Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00163623 Renewal 10/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Individual #1's physical examination, completed 10/12/18 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank. Individual #2's physical examination, completed 3/25/19 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left 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.Individual #1 is due for her next annual physical. She will not be accepted to return to the program after 10/27/19, for CPS until a new physical is received. Her new physical will be checked for completion of all required fields including the section about her health maintenance needs and medication and blood work regimens. Patrick Erkman, CSP Supervisor is responsible for this corrective action. Individual #2 is seeking to have his doctor complete this section of his physical. He has been advised that he cannot return to program without either a new physical or supplemental information about his health maintenance needs and blood work and medication regimens from his doctor to go along with his March 2019 physical. CSP supervisor, Alyssa Lenhart is responsible for this part of the plan of correction. The program will develop and implement a new physical form that is more straight forward and concise, based on the regulations by 12/31/19. The program Director, Andrea Morgan is responsible for this element of the Plan of Correction. All physicals will be checked for completion upon receipt by the assigned program specialist. [Individual #1 had a physical examination completed on 10/25/2019 to include required information. Audits of physical examinations shall be kept on Individual physical examination checklist (blank copy provided to the Department on 11/1/19). Staff persons responsible for auditing physical examinations were educated on their responsibilities and the requirements on 10/22/2019 (copies of training documentation provided to the Department on 11/1/19) At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of completed individuals' current physical examination and the checklists to ensure individuals have current physical examinations with all required information and health needs are provided and arranged. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/5/19)] 11/01/2019 Implemented
2380.111(c)(8)Individual #1's physical examination, completed 10/12/18, did not include the physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual.Individual #1 is due for her next annual physical. She will not be accepted to return to the program after 10/27/19, for CPS until a new physical is received. Her new physical will be checked for completion of all required fields including the section about physical limitations. Patrick Erkman, CSP Supervisor is responsible for this corrective action.The program will develop and implement a new physical form that is more straight forward and concise, based on the regulations by 12/31/19. The program Director, Andrea Morgan is responsible for this element of the Plan of Correction. All physicals will be checked for completion upon receipt by the assigned program specialist.[Individual #1 had a physical examination completed on 10/25/2019 to include required information. Audits of physical examinations shall be kept on Individual physical examination checklist (blank copy provided to the Department on 11/1/19). Staff persons responsible for auditing physical examinations were educated on their responsibilities and the requirements on 10/22/2019 (copies of training documentation provided to the Department on 11/1/19) At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of completed individuals' current physical examination and the checklists to ensure individuals have current physical examinations with all required information and health needs are provided and arranged. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/5/19)] 10/27/2019 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 10/12/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination, completed 3/25/19 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.Individual #1 is due for her next annual physical. She will not be accepted to return to the program after 10/27/19, for CPS until a new physical is received. Her new physical will be checked for completion of all required fields including the section about her medical info pertinent to dx and treatment in case of emergency section(s). Patrick Erkman, CSP Supervisor is responsible for this corrective action. Individual #2 is seeking to have his doctor complete this section of his physical. He has been advised that he cannot return to program without either a new physical or supplemental information about his medical info pertinent to dx and treatment in case of emergency from his doctor to go along with his March 2019 physical. CSP supervisor, Alyssa Lenhart is responsible for this part of the plan of correction. The program will develop and implement a new physical form that is more straight forward and concise, based on the regulations by 12/31/19. The program Director, Andrea Morgan is responsible for this element of the Plan of Correction. All physicals will be checked for completion upon receipt by the assigned program specialist.[Individual #1 had a physical examination completed on 10/25/2019 to include required information. Audits of physical examinations shall be kept on Individual physical examination checklist (blank copy provided to the Department on 11/1/19). Staff persons responsible for auditing physical examinations were educated on their responsibilities and the requirements on 10/22/2019 (copies of training documentation provided to the Department on 11/1/19) At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of completed individuals' current physical examination and the checklists to ensure individuals have current physical examinations with all required information and health needs are provided and arranged. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/5/19)] 11/01/2019 Implemented
