Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228367 Renewal 08/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The men's bathroom in zone 1 has white tiles on the floor, but under the sink, from the wall, three rows out has very dark and discolored tiles (approximately 12inch by 12 inch) that need replaced. And it reaches from one side of the bathroom to the other.Floors, walls, ceilings and other surfaces shall be in good repair.Senior Manager, Maintenance of UPMC Altoona hospital assessed the bathroom on 8/10/2023. They tried cleaning the area and discovered the tile is breaking and needs replaced. UPMC Altoona Hospital reported Degol Carpet will be sending someone to assess, remove, and replace the floor with like material. As of today 8/16/2023, Degol Carpet has not assessed the floor. Program Director will provide updates to ODP Licensing by the 8th of each month regarding the status of the construction project. Program Director will send photos of the completed project to ODP Licensing. 10/31/2023 Implemented
SIN-00207616 Renewal 07/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.83(a)The emergency evacuation plan did not include individual responsibilities, method of transportation, or the emergency shelter location. The form only specified staff responsibilities and recommended calling "various agencies" to find transportation, which is too vague.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.Emergency Evacuation Procedure (5200.17) updated 7/14/2022. The following information was added to the Evacuation Procedure: individual responsibilities, method of transportation, and emergency shelter location. Procedure was reviewed and approved by the Director of Clinical Care Services and Compliance & Regulatory Risk Specialist. Procedure reviewed with staff on 7/15/2022. 07/15/2022 Implemented
2380.188(a)Individual #2 most recent ISP dated 6/6/22 and most recent physical dated 5/23/22 state that individual #2 has a seizure disorder and takes medications to manage this disorder. However, there is no seizure protocol in the individual's chart. There is only an emergency medical and behavioral crisis plan in place, but this is not specific to the individual or specific to seizures. Individual #2 should have a seizure protocol so staff can be aware of the potential for individual #2 to have a seizure, and so staff can be sufficiently trained on what they should look for if individual #2 were to be having a seizure and what to do in the event that individual #2 does have a seizure.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.Seizure Protocol received from DO 7/15/2022. Staff were trained on the seizure Protocol on 7/15/2022. 07/25/2022 Implemented
2380.183(c)The list of persons who participated in the individual plan meeting that occurred on 6/23/2022, was not in the individual #1's file. An email requesting the sign in sheet from the SC was not sent until licensing requested it at the time of the inspection.The list of persons who participated in the individual plan meeting shall be kept.ISP Signature page for Individual #1 received on 7/14/2022. 07/15/2022 Implemented
SIN-00190331 Renewal 07/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.57Activity Area # 1's outside doorway does not have exterior lighting.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.Electrician installed light outside Area #1 doorway on 7/28/2021. Photo of installed light to be sent with attachments through secure email. 07/28/2021 Implemented
2380.59(b)At the time of the inspection, hot water temperature read 122.3 degrees.Hot water temperatures in areas accessible to individuals may not exceed 120°F.On 7/27/2021 electrician turned down the temperature on the water heater and replaced the bottom heating element. 07/27/2021 Implemented
2380.89(c)Fire drill records shall identify the exit routes used. Exit routes are identified on the fire drill logs as '1-5', which is based off of the number of activity arears in the facility. However, 'activity area 1' has 3 exits and 'activity area 5' has 2 exits. There is no way to identify which exit door was used within those activity areas.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.Floorplan exit diagram and fire drill record have been revised to align and reflect exit routes, particularly for areas that have multiple exits. Please reference attachments that will be sent through secure email. 07/30/2021 Implemented
2380.115(2)The method of Emergency Transportation is not identified in the agency Emergency Medical Plan.The facility shall have a written emergency medical plan listing the following: The method of transportation to be used.Emergency Medical Procedure was revised on 7/20/2021 to reflect the method of transportation to be used. 07/22/2021 Implemented
2380.39(c)(6)Individual # 3 has a Seizure Protocol which was developed in 2017. The last staff training on the protocol was dated 11/29/17. Annual staff training should include implementation of the individual plan. All staff who directly support individual #3 should receive training on his health and safety protocols. Individual # 5 has a seizure protocol that staff are to follow in the event that the individual experiences a seizure. At this time, there is no documentation that staff have been trained in the content related to the needs of the individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff have been trained on the seizure protocols for individual #3 and #5. Please reference training attachments that will be sent through secure email. 07/26/2021 Implemented
