Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224904 Renewal 05/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's Tetanus, Diphtheria, and Pertussis vaccinations were completed on 1/15/2013 and then again 2/1/2023.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1"s Tetanus, Diphtheria, and Pertussis (TDP) vaccinations were completed on 2/1/2023 and are now regulatory compliant. TDP dates for all other program individuals were immediately reviewed to ensure compliance. 06/01/2023 Implemented
2380.181(f)Individual #1's assessment complete 3/29/2023 was provided to the plan team on 3/29/2023 for the ISP meeting held 3/3/2023.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/Supervisor has reviewed current assessment and expected ISP meeting dates for all individuals to determine any immediate needs for assessment completion or adjusting of ISP meeting dates in order to ensure regulatory compliance. 06/01/2023 Implemented
SIN-00205959 Renewal 06/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)2380.111(d) states: Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. Individual #1 had a tuberculin skin test placed by a medical assistant on 8/17/21; the results of the tuberculin skin test were read by a medical assistant on 08/19/21.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.Letter was prepared by Program Director and will be sent to guardians of all individuals prior to physical/mantoux appointments. Letter will inform guardians of what medical staff, per regulations, are able to place and read the mantoux test. 06/17/2022 Implemented
2380.113(c)(2)Program Specialist #1's most recent tuberculin evaluation was completed on 01/10/20.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Program Specialist was immediately scheduled for physical and mantoux test. Program Specialist attended appointment on 6/14/2022 - physical was completed and mantoux was placed. 06/17/2022 Implemented
SIN-00144864 Renewal 11/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The written fire drill record completed for the drill held 8/23/18 did not include the exit route used.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 Director updated the Fire Drill form on 11/8/19 to include a specific space that is labeled ¿Exit Route Used¿ (supporting document #1, new fire drill form). The Program Director will train AHC staff on the new Fire Drill form during a group staffing on 11/19/18 (supporting document #2, group staffing signature page). Each month when a fire drill is completed, the responsible staff completing the form will review form to ensure that it is completed in its entirety prior to giving it to the Program Director. The Program Director will then review the fire drill form to ensure that all necessary information is present and initial it prior to filing it. The Operations Director will review the monthly Fire Drill form with the Program Director during regular supervision and at least quarterly to ensure regulatory standards are being met. The Program Director was retrained on this standard when meeting with the Operations Director on November 21, 2018. [Documentation of trainings and reviews shall be kept. (DPOC by AES,HSLS on 11/27/18)] 11/21/2018 Implemented
2380.111(c)(4)Individual #1's physical examination, completed 4/2/18, did not include a vision and hearing screening; this section was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Each month the Program Director will send a reminder letter to the family or caregiver of any individual that is in need of a physical the next month. The letter will include a highlighted paragraph stating that all areas on the physical form must be filled in completely (supporting document #3, example of the letter that will be sent out). Once the physical is returned to the AHC the Program Director will review physical form to ensure that there are no blanks. If there are blanks on the form it will be sent back to the family or caregiver so that they can get the form completed in full and then return it to the program again. A form was developed on 11/21/18 that will be sent back with the physical indicating the missing portions (supporting document #4). Program Director will complete monthly chart audits where the physical form will be examined to make sure that there are no blanks. The Operations Director will review the physical forms that were due each month with the Program Director during regular supervision and at least quarterly to ensure regulatory standards are being met. The Program Director was retrained on this standard when meeting with the Operations Director on November.