2380.111(c)(11)Individual #1's physical examination, completed 10/12/18 did not special instructions for an individual's diet. This section was left blank.The physical examination shall include: Special instructions for an individual's diet.Individual #1 is due for her next annual physical. She will not be accepted to return to the program after 10/27/19, for CPS until a new physical is received. Her new physical will be checked for completion of all required fields including the section about her diet/special diet/recommended diet. Patrick Erkman, CSP Supervisor is responsible for this corrective action. The program will develop and implement a new physical form that is more straight forward and concise, based on the regulations by 12/31/19. The program Director, Andrea Morgan is responsible for this element of the Plan of Correction. All physicals will be checked for completion upon receipt by the assigned program specialist.[Individual #1 had a physical examination completed on 10/25/2019 to include required information. Audits of physical examinations shall be kept on Individual physical examination checklist (blank copy provided to the Department on 11/1/19). Staff persons responsible for auditing physical examinations were educated on their responsibilities and the requirements on 10/22/2019 (copies of training documentation provided to the Department on 11/1/19) At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of completed individuals' current physical examination and the checklists to ensure individuals have current physical examinations with all required information and health needs are provided and arranged. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/5/19)] 10/27/2019 Implemented
SIN-00142623 Renewal 10/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(e)Direct Service Worker #3, date of hire 06/06/18 did not receive general fire safety training prior to working with individuals.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.Direct Service Worker #3 will be trained on general fire safety by her supervisor Carrie Todd, program specialist, by 10/12/18. Supporting documentation of this occurrence will be sent in as required.The HR Director, Nancy Fulmer, will complete and document training, by 10/12/18, that all new employees including rehires must receive general fire safety training during orientation. Supporting documentation of this occurrence will be sent in as required. 4 staff files will be reviewed for compliance quarterly by the Program Director (in training), Andrea L. Morgan. This activity will begin the 2nd quarter of the 2018/2019 year. Documentation of this activity and results of these reviews will be completed by Andrea L. Morgan and emailed to Brenda Cole. 10/12/2018 Implemented
2380.113(a)Direct Service Worker #1, date of hire 01/30/18, and Direct Service Worker #2, date of hire 02/06/18, did not have physical examinations completed until 09/24/18.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.AS noted above, we found this violation/oversight prior to the inspection and sent DSW #1 and DSW #2 for physical and TB tests immediately. The HR Director now knows that no person may be hired to work for the Community Supports Program in any capacity nor may any person transfer into the Community Supports Program without a current physical and negative TB test on file. Training documentation to this effect will be completed by Nancy Fulmer, HR Director by 10/12/18 and supporting documentation will be sent in as required. 09/28/2018 Implemented
2380.181(d)Individual #1's assessment, dated 05/11/18, was not signed by the program specialist.The program specialist shall sign and date the assessment.The program specialist, Carrie Todd, will review and sign and date the assessment dated 5/11/18 for individual #1 by 10/12/18. This will be verified by Program Director (in training), Andrea L. Morgan, by 10/12/18. Supporting documentation of this correction will also be sent in as required. All program specialists will receive retraining on certain sections of the 2380 regulations including but not limited to 2380.33, 2380.171-177, and 2380.181. Training will be conducted by 11/30/18 during regularly held CSP leadership team meetings and will conducted and documented by the program director (in training). 10% (5) of participant (individual) records will be reviewed for compliance quarterly by the CSP leadership team which includes the director (in training), all program specialists, and other key staff persons. This activity will begin with the 2nd quarter of the 2018/2019 year and will be organized and documented (on meeting agenda) by the program director (in training), Andrea L. Morgan. 10/12/2018 Implemented
SIN-00122178 Renewal 10/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The program specialist provided Individual #1's assessment completed 3-22-17 to the plan team on 3-29-17 for an annual ISP meeting on 4-24-17. The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The violation cannot be corrected at this point. It was verified that the SC did receive a copy of individual #1's assessment. To prevent this from occurring in the future, the center will utilize a cover sheet on all assessments that clearly indicates the date the assessment was mailed or given to team members. Program Director will review 181(f) with both Program Specialists at the center and train them on the use of the new Assessment Cover Sheet by 10/18/17. [At least quarterly for 1 year, the Program Director shall audit a 25% sample of assessments, correspondence documentation and tracking system to ensure the program specialist provided all individuals' assessments to all the plan team members, timely. Documentation of audits shall be kept. (AS 10/17/17)] 10/18/2017 Implemented