SIN-00177328 Renewal 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(d)There was no gauze located in the first aid kit in the first aid room at the time of inspection.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.10/6/2020 - The gauze was moved from the second drawer to the First Aid kit located in the top drawer. 10/7/2020 - First Aid Area check list was developed to help all employees remember the first aid room and first aid kit requirements. 10/14/2020 - Program Specialist training - Discussion of citation and review of new form. This task and form completion has been added to the monthly safety report and will be completed at the end of the month. 10/14/2020 Implemented
2380.111(a)Most current physical for individual #2 is dated 6/9/2020; last year's physical is dated 2/14/19. Therefore, the yearly physical was due on 2/14/20; with a 15 day grace the date would be 2/28/20 (which is Pre- COVID; b/c COVID did not occur until the second week of march). Therefore, the yearly physical was completed late.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.10/9/2020 - Procedure 5221 Admission Documentation Requirements updated and approved by senior leadership. 10/14/2020 - Program Specialist Training - review of citation and review of updated procedure "1. a. Physical exam must be complete within 12 months prior to admission and annually thereafter f) Participant will not be able to attend ACEL until a complete physical is on file in the person's medical record" 10/14/2020 Implemented
2380.111(c)(8)The physical examination shall include: Physical limitations of the individual. Individual #1's most recent physical dated 8/10/2020 stated "see note" in section indicating recommended modifications/limitations for activities/exercise, however there was no notation attached to indicate any recommendations. On the individual's emergency information form, the section indicating physical limitations was left blank. However, the most recent ISP dated 8/25/2020 indicates that the individual uses a wheeled walkerThe physical examination shall include: Physical limitations of the individual.10/9/2020 - Procedure 5221 Admission Documentation Requirements updated and approved by senior leadership. 10/14/2020 - Program specialist training - Review of citation and training on procedure 5221 - 1) All spaces of the physical form are to be completed f) Participant will not be able to attend ACEL until a complete physical is on file in the person's medical record 10/14/2020 - Received physical from Dr. office with physical limitations added to the physical form. 10/14/2020 Implemented
2380.111(c)(10)The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 most recent physical dated 8/10/2020, did not contain Information pertinent to dx/tx in case of emergency, it was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.10/9/2020 - Procedure 5221 Admission Documentation Requirements updated and approved by senior leadership. 10/14/2020 - Program specialist training - Review of citation and training on procedure 5221 - 1) All spaces of the physical form are to be completed f) Participant will not be able to attend ACEL until a complete physical is on file in the person's medical record 10/14/2020 - Received physical from Dr. office with medical information pertinent to diagnosis and treatment in case of an emergency added to the physical form. 10/14/2020 Implemented
2380.111(c)(11)The physical examination shall include: Special instructions for an individual's diet. Individual #1's most recent physical dated 8/10/2020 did not indicate special dietary instructions; it was left blank. However, the emergency information form indicates that the individual should have puree foods only. The most recent ISP dated 8/25/2020 indicates that the necessity for pureed food is per the individual's mother.The physical examination shall include: Special instructions for an individual's diet.10/9/2020 - Procedure 5221 Admission Documentation Requirements updated and approved by senior leadership. 10/14/2020 - Program specialist training - Review of citation and training on procedure 5221 - 1) All spaces of the physical form are to be completed f) Participant will not be able to attend ACEL until a complete physical is on file in the person's medical record 10/14/2020 - Received physical from Dr. office with special instructions for an individual's diet added to the physical form. 10/14/2020 Implemented
2380.115(1)There was no hospital location listed in the plan for the emergency medical plan.The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.10/6/2020 - Procedure 5204 Emergency Medical and Behavioral Crisis updated and approved by senior leadership. 10/14/2020 - Program Specialist training - review and discussion of citation 10/15/2020 - All staff trained on Procedure 5204. Procedure has been posted in the center. 10/15/2020 Implemented