[Within 2 weeks of receipt of the plan of correction, the program specialist shall audit all individuals current physical examination to ensure all required information is included and health needs are provided. Aforementioned plan to obtain missing information shall be implemented. Documentation of trainings, audits and reviews shall be kept. (DPOC by AES,HSLS on 11/29/18)] 11/21/2018 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 4/2/18, did not include medical 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.Each month the Program Director will send a reminder letter to the family or caregiver of any individual that is in need of a physical the next month. The letter will include a highlighted paragraph stating that all areas on the physical form must be filled in completely (supporting document #3, example of the letter that will be sent out). Once the physical is returned to the AHC the Program Director will review physical form to ensure that there are no blanks. If there are blanks on the form it will be sent back to the family or caregiver so that they can get the form completed in full and then return it to the program again. A form was developed on 11/21/18 that will be sent back with the physical indicating the missing portions (supporting document #4). Program Director will complete monthly chart audits where the physical form will be examined to make sure that there are no blanks. The Operations Director will review the physical forms that were due each month with the Program Director during regular supervision and at least quarterly to ensure regulatory standards are being met. The Program Director was retrained on this standard when meeting with the Operations Director on November. [Within 2 weeks of receipt of the plan of correction, the program specialist shall audit all individuals current physical examination to ensure all required information is included and health needs are provided. Aforementioned plan to obtain missing information shall be implemented. Documentation of trainings, audits and reviews shall be kept. (DPOC by AES,HSLS on 11/29/18)] 11/21/2018 Implemented
SIN-00125343 Renewal 11/30/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)The monthly documentation for Individual #1 and Individual #2 from November 2016 through October 2017 were not signed and dated by a program specialist. The monthly documentation for Individual #3 from August 2017 through October 2017 were not signed and dated by a program specialist. The monthly documentation for Individual #4 from January 2017 through October 2017 were not signed and dated by a 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.Their was space made available on the monthly documentation for the Program Specialist to review/sign and date. This change was completed by the Program Director with the Program Specialist being the person responsible for monitoring the form to remain in compliance for future inspections. The corrected form was submitted on 11/30/2017 on the day of inspection to Tonya Volkman for review. [Immediately, the CEO or designee shall educated the program specialist(s) of the responsibilities of the position as per 2380.33(b)(1)-19) and the new forms and process for reviewing and signing and dating monthly documentation of the individuals' participation and progress toward outcomes. Documentation of trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individual monthly documentation to ensure that is reviewed, signed and dated by the program specialist. Documentation of reviews shall be kept. (AS 12/6/2017)] 12/01/2017 Implemented
2380.111(c)(5)The two most recent Tuberculin skin testing for Individual #3 were completed on 1/4/14 and 10/6/16.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.Addition to Mantoux Administration form: it will now be stated If the Mantoux is not completed in the mandatory amount of time according to 2380 regulations the consumer will not be able to attend the day program until completed. This change was made by the Program Director and will be monitored by the same. The new form was submitted on 11/30/2017 during inspection to Tonya Volkman for review. The new from will be distributed to Supports Coordinators and family members who assist individuals with their completion of physicals and Mantoux to assure compliance for future inspections. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals' have tuberculin skin testing completed, timely. Within 30 days of receipt of the plan of correction and continuing at least quarterly for 1 year, the CEO or designee shall audit the tracking system and a 10 % sample of completed Individuals' Tuberculin skin testing to ensure completion, timely. Documentation of audits shall be kept. (AS 12/6/17)] 12/01/2017 Implemented
SIN-00104489 Renewal 12/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical examination, completed 12/3/15, did not include medical information pertinent to diagnosis and treatment in case of an emergency; the section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.As of 12/1/2016 the physical in question has been updated with the appropriate information. In the future all incoming AHC physicals from the group homes as well as the community (living with family members) will be reviewed by both the Program Specialist and the Program Director to make sure all areas containing information pertinent to diagnosis and treatment in case of an emergency are completed. They will be initialed by the Program Specialist/Program Director before they are filed in the consumers chart to show they have been reviewed. This whole process will be discussed with the Program Directors Supervisor monthly to maintain compliance. [Immediately, the CEO shall train the Program Specialist and Program Director on information required to be included in individuals' physical examinations as per 2380.111(c)(1)-(11) and the aforementioned procedures and procedures for obtaining missing information and that no required areas on physical examination may be left blank. (AS 12/16/16)] 12/18/2016 Implemented
