Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00154231 Renewal 04/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(d)The kitchen trash can did not have a lid.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.Citation was immediately corrected after inspection exit meeting. Action 1: Program Director completed In-service with all program staff on regulation. Action 2: Ongoing education with new staff on regulation. Action 3: Monitoring for compliance 04/19/2019 Implemented
2380.70(b)The first aid area did not have a pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.Citation was immediately corrected after inspection exit meeting. Action 1: Program Director completed In-service with all program staff on regulation. Action 2: Ongoing education with new staff on regulation. Action 3: Monitoring for compliance 04/19/2019 Implemented
2380.111(a)There was no physical exam completed for 2018 for individual #1Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Action 1: Letters will be sent by Program Manager via mail 45 and 30 days prior to physical being due. Action 2: Phone calls by Program Manager and/or Program Nurse to participant or family/ caregivers alerting them that they will not be able to attend the day program if their physical is not turned in on time will be made 15 days prior to physical expiration date. Action 3: Continued use and maintenance of tracking log to alert nurse and manger when physicals are coming due. 05/23/2019 Implemented
2380.111(c)(10)Individual #2's physical exam dated 6/26/18 did not include 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.Action 1: Program Director completed training with Program Nurse on checking submitted physicals for complete information. Action 2: If physicals have blank fields, program nurse will coordinate with health care provider to ascertain missing information. Action 3: Annual Audits for compliance by Compliance Department. 05/22/2019 Implemented
2380.113(b)Staff member #2's physical exam dated 8/23/17 was not signed/dated by the physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Action 1: Program Director completed Training and Education on regulation with Occupational Health Department. Action 2: Occupational Health department will not accept physical forms that are incomplete moving forward. Action 3: Annual Audit for compliance by Compliance Department. 05/22/2019 Implemented
2380.113(c)(4)Staff member#1's physical exam dated 4/5/19 did not include medical problems, it was left blank.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.Action 1: Program Director completed Training and Education on regulation with Occupational Health Department. Action 2: Occupational Health department will not accept physical forms that are incomplete moving forward. Action 3: Annual Audit for compliance by Compliance Department. 05/22/2019 Implemented
2380.181(c)It could not be determined what the assessment for individual #2 was based on.The assessment shall be based on assessment instruments, interviews, progress notes and observations.Action 1: This citation was not corrected on the Annual Assessment form reviewed due to the participant passed away after the inspection date and before the report was provided. Action 2: Audit to ensure that no Assessments are being completed on the older version of the Assessment Form to ensure statement regarding where information is collected is on them completed 5/20/2019. Action 3: Training and Education with Program Specialist completing documentation to prevent further incidents of compliance completed. Action 4: Annual Audits to monitor compliance by Compliance Department. 05/23/2019 Implemented
2380.181(e)(5)It could be determined if individual #2 has the ability to self- administer medications.The assessment must include the following information: The individual¿s ability to self-administer medications.Action 1: This citation was not corrected on the Annual Assessment form reviewed due to the participant passed away after the inspection date and before the report was provided. Action 2: Training and Education with Program Specialist completing documentation to prevent further incidents of compliance completed. Action 3: Annual Audits to monitor compliance by Compliance Department. 05/23/2019 Implemented
2380.181(e)(6)It could not be determined if individual #2 has the ability to avoid poison materials.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.Action 1: This citation was not corrected on the Annual Assessment form reviewed due to the participant passed away after the inspection date and before the report was provided. Action 2: Training and Education with Program Specialist completing documentation to prevent further incidents of compliance completed. Action 3: Annual Audits to monitor compliance by Compliance Department. 05/23/2019 Implemented
2380.181(f)Individual #1's annual assessment was not sent to the team 30 days prior to the ISP meeting.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).Action 1: Annual assessments are sent to the SC by the Program Manager via email when notification of the ISP meeting is provided. Email copy is kept in chart as a record of this. Assessments are sent at the minimum 30 days, or ON THE DAY notification is provided to the program if it is less than 30 days. Action 2: Annual Audits to monitor compliance by Compliance Department. 05/23/2019 Implemented