SIN-00103675 Renewal 10/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The written fire drill record for the fire drill held on 8/15/16 did not include the amount of time it took for evacuation. The space to record the evacuation time was blank. 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.We are unable to correct the fire drill record from the month of August. To prevent this, and other possible errors on future fire drills, we have modified our fire drill form. The form now requires two signatures, one for the person conducting the drill and another for the person reviewing it for compliance. All program staff were trained on the importance of documenting all areas of the fire drill form and the addition of the second signature. [Immediately, the CEO shall train all staff persons responsible for participating and conducting fire drills of the requirements as per 2380.89(a)-(h). Documentation of the training shall be kept. (AS 12/6/16)] 12/01/2016 Implemented
SIN-00085477 Renewal 10/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(12)The assessments for Individual #1, Individual #2, Individual #3, and Individual #4, completed on 12/30/14, 3/31/15, 7/20/15, and 10/27/14, respectively, 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 assessments were completed and failed to include recommendation for specific areas of training, vocational programming and competitive community-integrated employment. We are unable to correct this error. Going forward, we have changed the hard copy of the assessment form to ensure that we address these areas. A copy of amended assessment will be forwarded to the regional licensing office. The first assessment completed on the modified assessment was 11/10/15. [CEO or designee will immediately update Individuals #1, #2, #3 and #4 assessments to include all required information. Program Specialist will review all individuals' current assessments to ensure all required information is present and will update accordingly. Updates will be sent to the Individuals' entire team as needed. Program Specialist will use amended assessment (copy provided to the department) to complete future assessments. CEO will review a 25% sample of assessments quarterly for the next 6 months to ensure assessments are completed with all required information. (AS 12/4/15)] 11/10/2015 Implemented
2380.186(d)The 3 month reviews for Individual #1 completed on 4/20/15 and 7/20/15 were not sent to all team members. The 3 month reviews for Individual #2 completed on 4/7/15, 7/7/15, and 10/7/15 were not sent to all team members. The 3 month reviews for Individual #3 completed on 5/5/15 and 8/5/15 were sent to the supports coordinator on 9/10/15 and were not sent to the entire team. The 3 month review for Individual #4 completed on 6/2/15 was not sent to the entire team. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The Golden Opportunities Center failed to provide documentation that the 3 month reviews were sent to all team members. We are unable to correct this error. Beginning 10/28/15, we began using a new form to track when and to whom we are sending 3 month reviews to. The form will be in the front of every 3 month review section in each participants file. A copy of the form will be mailed to the Regional Licensing Office.[CEO, PS or designee will immediately review all individuals' ISPs, invitation letter etc. to ensure all team members are included in receiving reviews for all individuals as required. Documentation of correspondence that reviews were sent to all team members will be accurately recorded and kept. (AS 12/4/15)] 10/28/2015 Implemented
SIN-00067829 Renewal 10/20/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's annual physical examinations were completed on 6/17/13 and 7/8/14.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.2380.111(a) Individual #1¿s physical was not completed within the timeframe and we are not able to correct this. Going forward, we will: 1.) track all physical dates on a spreadsheet. 2.) send out the physical form and reminder letters during the third month prior to the physical being due. 3.) send a second reminder letter when we have not received the form by the annual date. The letter will also inform the participant/family of the date the 15 day grace period will expire and that, after that date, they will not be permitted to attend programming without a properly completed physical form. The spreadsheet had previously been completed and the monthly reminders will continue. The final notice form letter was created on 10/22/14. A copy of this letter will be forwarded to you. All Program Specialists and the Assistant Coordinator were trained on this procedure on 10/22/14. The Program Specialist will be responsible for tracking and ensuring compliance. 10/22/2014 Implemented
2380.186(b)The quarterly reviews of the ISP were not signed by the following: Individual #1 from July 2013 to October 2014; Individual #2 from April 2014 to September 2014; Individual #3 from September 2013 to September 2014; and Individual #4 from July 2013 to July 2014.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.2380.186(b) Quarterly Review Forms will now include signature/date lines for both the Program Specialist and the Participant. Going forward, all Quarterly Reviews will be signed by the specialist and participant, before being filed. The program specialist made the change to the form on 10/21/14 and we will forward an example of the new form. All program specialist were trained on the change to the form on 10/22/14. We believe this change will ensure proper signatures/dates are obtained on each Quarterly Review Form in the future. 10/22/2014 Implemented
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SIN-00181786 Renewal 01/15/2021 Compliant - Finalized
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