, 10/15, 11/15, 1/16, 2/16, 3/16, 4/16, 5/16, 6/16, 7/16, 8/16, 9/16, 10/16 were not signed by program specialist. 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.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment #13 copy of Monthly for Consumer #1 signed by the Program Specialist and reviewed by the Assistant Director. 12/20/2016 Implemented
2380.36(g)Staff #1 was trained in frst aid on 3/18/14 and again on 10/6/16. Staff #3 was trained on first aid 2/14 and again on 10/6/16. The program did not have a minim of two staff certified in first aid between 3/16 and 10/16.There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment #10, #11 and #12 CPR certificates for all staff that are current. All new staff and transfers will receive CPF/First Aide as part of Orientation 12/20/2016 Implemented
2380.70(b)The first aid kit was not located in the first aid area. The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment #8 receipt for locking tote and attachment #9 Picture of 1st Aide Tote on shelf near cot. 12/20/2016 Implemented
2380.89(a)There was no fire drill held in January 2016 or March 2016.An unannounced fire drill shall be held at least once a month.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment # 7 Fire Drill Record with drills completed since inspection 12/20/2016 Implemented
2380.89(c)Repeat 12/29/15: The 10/31/16 fire drill did not indicate if 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.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment # 7 Fire Drill Record with drills completed since inspection 12/20/2016 Implemented
2380.111(c)(4)Individual #1's physical dated 6/15/16 did not inlcude hearing screening. The physical examination shall include: Vision and hearing screening, as recommended by the physician.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment # 6 physical for new Consumer Individual #1. 12/20/2016 Implemented
2380.111(c)(5)Individual #2 did not have tuberculin skin testing in the record. 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 Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment # 6 physical for new Consumer Individual #1. 12/20/2016 Implemented
2380.111(c)(10)Repeat 12/29/15: Individual #2's physcial dated 6/15/16 did not inlcude information pertinent to diagnosis in case of emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment # 6 physical for new Consumer Individual #1. 12/20/2016 Implemented
2380.173(9)Individual #1's ISP dated 10/28/15 states that they are self medicating. Individual #1's assessment dated 9/23/16 states that they are not self medicating. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to attachment #5 email to consumer #1¿s Supports Coordinator requesting a change in the ISP regarding ability to self medicate 12/20/2016 Implemented
2380.176(a)Individual #2 private information that contained SSN, phone number, and address was located in the trash can in the program area. Individual records shall be kept locked when they are unattended.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. 12/20/2016 Implemented
2380.181(b)Individual #2's assessment dated 5/2/16 and 7/12/16 was not updated after diagnosis of diabetes on 8/23/16.If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under §  2380.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7 Program Specialist/staff training sign-in and content. Also refer to Attachment #3 letter to Consumer #2's supports coordinator dated 12/6/16 and Attachment #4 updated assessment for consumer #2 12/20/2016 Implemented
2380.181(e)(4)Individual #2's assessment did not include unsupervised time. The assessment must include the following information: The individual¿s need for supervision.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7 Program Specialist/staff training sign-in and content. Also refer to Attachment #3 letter to Consumer #2¿s supports coordinator dated 12/6/16 and Attachment #4 updated assessment for consumer #2 12/20/2016 Implemented
2380.183(4)Individual #2's ISP indicated that they could be unsupervised at day program for supervision. No time period is specified. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment #3 email to Consumer #2¿s supports coordinator and Attachment #4 updated assessment for consumer #2 12/20/2016 Implemented
2380.184(b)Individual #2's ISP meeting only had individual, SC, and UCP in attentance. At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting.The Program Supervisor/Specialist is responsible to ensure that all regulations are adhered to and all documentation is completed accurately and within the time frame outlined in the 2380 Regulations. The Program Manager and or the Assistant Director of Adult Services is responsible to ensure the Program Specialist is in compliance with all regulations. Please refer to Attachment #1 page 1 to 7¿ Program Specialist/staff training sign-in and content. Also refer to Attachment #2 Sign-in sheet for ISP meeting held on 12/8/16 for Individual #1 12/20/2016 Implemented
SIN-00086366 Renewal 12/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)Staff person #2 did not sign or date the monthly documentation for Individual #2's participation and progress towards outcomes. 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.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also see Attachment #13 Monthly for Consumer #2 for January 2016. 02/25/2016 Implemented
2380.33(b)(18)Staff #2 did not coordinate trainings for direct service workers in the health and safety needs for Individual #3 who has on going seizures that are not bering documented.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 14 page 1 to 5 staff training log dated 1/15/16. 02/25/2016 Implemented
2380.36(d)Staff person #1 who was hired on 6/22/15 was not trained in program planning and implementation until 8/28/15. This was not completed within the 30 calendar days after the day of the inital employment. 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.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also see Attachment # 11 Transfer letter for SS new program Specialist dated 1/10/16 and Attachment # 12 pages 1 to 3 orientation checklist for SS with training dated listed and initialed by SS. 02/25/2016 Implemented