2380.181(f)Individual #2's annual assessment was not sent to the team 30 days prior to the ISP meeting.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).Action 1: Annual assessments are sent by Program Manager to the SC via email when notification of the ISP meeting is provided. Email copy is kept in chart by Program Manager as a record of this. Assessments are sent at the minimum 30 days, or ON THE DAY notification is provided to the program if it is less than 30 days. Action 2: Audits to monitor compliance by Compliance Department. 05/23/2019 Implemented
2380.184(c)Individual #2's ISP meeting participants and signatures could not be found during inspection.A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.Action 1: When Inglis attends ISP meeting, Program Manager makes a copy of the signature page is after the meeting ends. Action 2: When Inglis does not attend, but is aware the meeting occurred, the Program Manager will request a signature page from SC via email. The email will be printed and made part of the record. Action 3: Audit for compliance. 05/23/2019 Implemented
2380.186(b)Individual #1's ISP 3 month review was not signed and dated by the program specialist and the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Action 1: Annual assessment was updated and reviewed by program director with participant and signed and dated. Action 2: In-service with Program Specialists on this topic completed 5/22/2019. Action 3: Audit for compliance. 05/22/2019 Implemented
SIN-00127878 Renewal 12/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)REPEAT 12/07/16- Individual # 1's annual physicals were late. Physical dated 03/8/16 and 05/24/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Manager and Program Nurse are responsible for the following actions: Letters will be sent home 45 and 30 days prior to physical being due. Phone calls to participant or family/ caregivers alerting them that they will not be able to attend the day program if their physical is not turned in on time will be made 15 days prior to physical expiration date. Continued use and maintenance of tracking log to alert nurse and manger when physicals are coming due. 01/30/2018 Implemented
2380.111(c)(1)Individual # 2's physical dated 08/15/17 does not indicate that the physician reviewed the medical historyThe physical examination shall include: A review of previous medical history.Updates to physical form completed 1/26/18 (attachment #2). Training with program nurse on new physical form and responsibility to check for completeness (completed 1/30/18 ¿ attachment #10). Inglis compliance department to audit for compliance. 01/30/2018 Implemented
2380.111(c)(7)Individual # 2's physical dated 08/15/17 does not assess health maintenance needs. Space left blankThe physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Updates to physical form completed 1/26/18 (attachment #2). Training with program nurse on new physical form and responsibility to check for completeness (completed 1/30/18 ¿ attachment #10). Inglis compliance department to audit for compliance. 01/30/2018 Implemented
2380.111(c)(10)Individual # 2's physical dated 08/15/17 does not indicated information pertinent to diagnosis in case of an emergency. Individual # 1's physical dated 05/24/17 did not include information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Updates to physical form completed 1/26/18 (attachment #2). Training with program nurse on new physical form and responsibility to check for completeness (completed 1/30/18 ¿ attachment #10). Inglis compliance department to audit for compliance. 01/30/2018 Implemented
2380.113(c)(4)Staff # 4's 07/21/17 physical exam did not indicated physical limitations or medical problems. Space left blank.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.Program Director completed training with Occupational Health Department (completed 1/30/18 ¿ attachment #9). Inglis compliance department will audit for compliance. 01/30/2018 Implemented
2380.173(6)(ii)No signature page for Individual # 2's ISP meeting on 10/13/17 contained in recordEach individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting.When Inglis attends ISP meeting, Program Manager and Director are responsible for making a copy of the signature page is made after the meeting ends. When Inglis does not attend, but is aware the meeting occurred, they will request a signature page from SC via email. The email will be printed and made part of the record. Inglis Compliance office will Audit for compliance. 01/30/2018 Implemented
2380.173(7)Individual # 1's current ISP was not contained in the record.Each individual's record must include the following information:  A copy of the current ISP.Program Director completed audit of charts ¿ all participant records updated with most current version of the ISP (completed 2/2/18). Inglis Compliance department to audit for compliance. 02/02/2018 Implemented