2380.173(1)(ii)Each individual's record must include the following information: The race, height, weight, color of hair, color of eyes and identifying marks. Individual #1's chart did not contain information on identifying marks; this section of the information sheet in the chart was left blank. Individual #2's chart did not contain information on identifying marks; this section of the information sheet in the chart was left blank.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.10/8/2020 - Identifying marks added to emergency information form. 10/14/2020 - Program Specialist Training - Review and discussion of citation. It was suggested that program specialists use electronic internal chart audit to help them remember medical record requirements. 10/14/2020 Implemented
2380.183(a)(3)Individual #3's 10/10/19 ISP meeting had no Direct Care Staff in attendance.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.10/7/2020 - Individual Plan Team Signature Form developed. 10/14/2020 - Program Specialist Training - Review and discussion of citation. Individual Plan Team signature form to be used only when direct care employees are not able to attend the ISP meeting. 10/14/2020 Implemented
SIN-00135107 Renewal 06/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Staff #2 and staff #3 was not oriented before working with the individuals.The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.Office Manager revised the orientation form adding the date training was completed to the form. The revised form shows the exact date of training before the employee began working with individuals. Please reference Attachment 1 and 2. (Attachment 1 is the revised form and Attachment 2 is the old orientation form) 06/20/2018 Implemented
2380.36(d)Staff #2 and staff #3 was not trained on disabilities, programming, and implementation.Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.Office Manager revised the orientation form adding the date training was completed to the form. The revised form shows the exact date for training on disabilities, programming, and implementation. Please reference Attachment 1 and 2. (Attachment 1 is the revised form and Attachment 2 is the old orientation form) 06/20/2018 Implemented
2380.36(e)Staff #2 and staff #3 did not have fire safety training completed upon hire.Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Office Manager revised the orientation form adding the date training was completed to the form. The revised form shows the date employee received training for general fire safety before working with individuals. Please reference Attachment 1 and 2. (Attachment 1 is the revised form and Attachment 2 is the old orientation form) 06/20/2018 Implemented
2380.36(h)Staff #2 did not have medication administration training.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Office Manager revised the orientation form adding the date training was completed to the form. The revised form shows training source, content, dates, and length of training. Please reference Attachment 1 and 2. (Attachment 1 is the revised form and Attachment 2 is the old orientation form) 06/20/2018 Implemented
2380.111(c)(10)Individual #1's physical dated 6/2/17 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.Program Director held training/discussion regarding information to include in the ¿information pertinent to diagnosis in case of emergency¿ section of the physical on 7/23/18. (Please reference Attachment 3). Program Director added information pertinent to diagnosis in case of an emergency to Individual #1 physical on 7/23/18. (Please reference Attachment 4). All files were audited between 7/23/18 through 7/27/18. Of the 53 charts that were audited, 45 charts required additional information that would be pertinent in case of an emergency. This information has been added to the charts (hand written and initialed). In the future, to prevent future occurrences, Program Specialist will review this information in the physical and add/revise information if necessary. We already have an automatic alert system in place to generate alerts for physical due letters. The information will be reviewed at the time of the automatic alert to assure information is added timely. 07/27/2018 Implemented
SIN-00111410 Renewal 05/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)Individual #1's assessment completed on 12/30/2016 did not include his/her lifetime medical history. In the assessment it stated to see the attached lifetime medical history however the lifetime medical history attached was not completed until 1/6/2017 which was after the assessment was sent to team members.The assessment must include the following information: A lifetime medical history.On 5/30/2017, Program Director completed Licensing Exit Summary Training and Discussion with Program Specialists and Office Staff. (Reference Attachment 1) On 5/30/2017, Program Director reviewed and revised the ACEL Internal Chart Audit form as a tool for Program Specialists to identify errors in the chart. (Reference Attachment 2) Program Director reviewed all charts on 5/26/2017. (Note, all medical histories are a separate document for our organization due to the size of the medical histories) No other plans were found where the assessment/medical histories were updated after the documents were sent to team members. Program Specialist corrected Individual #1 assessment and medical history on 5/30/2017. (Reference Attachment 3) Program Specialist completed an assessment for an individual on 5/31/2017. Program Specialist used the Internal Chart Audit Form on 5/31/2017 to assure medical history was included with the assessment and sent to team members. (Reference Attachment 4) As of 5/30/2017, Programs Specialists will complete the ACEL Internal Chart Audit after completing the person¿s assessment to prevent future issues. 05/31/2017 Implemented