2380.53(b)Hand sanitizer was not in its original, labeled container that was located hanging by the front and back exits. Poisonous materials shall be stored in their original, labeled containers.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 14 page 1 and 2 staff training log dated 1/15/16. 02/25/2016 Implemented
2380.89(c)On 2/19/15 the fire drill log did not indicate the amount of time it too to evacuate. The fire drill log for this date had " Less than 60 seconds" to evacuate. 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.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 6 Fire Drill Form showing all drills after 2/19/15 have been documented correctly 02/25/2016 Implemented
2380.111(c)(3)The physical exam for Individual #1 dated 9/16/15 did not list the Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. This section on the physical exam was left blank. The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(4)The 9/16/15 physical examination form for Individual #1 did not include; Vision and hearing screening, as recommended by the physician. This section on the physical exam form did not contain any information, it was left blank. The physical examination shall include: Vision and hearing screening, as recommended by the physician.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(6)The physical examination form for Individual #1 dated 9/16/15 and the physical examination form for Individual #2 dated 7/16/15 did not include information if they were free of a serious communicable disease. This section of the physical exam form was left blank for Individual #1 & #2.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.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(7)The physical examination for Individual #1 dated 9/16/15 and the physical examination dated 7/16/15 for Individual #2 did not include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank and not completed on either physical 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.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(8)The physical examination for Individual #1 dated 9/16/15 and for Individual #2 dated 7/16/15 did not include: Physical limitations of the individual. This section of the physical examination form was left blank.The physical examination shall include: Physical limitations of the individual.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(9)The physical examination for Individual #1 dated 9/16/15 and for Individual #2 dated 7/16/15 did not include: Allergies or contraindicated medication. This section of the physical exam form was blank. The physical examination shall include: Allergies or contraindicated medication.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(10)The physical examination for Individual #1 dated 9/16/15 did not include: Medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical exam form was blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.111(c)(11)The physical examination for Individual #2 dated 7/16/15 did not include Special instructions for an individual's diet. This section of the physical exam form was blank.The physical examination shall include: Special instructions for an individual's diet.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment # 10 pages 1 to 7 current physical using the correct form which includes all required information 02/25/2016 Implemented
2380.173(7)Individual #1's record did not contain a copy of the current ISP. Each individual¿s record must include the following information:  A copy of the current ISP.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. 02/25/2016 Implemented
2380.181(e)(14)Individual #1's assessment dated 9/25/15 did not include the following information: The individual¿s 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.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment #9 email to Supports Coordinator requesting updated information an ability to swim plan be added to ISP dated 3/7/16 and Attachment #9 page 2 updated assessment page on swimming/water safety. 03/07/2016 Implemented
2380.181(f)Staff person #2 did not 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 for Individuals #1 & Individual #2. 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 Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment #4 invitation to ISP review for Consumer #2 dated 11/16/15 for 2/25/16 meeting and Attachment #5 reminder letter indicating assessment attached within 30 days prior to the planned meeting 02/25/2016 Implemented
2380.183(5)The ISP for Individual #1 did not including: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment #7 email to Supports Coordinator requesting SEEN plan be added to ISP dated 3/7/16 and Attachment #8 SEEN Plan for Consumer #1. 03/07/2016 Implemented
2380.186(b)Staff person #2 did not sign and date the ISP reviews for Individual #1 (12/8/15, 9/8/15, 6/8/15) or for Individual #2 (11/16/15, 8/17/15, 5/20/15, 3/26/15.)The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment #2 pages 1 to 3 nine month ISP Review for Consumer #2 dated 2/25/16 02/25/2016 Implemented
2380.186(c)(2)The ISP reviews for Individual #1 and Individual #2 did not include the following: A review of each section of the ISP- Community Involvement/activities was not being reviewed. There was no documentation of any community involvement or activities on the ISP reviews.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment #2 pages 1 to 3 nine month ISP Review for Consumer #2 dated 2/25/16 02/25/2016 Implemented
2380.186(d)Staff person #2 did not provide the ISP review documentation, including recommendations, to the SC or plan lead, and plan team members within 30 calendar days after the ISP review meeting for Individual #1 and Individual #2. There was no documentation that the ISP reviews where being sent out to any team member. 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. The Program Supervisor/Specialist is responsible to ensure that all 55PA Code Chapter 2380 Regulations are adhered to. This pertains to all documentation and physical site including equipment. Please refer to Attachment #1 pages 1 to 7 Program Specialist Training dated 1/5/16 and 2/25/16. Also refer to Attachment #2 pages 1 to 3 nine month ISP Review for Consumer #2 dated 2/25/16 and Attachment #3 revised ISP review Meeting sign-in sheet with column indicating team members received a copy of the review. 02/25/2016 Implemented
SIN-00072406 Initial review 12/08/2014 Compliant - Finalized