2380.181(e)(3)(iii)Individual # 2's assessment dated 08/01/17 does not indicate his/her current level of performance and progress in the area of personal adjustment.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Personal adjustment.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(5)Individual # 2's assessment dated 08/01/17 does not indicate his/her ability to self-medicate. Individual #2 is administered all medication by a nurse at the program'. Individual # 1's 11/03/17 assessment does not indicate his/her ability to self-medicate.The assessment must include the following information: The individual¿s ability to self-administer medications.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(7)Individual # 2's assessment dated 08/01/17 does not indicate his/her ability to sense and move away from heat sourcesThe 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.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(10)Individual # 2's assessment dated 08/01/17 does not include a lifetime medical history. Individual # 1's assessment dated 11/03.17 does not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.All Lifetime medical histories were removed from their own section of the chart to the Assessment area of the chart. Updates to annual and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education Program Nurse on where to file Lifetime medical history (completed 2/1/2018 ¿ attachment #8). 02/01/2018 Implemented
2380.181(e)(12)Individual # 2's assessment dated 08/01/17 does not indicate his/her recommendations for specific areas of training. ) Individual # 1's assessment dated 11/03/17 does not indicate his/her recommendations for specific areas of trainingThe assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(13)(i)Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for Health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(13)(ii)Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for Motor and communication skillsThe 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.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(13)(iv)Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for SocializationThe assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.181(e)(13)(v)Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for RecreationThe assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.183(3)The method of evaluating progress towards goals in Individual # 1's current ISP states SC will document progress in monitoring concern sheets. Individual # 1 will go out on community outings with his/her staff of his/her choice during the week.' Inglis House not included in evaluation of outcome.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.Email to individual 1¿s SC to request new outcome for day program (attachment #7). Will follow up when response is received. (Note- individual #1 is scheduled to move into LTC in February 2018, so no resolution to this issue may occur). emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. 01/30/2018 Implemented
2380.183(7)(i)Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in vocational programming. Space left blank. ) Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.Updates to Quarterly ISP reviews completed to review this information (completed 1/26/18 - attachment #4)Emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. 01/30/2018 Implemented
2380.183(7)(i)Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in vocational programming. Space left blank. ) Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Vocational programming.Program specialists send emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. 01/30/2018 Implemented
2380.183(7)(iii)Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in competitive community integrated employment. Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in community integrated employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following:  Competitive community-integrated employment.emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. 01/30/2018 Implemented
2380.183(7)(iii)Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in competitive community integrated employment. Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in community integrated employmentThe ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. 01/30/2018 Implemented
2380.186(a)Individual # 1's ISP reviews for the annual review year do not include review of outcome socialization'.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.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, to be completed 5/1/2018). 05/01/2018 Implemented
2380.186(b)) Individual # 2 did not sign quarterly review on 11/02/16, 02/02/17 or 05/01/17. Individual # 1 did not sign quarterly reviews on 02/07/17, 05/05/17, 08/04/17 and 09/07/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, to be completed 5/1/2018). 05/01/2018 Implemented