2380.181(e)(13)(vi)Individual #2's assessment dated 7/22/2016 did not include progress and growth over the last 365 calendar days in the area of community integration. The information in this section of the assessment was the same as the assessment completed on 7/24/2015.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.On 5/30/2017, Program Director completed Licensing Exit Summary Training and Discussion with Program Specialists and Office Staff. (Reference Attachment 1) On 5/30/2017, Program Director reviewed and revised the ACEL Internal Chart Audit form as a tool for Program Specialists to identify errors in the chart. (Reference Attachment 2) Program Specialists reviewed all charts on 5/31/2017 and 5/31/2017 and 13 plans were found where progress and growth for community integration remained the same from the previous year to the current year. It was discovered that community information was present, but added to the incorrect sections i.e. recreation. Program Specialist will begin correcting these assessments and it is estimated they will be corrected by 6/14/2017. Program Specialist corrected Individual #2 assessment on 5/31/2017. (Reference Attachment #5) Program Specialist completed assessment for an individual on 5/31/2017. Program Specialist used the ACEL Internal Chart Audit form on 5/31/2017 to assure progress and growth were updated in the Community Integration Section of the assessment. (Reference Attachment 4) As of 5/30/2017, Programs Specialists will complete the ACEL Internal Chart Audit after completing the person¿s assessment to prevent future issues. 06/14/2017 Implemented
SIN-00094910 Renewal 05/23/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Lysol disinfectant spray, windex, WD-40 big blast, Cavi disinfectant wipes, and Assured foot powder were stored in an unlocked cabinet in the light blue room. Palmolive soap, Clorox stain remover, and Dishmachine detergent were stored in an unlocked cabinet in the Level 1 kitchen. Both kitchens and bathrooms contained personal hygiene systems filled with skin cleanser that indicated to contact poison control if ingested. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.This cabinet is now locked. All employees were trained during 5/25/2016 staff meeting. Poisons will be checked weekly using the poison monitor form. Please reference attachment 5. 07/05/2016 Implemented
2380.53(b)A clear, unlabeled spray bottle containing an alcohol mixture was stored in an unlocked cabinet in the light blue room. Poisonous materials shall be stored in their original, labeled containers.Spray bottle was discarded. Staff are using Asepti-Wipe II. Employees were trained in using cleaning products that are in their original containers during 5/25/2016 staff meeting. Poisons to be tracked using Poison Monitor Form. Please see attachment 6. 07/05/2016 Implemented
2380.173(6)(ii)Individual #3's record did not include a signature page from the Individual #3's Indiviudal Support Plan update meeting.Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting.Program Specialist emailed Support Coordinator on 4/20/2016 requesting a copy of Individual #3 signature page. Signature page was received on 5/24/2016. Please see attachment 4. In the future, all email requests regarding the ISP will be filed in the Individual's chart. 05/24/2016 Implemented
2380.183(3)Indiviudal #1's Individual Support Plan does not include a method to determine progress toward the "music man" 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.Program Specialist revised outcome so that progress can more easily be tracked. Program Specialist sent track changes to Support Coordinator on 5-24-16. Support Coordinator updated ISP. ISP was approved 6-3-16. Please reference attachment 3. 06/03/2016 Implemented
2380.185(b)Individual #3's Individual Support Plan (ISP) includes a "predictability" outcome. This outcome was not reviewed on the ISP reviews and was not implemented by the Adult Center for Exceptional Learning.The ISP shall be implemented as written.This Outcome was discontinued during Individual#3 ISP meeting on 4-18-16. Please see attachment 2. Office Manager will make sure the newest copy of the ISP is in the individual's file. 06/13/2016 Implemented
2380.186(c)(1)Individual #2's 4/1/16, 12/31/15, 10/2/15, and 7/2/15 Individual Support Plan (ISP) reviews do not include Individual #2's progress toward the "staying connected" goal. 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.Program Specialist met with Program Assistant on 5-23-16 and discussed what needs to be documented to show progress. Program Specialist and Program Assistant met on 5-30-16 to complete May monthly progress note. Program Specialist and Program Assistant met on 6-22-16 to complete June Progress Report. Please reference attachment 1. 06/22/2016 Implemented