SIN-00086033 Renewal 10/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)The the two most recent physical examinations for Program Specialist #1 were completed on 2/5/13 and 2/27/15. 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.Physicals will be monitored in DCI's Relias Training System to prompt Program Director to make sure physicals are done within the proper time frame to avoid future citations. 10/29/2015 Implemented
2380.173(1)(ii)The record for Individual #1 did not include height, weight, and eye color. The record for Individual #2 did not include identifying marks. Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Record for individual #1 and #2 were updated 10/29/2015. Information sheet moving forward will be reviewed by Program Specialist to make sure all areas are completed before admission.[Program Specialist will immediately review all individuals' records to ensure completion of all required personal information and will address as needed. (AS 12/4/15)] 10/29/2015 Implemented
2380.173(1)(iv)The record for Individual #1 did not include information regarding religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.Record for individual #1 was updated 10/29/2015. Moving forward information sheet will be reviewed by Program Specialist to make sure all areas are completed before admission. [Program specialist will immediatley review all individuals' records to ensure all personal information is included and will update as needed. (AS 12/4/15)] 10/29/2015 Implemented
SIN-00063648 Renewal 11/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(1)The assessment for Individual #1, completed on 7-8-14, did not include the functional strengths, and the needs and preferences of the individual. The assessment for Individual #2, completed on 1-9-14, did not include the functional strengths, and the needs and preferences of the individual. The assessment for Individual #3, completed on 3-24-14, did not include the functional strengths, and the needs and preferences of the individual.The assessment must include the following information: Functional strengths, needs and preferences of the individual.The narrative assessment addendum will be the responsibility of the Program Specialist to complete with each annual assessment from 11/6/2014 and on. The attachment #2 shows under #3 the statement " Functional strengths/needs and preferences of the individual" being addressed on future assessments. [All individual's current assessments will be updated with any missing information including functional strengths and the needs and preferences of the individual, likes, dislikes and interests of the individual including vocational and employment interests, specific area of training, vocational programming and competetive community-integrated employment by the program specialist within 60 days upon receipt of the plan of correction. (CHG 12/2/14)] 11/27/2014 Implemented
2380.181(e)(2)The assessment for Individual #1, completed on 7-8-14, did not include the likes, dislikes and interests of the individual, including vocational and employment interests. The assessment for Individual #2, completed on 1-9-14, did not include the likes, dislikes and interests of the individual, including vocational and employment interests. The assessment for Individual #3, completed on 3-24-14, did not include the likes, dislikes and interests of the individual, including vocational and employment interests. The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.The narrative assessment addendum will be the responsibility of the Program Specialist to complete with each annual assessment from 11/6/2014 and on. Attachment #2 shows under #3,#4, #5 and #6 the statement "Includes likes/dislikes and interests of the individual, including Vocational and Employment Interests" being addressed on future assessments.[All individual's current assessments will be updated with any missing information including functional strengths and the needs and preferences of the individual, likes, dislikes and interests of the individual including vocational and employment interests, specific area of training, vocational programming and competetive community-integrated employment by the program specialist within 60 days upon receipt of the plan of correction. (CHG 12/2/14)] 11/27/2014 Implemented
2380.181(e)(12)The assessment for Individual #1, completed on 7-8-14, did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. The assessment for Individual #2, completed on 1-9-14, did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. The assessment for Individual #3, completed on 3-24-14, did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The narrative assessment addendum will be the program Specialists responsibility to complete with each annual assessment from this date 11/6/2014 on. The form submitted as attachment #3 will show statement under #17 as "recommendations for specific areas of training, vocational programming and competitive community integrated employment" being addressed on future assessments.[All individual's current assessments will be updated with any missing information including functional strengths and the needs and preferences of the individual, likes, dislikes and interests of the individual including vocational and employment interests, specific area of training, vocational programming and competetive community-integrated employment by the program specialist within 60 days upon receipt of the plan of correction. (CHG 12/2/14)] 11/27/2014 Implemented