2380.186(c)(1)Program Specialist indicated that Individual # 1 is working on an outcome to socialize at day program. Monthly documentation states Individual # 1 socialized today'. No details of support or services provided to Individual # 1.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.186(c)(2)Individual # 2's ISP reviews dated 08/01/17, 05/01/17, 02/02/17 and 11/02/16 do not include reviews of seizures (protocol/frequency). ISP review dated 05/01/17 did not include the health updated of an illness described in 03/03/17 progress note. 08/01/17 review did not include 07/10/17 progress note of individual # 2 coming to program with abrasions. 3 seizures occurred on 03/03/17 at the program without documentation in reviews. The meaningful day outcome was not reviewed as per no documentation of the tracking of Individual # 2's engagement in activities while at the program two times per day.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). 05/01/2018 Implemented
2380.186(d)No documentation that Individual # 2's ISP reviews were sent to team members within 30 days of meetings.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.When Inglis is made aware of the ISP meeting, Program Manager is responsible for sending Annual Assessment and newly formatted quarterly ISP reviews to the SC at time of notification of ISP meeting. All communications are done via email, and will be printed and placed in the participant record to document the communication. 02/02/2018 Implemented
2380.186(e)No option to decline Individual # 2's ISP reviews contained in record.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Issue 8: Program Manager and Program Director are responsible to collect this information at ISP¿s meetings when possible. Form created to allow for option to decline (attachment #6) 02/02/2018 Implemented
2380.188(a)- Individual # 1 has a seizure disorder. There is no seizure protocol in place.The facility shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment.Program Manager and Program nurse are responsible for the following actions: create a seizure protocol form (completed 1/2/2018 ¿ attachment #1). Update all participant records with a seizure protocol if needed (completed 1/12/18). Physical Form updated to collect seizure protocol at time of admission and annually (completed 1/26/18 ¿ attachment #2). Complete seizure training with all program staff at least annually (completed 1/2/18 ¿ attachment #3). 01/26/2018 Implemented
2380.188(b)No documentation that Individual # 1 and Individual # 2 were provided services for participation in community life.The facility shall provide opportunities and support to the individual for participation in community life, including work opportunities.Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (scheduled 2/2/2018 ¿ attachment #5). Phase in new documentation starting 2/1/2018, to be completed 5/1/2018). 05/01/2018 Implemented
SIN-00104451 Renewal 12/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's physical examination dated 7/5/16 wa more than a year from previous physical examination dated 6/15/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Action 1: Letters will be sent home 45 and 30 days prior to physical being due by Program Manager. This information is tracked via Operational Tracker already in use. Action 2: Phone calls to participant or family/ caregivers alerting them that they will not be able to attend the day program if their physical is not turned in on time will be made 15 days prior to physical expiration date (responsible party: shared responsibility of Program Manger and Program Nurse). Action 3: Continued use and maintenance of tracking log to alert nurse and manger when physicals are coming due (Log maintained by Program Manager and Program Nurse). 12/09/2016 Implemented
2380.111(c)(3)Individual #2's physical examination dated 2/8/16 did not include diptheria and tetanus immunization. The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Action 1: Physical was sent to doctors' office to obtain missing information (Responsible Party: Program Nurse). Action 2: Education with LPN to review use of checklist so that physicals being turned into the program are checked for completion. If a physical is not complete when turned in, LPN is responsible for contacting individual and/or dr's office for missing information (responsible party: Program Manager/Program Nurse). Action 3: Audits to monitor compliance (Inglis Compliance Department responsible for audit/monitoring). 12/23/2016 Implemented
2380.111(c)(8)Individual #2's physical examination dated 2/8/16 did not include information pertinent to diagnosis in case of an emergency. The physical examination shall include: Physical limitations of the individual.Action 1: Physical was sent to doctors' office to obtain missing information (Responsible Party: Program Nurse). Action 2: Education with LPN to review use of checklist so that physicals being turned into the program are checked for completion. If a physical is not complete when turned in, LPN is responsible for contacting individual and/or dr's office for missing information (responsible party: Program Manager/Program Nurse). Action 3: Audits to monitor compliance (Inglis Compliance Department responsible for audit/monitoring). 12/23/2016 Implemented