SIN-00080856 Renewal 04/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)The Tuberculin skin testing for Individual #1 was not completed in the 2 year time frame- 5/26/11- 7/12/13The 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.In 2011, Individual #1 had a Mantoux test done on 5/24/11 and was read on 5/26/11 (negative). He was hospitalized on 4/29/13. Individual #1 was absent from Day Program from 4/26/13 until 7/30/13. He returned to Day Program on 7/31/13. During his absence, he had his Mantoux completed on 7/10/13 with a negative reading on 7/12/13. To summarize, even though Individual #1 did not have his Mantoux done in the two year period from 5/24/11 to 5/24/13, he was not at day program between the dates of 4/26/13 and 7/30/13. He did have his Mantoux administered and read prior to returning to the program on 7/31/13. Office Manager developed a form to be filed under medical information, in front of the physical, titled Physical/TB Test Exclusions. This form will alert anyone who reviews the person's file that they were absent and documentation appears to be out of compliance, along with a short explanation. This form will be used in the future for folks who are absent and have physical/Mantoux completed during their absence. Office Manager completed this new form for Individual #1. Please reference this attachment titled "Physical/TB Test Exclusions." (Attachment to be sent via Certified US Mail) 04/23/2015 Implemented
2380.173(9)Individual #2 record contained the following content discrepancies: the physical exam states to be on a Mediterranean diet, the ISP states reduced 1500 calorie diet. The ISP stated doesn't react well to changes in the routine, but the assessment states there isn¿t a problem when there is a change.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist emailed Individual #2 Support Coordinator requesting the following: "According to Individual #2 physical she is to follow a Mediterranean Diet, however, in her ISP under the Meals/Eating section it states she is to follow a 1500 calorie diet. Can you please change it to Mediterranean Diet so that it matches with her physical." Please reference attachment, email to Individual #2 Support Coordinator. (Attachment to be sent via Certified US Mail) In the future, Program Specialist will cross reference information in the physical/ISP when doing monthly file audits. Program Specialist completed file audit form for Individual #2. Please reference attachment, file audit form for Individual #2. (Attachment to be sent via Certified US Mail) 09/25/2015 Implemented
2380.181(c) Individual #2's annual assessment held on 7/11/14 did not contain the basis of how the assessment was obtained. The assessment shall be based on assessment instruments, interviews, progress notes and observations.Program Specialist added the instruments used for assessment on 4/24/15. Please reference attachment, copy of assessment for Individual #2. (Attachment to be sent via Certified US Mail) In the future, Program Specialists will complete ACEL Internal File Audit Form in order to assure compliance with regulations. Please reference attachment, ACEL Internal File Audit Form for Individual #2. (Attachment to be sent via Certified US Mail) 09/25/2015 Implemented
2380.181(e)(3)(i)The assessment for Individual #2 did not contain the current level of performance and progress in acquisition of function skills.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Acquisition of functional skills.Program Director and Program Specialists met and revised our assessment on 4/24/2015 to include current skill level and progress. Program Specialist added current skill level and progress in acquisition of function skills on 7/10/2015. In the future, Program Specialists will complete ACEL Internal File Audit in order to assure compliance with regulations. Please reference attachment. (Attachment to be sent via Certified US Mail) 09/25/2015 Implemented
2380.181(e)(3)(iii)The annual assessment for Individual #2 did not contain progress in personal adjustment. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Personal adjustment.Program Director and Program Specialists met on 4/24/2015 and updated our assessment to include progress and growth. Program Specialist added progress in personal adjustment to Individual #2 assessment. Please reference attachment, Individual #2 assessment. (Attachment to be sent via Certified US Mail) In the future, Program Specialists will complete ACEL Internal File Audit Form in order to assure compliance with regulations. Program Specialist completed Internal File Audit Form for Individual #2. Please reference attachment. (Attachment to be sent Certified US Mail) 07/10/2015 Implemented
2380.181(e)(13)(vi)The annual assessment for Individual #2 did not contain progress in community integration.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.Program Director and Program Specialists met on 4/24/2015 and updated our assessment to include progress and growth. Program Specialist added progress in community integration to Individual #2 assessment. Please reference attachment, Individual #2 assessment. (Attachment to be sent via Certified US Mail) In the future, Program Specialists will complete ACEL Internal File Audit Form in order to assure compliance with regulations. Program Specialist completed Internal File Audit Form for Individual #2. Please reference attachment. (Attachment to be sent Certified US Mail) 07/10/2015 Implemented
