Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217157 Renewal 01/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(b)The first aid area did not contain a pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.On January 16, 2023, Center Director purchased 2 pillows. One pillow will be stored with bed and the second pillow will be stored in Center Director Office in cabinet for extra supply. Center Director has added pillow and blanket to Monthly Supply Check List. 01/16/2023 Implemented
SIN-00171004 Renewal 02/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Immunizations were not currently listed on physical exams dated on 4/3/19 and 4/2/18 for individual 1; Tetanus immunization date is unknownThe physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Prior to admission, request of updated immunization record with physical form to be completed by PCP. First check of the form will be performed by the nurse. Second check of the form will be performed by the Center Director. Admission will not be allowed until all paperwork is received and completed accurately. Attachment #2 03/03/2020 Implemented
2380.111(c)(10)Information pertinent to diagnosis in case of emergency was not found on individual 1's annual physical exam dated on 4/3/19. The field was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.First check of physical will be performed by the nurse. Second check of the physical will be performed by the Center Director. If any information is missing from physical form, it will be returned to the clinician on the day it is reviewed. 03/03/2020 Implemented
2380.181(a)Assessment was not completed annually for individual 1. The previous assessment was completed 3/2018 and subsequent assessment was not completed until 8/5/19.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.Between terminating Program Specialist on March 22, 2019 and hiring new Program Specialist on April 16, 2019, Center Director was acting Program Specialist during the interim. On hiring new Program Specialist, Regional / Center Directors trained and created a excel sheet for all ODP paperwork due dates. Upon using excel sheet the new Program Specialist found an assessment uncompleted and corrected it. She then reviewed every chart. The Program Specialist will and is using the new excel sheet to ensure that all ODP paperwork is being completed on time. 08/05/2019 Implemented
2380.181(f)There was no documentation verifying the assessment dated 8/5/19 for individual 1 was sent to team 30 days prior to ISP meeting.The 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 will email the assessment to the team 30 days prior to ISP meeting. Outlook Calendar reminders will be set so this step is not overlooked. The assessment will be added to the excel check list due date by adding another column to check off that assessment was sent. A copy of the email will be attached to the assessment. Attachment #1 03/03/2020 Implemented
SIN-00144255 Renewal 10/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The drawer on the entertainment center in the program area was missing a knob.Floors, walls, ceilings and other surfaces shall be in good repair.it is important for all surfaces be in good repair to ensure the health and safety of all members. At the time of the inspection the knob from the entertainment center was missing. On 11/12/2018 the knob was replaced with a new functioning knob. (Attachment # 5) The Center Director will do a walkthrough of the center on a weekly basis to ensure all surfaces are in good repair and contact the handyman to complete repairs if necessary. 11/12/2018 Implemented
2380.111(c)(10)Individual #1's physical exam dated 6/28/2018 did not indicate if there was any medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.It is important to have a current physical for all person supported within the program in order to ensure their health and safety. Individual #1 physical did not include information regarding his medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 physical was updated 11/14/2018 that states that call 911 in case of emergency. (Attachment #3) The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information. The RN and Center Director were both trained on their responsibility on 11/5/2018 (Attachment #4) on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance 11/14/2018 Implemented
2380.181(d)Individual #1's Annual Assessment does not have the complete date (month, day & year).The program specialist shall sign and date the assessment.The Program Specialist was trained on completion of assessments on 11/5/2018 and she will ensure that all Assessments for all members are signed and dated in the future. (Attachment #1) 11/05/2018 Implemented
2380.181(e)(12)Individual #1's Annual Assessment dated 6/2018 does not include Recommendations for additional training.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The program specialists updated the assessment for individual #1 to include recommendations for areas of training, vocational programming and competitive community-integrated employment. (Attachment #2) 11/14/2018 Implemented
2380.181(e)(13)(v)Individual #1's Annual Assessment dated 6/2018 does not include progress and growth in the area of recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.The Program Specialist updated the assessment for individual #1 to include progress over the last 365 calendar days and current levels in the following areas: Recreation (Attachment 2) 11/14/2018 Implemented
2380.181(e)(13)(vi)Individual #1's Annual Assessment dated 6/2018 does not include progress and growth in Community Involvement.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.The Program Specialist updated the assessment for individual #1 to include progress over the last 365 calendar days and current levels in the following areas: Community Involvement (Attachment #2) 11/14/2018 Implemented
SIN-00241170 Renewal 02/16/2024 Compliant - Finalized
SIN-00129896 Initial review 03/01/2018 Compliant - Finalized