SIN-00084472 Renewal 10/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The participants of the program exited to the lobby of the building during the fire drills. There was no documentation to show the lobby was a fire safe area.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Action 1: UL Recognized Risk Engineer and Risk Control Consultant from Inglis' existing insurance company completed on site inspection 11/18/2015. He did an analysis of the area the Day Program participants evacuate to document compliance with regulation. Verbally gave approval of area, expect to receive written report in 2-3 weeks. Joe K, Safety Manager responsible staff. Action 2: Annually, our insurance company will provide this inspection and the required documentation. Inglis' Safety Manger is responsible for collecting this documentation for the Day Program. This documentation will be kept with our annual fire safety inspection information. Joe K, Safety manager and Nicole P. Program Manager responsible staff. Action 3: Audits to occur to monitor compliance. Nicole A, compliance department responsible staff. 11/18/2015 Implemented
2380.111(c)(3)Individual #1 was admitted to the program on 7/17/15. The physical examination, dated 2/27/15, did not include a tetanus/diptheria immunization.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Action 1: Physical examination form was sent to doctor's office to obtain missing information. Completed 11/10/15. (attachment #13) Action 2: Education with LPN to review the use of required documentation checklist so that physical examination documentation submitted is checked for completion. If a physical examination document for a participant is not complete upon submission,the LPN is responsible for contacting the individual and/or physician¿s office to obtain all missing information. training completed 11/16/15 (attachment #14) Action 3: Audits to occur to monitor compliance. Nicole A, compliance department responsible staff. 11/16/2015 Implemented
2380.111(c)(6)Individual #2's physical exam, dated 8/21/15, did not include if the individual is free of communicable disease and what precautions to take if a communicable disease is present.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.Action 1: Physical examination form was sent to doctor's office to obtain missing information. Completed 11/2/15. (attachment #15) Action 2: Education with LPN to review the use of required documentation checklist so that physical examination documentation submitted is checked for completion. If a physical examination document for a participant is not complete upon submission, the LPN is responsible for contacting the individual and/or physicians office to obtain all missing information. training completed 11/16/15 (attachment #14) Action 3: Audits to occur monthly to monitor compliance. Nicole A, compliance department responsible staff. 11/02/2015 Implemented
2380.173(1)(ii)Individual #2's record did not include hair color, eye color, weight, and identifying marks. Individual #4's record did not include height, weight, hair color, eye color, and 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.Action 1: Records reviewed have been corrected. Annual assessment form has been updated to document this information clearly and annually. Completed 10/15/15. Nicole P, program manager responsible staff. (attachment #11 & 4) Action 2: In-service & educate other staff who complete assessments on documentation requirements to ensure compliance with the regulation. Completed 10/26/15, Nicole P., responsible staff. (attachment #6) Action 3: For New admissions to the program, this information will be collected at the intake interview. Intake Interview Form has been updated to reflect documentation requirements. Completed 10/16/15. (attachment #7) Action 4: Audits to occur bi-annually to monitor compliance. Nicole A, compliance department, responsible staff. 10/26/2015 Implemented
2380.173(1)(iv)The records of Individual #2 and #4 did not include religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Action 1: Records reviewed have been corrected. Annual assessment form has been updated to document this information clearly and annually. Completed 10/15/15. Nicole P, program manager responsible staff. (attachment #11 & #4) Action 2: In-service & educate other staff who complete assessments on documentation requirements to ensure compliance with the regulation. Completed 10/26/15, Nicole P., responsible staff. (attachment #6) Action 3: For New admissions to the program, this information will be collected at the intake interview. Intake Interview Form has been updated to reflect documentation requirements. Completed 10/16/15. (attachment #7) Action 4: Audits to occur bi-annually to monitor compliance. Nicole A, compliance department, responsible staff. 10/26/2015 Implemented
2380.173(1)(v)Individual #3's record did not include a dated photograph.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Action 1: Photo, which was taken and dated 12/9/2014 was presented at time of exit interview. It was placed on the chart 10/9/2015 by Nicole P. program manager. (attachment #12) Action 2: Chart review to ensure all other participants have a photo on their chart. Photos are taken on admission and placed in electronic record and in paper record. Nicole P. responsible staff. completed 10/12/15. Action 3: Auditing to occur bi-annually to monitor compliance, Nicole A, compliance department responsible staff. 10/09/2015 Implemented