2380.181(e)(14)The annual assessments for Individual #1, #2 and # 3 did not assess the individual¿s ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Program Director and Program Specialists met on 4/24/2015 and updated our assessment to include the individual's knowledge of water safety and ability to swim. Program Specialist's added knowledge of water safety and ability to swim to Individual #1, #2, and #3 assessments. Please reference attachments, Individual #1, #2, and #3 assessments. (Attachments to be sent via Certified US Mail) In the future, Program Specialists will complete ACEL Internal File Audit Form in order to assure compliance with regulations. Program Specialist completed Internal File Audit Form for Individual #1, #2, and #3. Please reference attachments. (Attachments to be sent Certified US Mail) 09/25/2015 Implemented
2380.186(c)(2)The ISP reviews for Individual #1 & #2 did not review the SEEN plans/Behavioral Support Plans that are in place in their ISP's. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Director met with Program Specialist and discussed 2380.186 (c) (2) as well as use of ACEL Internal Chart Audit to assure compliance. Please reference attachment documenting training and copy of ACEL internal chart audit. Program Specialist added a Plan of Support to Individual #2 ISP review. Program Specialist updated Plan of Support for Individual #1 ISP review to address progress, symptoms/behaviors, and recommendations. Please reference attachments that will be sent via US Certified Mail. In the future, Program Specialists will complete internal chart audits while completing assessments in order to assure compliance with regulations. Program Specialist completed ACEL Internal Chart Audit for Individual #1 and #2. Please reference attachment. (Attachment to be sent via Certified US Mail) 09/25/2015 Implemented
SIN-00065079 Renewal 04/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.183(7)(i)The ISP for Individual #2 did not include her 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 Director contacted the Support Coordinator on 7/1/2014 requesting information on Vocational Programming to be added to the ISP. Copy of email and information to be added to the ISP was printed and filed in the individual's chart. This information will also be mailed with the Plan of Correction for review. Program Specialists to complete ACEL Internal Chart Audit Form as a reminder to make sure section 183 (7) (i) is included in the ISP. Copy of revised Internal Chart Audit included for review. 07/01/2014 Implemented
2380.183(7)(iii)The ISP for Individual #2 did not include her potential to advance in competitive 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.Program Director contacted the Support Coordinator on 7/1/2014 requesting information on Competitive Community-Integrated Employment to be added to the ISP. Copy of email and information to be added to the ISP was printed and filed in the individual's chart. This information will also be mailed with the Plan of Correction for review. Program Specialists to complete ACEL Internal Chart Audit Form as a reminder to make sure section 183 (7) (iii) is included in the ISP. Copy of revised Internal Chart Audit included for review. 07/01/2014 Implemented
2380.186(b)Individual #2 did not sign and date the ISP review held on 3/13/14. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Program Specialist and Individual signed ISP review signature sheet on 6/13/2014. Copy to be mailed with Plan of Correction for review. 06/13/2014 Implemented
2380.186(d)There was no documentation to show that the ISP review dated 3/13/14 was sent to team members within 30 days of the review.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.ISP Review Signature Sheet was revised by Program Director on 4/28/2014. Revisions include date sent to team at the bottom of the form. New form was utilized by Office Manager on 5/1/2014. Office Manager replaced all old forms with the new one. Copy of blank form and completed form to be mailed with the Plan of Correction for review. 05/01/2014 Implemented
SIN-00046503 Renewal 04/15/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)There were cleaning chemicals found unlocked in the kitchen area. Not all individuals are safe around poisonous substances.(a)  Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Fully Implemented. JW 5/14/13. Program Director provided training on locking poisonous substances during staff meeting on 4/18/13. Program Specialist installed magnetic locks to cabinet. The magnet automatically shuts the door and keeps it locked. A magnet must be used to unlock the door. Please see staff meeting minutes and digital photo of installed lock. (Attachment 1) 05/08/2013 Implemented
2380.173(7)The current ISP for Individual #1 was not in his record. Each individual¿s record must include the following information: (7)  A copy of the current ISP.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/20/13 Office Manager and Administrative Assistant have reviewed all files assuring the most currect ISP is in the individual record. Office Manager will check alerts in HCSIS each Tuesday and see if there are plans that need to be printed. If there are plans, Office Manager will print the plan and file in the individual record. 05/15/2013 Implemented