2380.181(f)The program specialist for Individual #1 did not send the assessment completed on 7-8-14 to the plan team at least 30 calendar days prior to the ISP meeting held on 8-11-14. The program specialist for Individual #2 did not send the assessment completed on 3-11-13 to the plan team at least 30 calendar days prior to the ISP meeting held on 11-26-13. The program specialist for Individual #3 did not send the assessment completed on 3-25-13 to the plan team at least 30 calendar days prior to the ISP meeting held on 12-9-13.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).Ongoing completion of annual assessments from this date 11/6/2014 will be sent to all team members and verified with a cover letter submitted to you as attachment #1. It will be the Program Specialists responsibility to assure this is completed with all annual assessments in the future.[Program Specialists will audit individual records once every three months to ensure the record contains documentation of compliance per 2380.181f that the assessment was sent at least 30 days prior to the ISP meeting. (CHG 12/2/14)] 11/27/2014 Implemented
SIN-00050415 Renewal 12/03/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.17(b)The Unusual Incident policy does not include procedures on the prevention of unusual incidents. (b)  Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the facility.Attachment #1 is an update on the Unusual Incident Policy that involves a section on Prevention. It will be the responsibility of the program Director to disseminate the policy to all caregivers as well as place it in the Policy and Procedure Manual upon acceptance of this plan of correction. 12/09/2013 Implemented
2380.22The grievence procedures did not address the ability and procedures for families and advocates to file a grievance. The facility shall have written grievance procedures for individuals and their families and advocates, that assure investigation and resolution of complaints.Attachment #2 is the proper procedure to follow for individuals,family, advocates and guardians in respect to filing a grievance procedure. The program specialsit will be responsible to provide a copy of this document to family, advocates and guardians upon request and to keep the original in consumers record. 12/12/2013 Implemented
2380.173(7)The records for Individual #1 and Individual #2 did not contain a copy of the current ISPs.(7)  A copy of the current ISP.Attachment #3 is the creation of a memo to remind program specialists to be vigilant in regards to updating current ISP information for consumers. This memo has been put on the black filing cabinet in Prog Specs. office to increase awareness of its importance. It will be the program specialists responsibility to keep ISP records current. This memo has been signed by both Specialists. Individuals # 1 and #2 had their current ISP info put into their records onn the day of inspection to make them current. [The Director will audit a sample of individual's records every month and check for regulatory content including a copy of the current ISP. (CHG 12/19/13)] 12/03/2013 Implemented
2380.176(a)Individual records are kept in the cupboard in the Program Specialist's office which was found to be unattended during the physical site inspection.(a)  Individual records shall be kept locked when they are unattended.Attachment # 4 is the creation of a memo that has been placed on the black cabinet(Consumers Records) in Program Specialists office that was found unlocked the day of inspection to help remind all staff the importance of locking cabinet when room is unattended. All staff read and signed/dated this memo acknowledging their understanding of the procedure. The cabinet was locked immediately when found on 12/3/2013. The key will be located at the program Specialists desk area when locked. 12/03/2013 Implemented
2380.181(e)(11)The records for Individual #2 and Individual #3 did not contain psychological evaluations.(e)  The assessment must include the following information: (11)  Psychological evaluations, if applicable.Attachment #5 is the creation of a cover letter addressed to every Supports coordinator that has a consumer who attends the day program requesting any Psychological evaluations they may have and to send them to Program Specialist. They are also requested to reply if no information is availiable. Attachment #s 6 and 7 are letters sent to individuals #1 and #2. It will be the program Specialists responsibility to keep up on this info with regards to future admissions. [The Director will audit a sample of individual's records monthly to check for requirements required by regulations including psychological evaluations. (CHG 12/19/13)] 12/09/2013 Implemented
SIN-00188565 Renewal 06/09/2021 Compliant - Finalized
SIN-00164511 Renewal 10/17/2019 Compliant - Finalized
SIN-00040626 Initial review 12/16/2015 Compliant - Finalized