2380.181(c)Individual #4's assessment, dated 11/11/14, and Individual #2's assessment, dated 3/1/15, did not include the basis of the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations.Action 1: Assessments for Individuals #2 and #4 were updated to include the basis of the assessments. Action 2: Chart review to ensure all other participants have a complete assessment on their chart. Action 3: Auditing of all participants assessments to occur bi-annually to monitor compliance, Nicole A, compliance department responsible staff. 11/23/2015 Implemented
2380.181(e)(6)Individual #4's assessment, dated 11/11/14, did not include the ability to safely use or avoid poisonous materials.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.Action 1: Corrections have been made to Individual #4 and #1s assessments. completed 10/12/2015. (see attachments #4) Action 2: All existing Annual assessments will be reviewed to ensure compliance with this regulatory requirement if needed, amendments will be made during quarterly reviews. Nicole P, program manager responsible staff. Plan to be completed by 1/1/2016. Action 3: Re-Educate all staff who write annual assessments (Jen W.) on documentation requirements to ensure compliance with this regulation. completed 10/26/15. (attachment #6) Action 4: Audits to occur to monitor compliance, Nicole A. compliance department responsible staff. 10/26/2015 Implemented
2380.181(e)(10)Individual #1's assessment, dated 9/2/15, and Individual #3's assessment, dated 10/5/15, did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.Action 1: Lifetime Medical history completed for all missing persons completed 10/15/15. (attachment #8 & #9) Action 2: Education with LPN, who is responsible for the completion of the lifetime medical history, on the regulatory requirements to ensure compliance with timely completion. completed 10/12/15. (attachment #10) Action 3: Audits to occur bi-annually to monitor compliance. Nicole A, compliance department responsible staff. 10/15/2015 Implemented
2380.181(e)(14)Individual #1's assessment, dated 9/2/15, did not include 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.Action 1: Corrections have been made to Individual #4 and #1s assessments. completed 10/12/2015. (attachment #5) Action 2: All existing Annual assessments will be reviewed to ensure compliance with this regulatory requirement if needed, amendments will be made during quarterly reviews. Nicole P, program manager responsible staff. Plan to be completed by 1/1/2016. Action 3: Re-Educate all staff who write annual assessments (Jen W.) on documentation requirements to ensure compliance with this regulation. completed 10/26/15. (attachment #6) Action 4: Audits to occur bi-annually to monitor compliance, Nicole A. compliance department responsible staff. 10/26/2015 Implemented
2380.181(f)Individual #4's assessment, dated 11/11/14, was sent to the Supports Coordinator on 9/11/15. The Individual Support Plan meeting was held on 9/11/15.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).Action 1: Annual assessments are sent to the Supports Coordinators (SC) via email 30 days prior to the ISP meeting date. Email copy is kept in chart as a record of this. Assessments are sent at the minimum 30 days, or ON THE DAY notification is provided to the program if it is less than 30 days (as was the case in the reviewed chart). Program Manager is responsible party for being compliant with ensuring that all assessments are sent to the SC 30 days prior to the ISP meeting date for all participants of the program, starting within 30 days of receipt of this plan of correction. [SW 11.23.15] Action 2: Audits to occur bi-annually to monitor compliance, Nicole A, compliance department, is responsible staff. 10/09/2015 Implemented
2380.182(c)An Individual Support Plan (ISP) was not developed for Individual #2.The plan lead shall be responsible for developing and implementing the ISP, including annual updates and revisions.Action 1: ISP's for these three individuals was collected from SC or created and added to the participants record. (see attachment #1) Action 2: ISP's for all individuals in the program will be obtained from SC's. When SC declines providing a copy of the ISP, one will be written by Program Specialist using Annotated ISP form provided by state. Nicole P, Program Manager, responsible staff, plan to be completed by 1/1/2016. Action 2: ISPs will be collected from SC's when possible for new admissions. When SC refuses to provide the individuals ISP to the program, the program specialist will write an ISP within accordance with the regulations using the annotated ISP Form provided by the state. Nicole P., Program Manager responsible staff. Action 2: Annual audits to monitor compliance, Nicole A, compliance department, responsible staff 11/18/2015 Implemented