2380.181(e)(3)(i)The assessment for Individual #2 did not include progress in functional skills, communication, personal adjustment or personal needs with or without assistance. The assessments for Individual #1 and Individual #3 did not include progress in functional skills.(e)  The assessment must include the following information: (3)  The individual's current level of performance and progress in the following areas:(i)   Acquisition of functional skills. (ii) Communication (iii) Personal Adjustment (iv)   Personal needs with or without assistance from otherPARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/20/13 Program Director and Program Specialists met on 4/23/13 and agreed to use the Blair County assessment. Program Specialist tested and used the assessment for a person on 4/26/13. The assessment meets the requirements outlined in 181(e)(3)(i). The Program Specialist will randomly select 4 records a month and assure compliance with 181(e)(3)(i). Upon receipt of the final approved ISP, the Program Specialist will complete the ISP Approval Check off List. If discrepencies are found, the Support Coordinator will be notified via email of the changes that need to be made. The Program Specialist will copy the email and the Office Mananger will file the email in the individual record. Please see attachemnt 2 (blank assessment), attachemnt 3 (complete assessment) and attachemnt 4 (ISP Approval Check Off List). 05/15/2013 Implemented
2380.181(e)(13)(i)The assessment for Individual #2 did not include progress and growth in health, motor and communication, personal adjustment, socialization, recreation and community integration. Also, the assessment for Individual #1 did not include progress and growth in community integration. (e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (i)   Health (ii) Motor and Communication (iii) Personal Adjustment (iv) Socialization (v) Recreation (vi) Community IntegrationPARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/20/13 Program Director and Program Specialists met on 4/23/13 and agreed to use the Blair County assessment. Program Specialist tested and used the assessment for a person on 4/26/13. The assessment meets the requirements outlined in 181(e)13(i). The Program Specialist will randomly select 4 records a month and assure compliance with 181(e)(13(i). Upon receipt of the final approved ISP, the Program Specialist will complete the ISP Approval Check off List. If discrepencies are found, the Support Coordinator will be notified via email of the changes that need to be made. The Program Specialist will copy the email and the Office Mananger will file the email in the individual record. Please see attachemnt 2 (blank assessment), attachemnt 3 (complete assessment) and attachemnt 4 (ISP Approval Check Off List). 05/15/2013 Implemented
2380.181(f)The assessment for Individual #3 was not sent to plan team members at least 30 days prior to his ISP meeting. His ISP meeting was held on 2/8/13, but his assessment was not sent until 1/15/13. (f)  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).PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/20/13 Program Specialist completed the assessment and sent to the plan team members on 4/26/13. The Program Specilist will randomly selelct 4 records a month to assure compliance with 181(f). Please see attachment 3. 04/26/2013 Implemented
2380.183(7)(i)The ISPs for Individual #1, Individual #3 and Individual #4 did not include their potential to advance in vocational programming, community involvement and competitive community-integrated employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: (7)  Assessment of the individual's potential to advance in the following:(i)   Vocational programming (ii) Community Involvement (iii) Competitive community-integrated employment.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/20/13 Program Director and Program Specialists met on 4/23/13 and agreed to use the Blair County assessment. Program Specialist tested and used the assessment for a person on 4/26/13. The assessment meets the requirements outlined in 183(7)(i). The Program Specialist will randomly select 4 records a month and assure compliance with 183(7)(i). Upon receipt of the final approved ISP, the Program Specialist will complete the ISP Approval Check off List. If discrepencies are found, the Support Coordinator will be notified via email of the changes that need to be made. The Program Specialist will copy the email and the Office Mananger will file the email in the individual record. Please see attachemnt 2 (blank assessment), attachemnt 3 (complete assessment) and attachemnt 4 (ISP Approval Check Off List). 05/15/3013 Implemented
2380.186(b)The ISP review for Individual #3 was not signed and dated by the individual. The parent signed for the individual.(b)  The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/20/13 Program Specialist met with the person on 4/30/13 and went over the ISP review. The person and Program Specialist signed the review. The Office Mananger has reviewed all files and all ISP reviews have been signed and dated by the person supported and the program specialist. The Program Specialist will continue to go over the ISP review with the individual and sign and date after the review. The Office Manager and Administrative Assistant will randomly select 4 records a month to assure compliance with regulation 186(b). 05/15/2013 Implemented
SIN-00154490 Renewal 07/09/2019 Compliant - Finalized