2380.182(d)(2)Individual #3 was admitted to the program on 12/5/2014. An Individual Support Plan was not developed. Individual #1 was admitted to the program on 7/7/2015. An Individual Support Plan was not developed.The plan lead shall develop, update and revise the ISP according to the following: The initial ISP shall be developed within 90 calendar days after the individual's admission date to the facility.Action 1: ISP's for these three individuals (#1, #2, #3) was collected from SC or created. (see attachment #2 &3) Action 2: ISP's for all individuals in the program will be obtained from SC's. When SC declines providing a copy of the ISP, one will be written by Program Specialist using Annotated ISP form provided by state. Nicole P, Program Manager, responsible staff, plan to be completed by 1/1/2016. Action 2: ISPs will be collected from SC's when possible for new admissions. When SC refuses to provide the individuals ISP to the program, the program specialist will write an ISP within accordance with the regulations using the annotated ISP Form provided by the state. Nicole P., Program Manager responsible staff. Action 2: Annual audits to monitor compliance, Nicole A, compliance department, responsible staff 11/18/2015 Implemented
SIN-00065119 Renewal 08/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.56The ventilation in bathrooms #1, #2 and #3 were inoperable. Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning.During the inspection, a Preventative maintenance check was bring performed. These checks are done monthly to all areas of the building. The motor on the ventilation system needed maintenance. Parts were ordered 8/27/2014, and work was completed 9/8/2014. Director of Engineering Services is responsible for ongoing compliance. Preventative maintenance checks will continue to be conducted monthly. The Director of Quality Assurance/Quality Management will ensure monthly checks are completed by developing a tool to be completed and quarterly selecting a month to evaluate. The tool will be able to clearly evaluate and ensure that all areas of the building are in compliance with regulations. 09/08/2014 Implemented
2380.111(c)(4)Individual #1's physical examination dated 6/25/14 did not include hearearing or vision screening. Individual #2's physical examination dated 1/9/14, did not include vision or hearing screening. The physical examination shall include: Vision and hearing screening, as recommended by the physician.After speaking with Melissa Clemmons and reviewing chapter 6400, regulation 141(b), On 10/8/2014, The Agency's LPN at Inglis Adult Day Program completed a general vision and hearing screening. She checked for significant areas of impairment, and no areas were observed. Moving forward, the Agency's LPN has a checklist (sent via email) that she will use to ensure physicals coming to Inglis are completed in all necessary areas. Doctor's offices of Individual #1 and Individual #2 have been educated on the need for all completed information. The Agency's LPN is responsible for continuing this informal information spreading to ensure compliance and awareness. These two individuals practitioners have been made aware via telephone call from the LPN, that it is of vital importance they complete all sections of the physical, including a vision and hearing screening. All interactions with practitioners moving forward will stress this information as well to ensure ongoing compliance. In the future, if a practitioner declines to complete the screenings, the programs LPN will conduct her screening and make recommendations as needed. 09/26/2014 Implemented
SIN-00038635 Renewal 07/18/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)One staff's accumulated training hours was 23 hours. (c)  Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.Staff of the Adult Day Program participate in annually scheduled in-services, as well as as-needed and as-available in-services and trainings. Generally, these trainings far exceed the minimum 24 training hours required. To ensure that this area of non-compliance does not occur again the following have been implemented: ¿ Tracking sheet to monitor accumulated hours of training will be checked monthly by program manager. ¿ Collaboration between Inglis Nurse Education Department and Program Manager will occur quarterly (first meeting occurred 8/2/2012) 08/02/2012 Implemented
2380.181(a)2 Individual's assessments did not contain the full required content. (a)  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.In response to survey, documentation currently used at the Inglis Day Program was reviewed and modified to accurately meet the regulations. ¿ Updated Annual Assessment Form to answer all required questions and areas of need for the participants, related to section 2380.181(a) ¿ Updated Lifetime Medical Form ¿ Updated Nurses Progress Notes ¿ Tracker used to monitor compliance with regulation updated for all participants 08/13/2012 Implemented
2380.186(a)2 individual records reviewed did not include review of the ISP services and expected outcomes. (a)  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.In response to survey, documentation currently used at the Inglis Day Program was reviewed and modified to accurately meet the regulations. ¿ Updated Quarterly Assessment Form to answer all required questions and areas of need for the participants, related to section 2380.186(a) ¿ Tracker used to monitor compliance with regulation updated for all participants ¿ Tracker and dates of assessments aligned with ISP review dates. 08/15/2012 Implemented