Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00193986 Renewal 10/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's most recent tetanus and diphtheria boosters were completed on 11-9-2009.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.An appointment was made for Individual #1 for 10/22/21 with her PCP to get her tetanus and diphtheria booster. When she went for the appointment the PCP informed the residential manager that she was not due for the booster, she had it in November 2019 when it was due, WGARS just did not have the documentation of this available. Therefore, Individual $1 is not due for her booster again until 2029. 11/08/2021 Implemented
SIN-00179093 Renewal 11/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #3, date of admission 9/25/2019, had an initial assessment completed on 12/12/2019, seventy-eight days following their admission.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.An initial assessment has been completed. However, it was completed past the 60 days and there is no way to correct that at this point. All current assessments will be reviewed to ensure they are in compliance with the completion time frame. In the future, an assessment will be prepared for any new admissions and distributed immediately. The assessment will be assigned to specific staff for accountability in order for program staff to go back to that staff and determine how the assessment is progressing. The staff will be given approximately 45 days to complete the entire assessment. After this time the assessments will be collected in order for the program staff to review the assessment for thoroughness and return it to the staff if more work is required. If there is a problem, for whatever reason. With the direct care staff completing the assessment on time the program staff will be responsible for the completion of the assessment within the first 60 days of admission. The program staff will be responsible for this plan of correction and will review all assessments upon completion. [Immediately, the agency shall develop and implement a tracking system for new admissions to ensure the completion of initial Individual Assessments within 60 calendar days of admission to the facility. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall complete an audit of Individual Assessments to ensure compliance with regulatory timelines. Documentation of the audit of Individual Assessments shall be kept. (DPOC by HDKP, HSLS on 12/23/2020)] 12/11/2020 Implemented
2380.181(e)(14)Individual #1's assessment, dated 9/3/2020, does not address if the individual can temper water temper. This section of the assessment stated "NA."The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.The assessment for Individual #1 has been reviewed and the areas concerning tempering water have been corrected. The assessments for all other individuals will be reviewed to ensure that they are completed thoroughly. A training will be completed with the staff by 12/29/2020 on how to properly complete an annual assessment. Once the assessments are complete the program specialist supervisor/QIDP is to review the assessment for thoroughness and if any areas are incomplete, they¿re to be returned immediately to the staff to complete them correctly. The Program Specialist Supervisor and QIDP will monitor 25% of the assessments monthly to ensure that they have been completed correctly and thoroughly. The Program Specialist Supervisor and QIDP will be responsible for this plan of correction. [Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall complete an audit of Individual Assessments to ensure that information contained in the Individual Assessments is concurrent with the information contained in the Individual Support Plan. Discrepancies between the Individual Assessment and Individual Support Plan shall be communicated to the party responsible for revisions to the Individual Support Plan. Documentation of the Assessment audits and communication of discrepancies shall be kept. (DPOC by HDKP, HSLS on 12/23/2020)] 12/30/2020 Implemented
2380.33(b)(2)The Program Specialist did not ensure that Individual #2's Assessment, dated 4/6/2020, and Individual Support Plan (ISP), last updated 9/15/2020, contained the same information regarding the individual's knowledge of water safety and ability to use and/or avoid poisonous materials. The ISP, last updated 9/15/2020, states that Individual #2 enjoys swimming requires line of sight supervision, staff temper water for Individual #2, and Individual #2 can use poisons with staff providing directions and being within line of sight; however, the assessment, dated 4/6/2020, indicates that Individual #2 is independent with tempering water, cannot swim, and can use and/or avoid poisons independently.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.The assessment for Individual #2 has been reviewed and the areas concerning knowledge of water safety and the ability to use and/or avoid poisonous materials have been compared to the information in the ISP. The incorrect information in the ISP has been sent to the Supports Coordinator and has been updated. The assessments for all other individuals will be reviewed and compared to the information contained in the ISP to ensure that all information is correct. The Program Specialist Supervisor will monitor all of the ISPs for needed revisions during the quarterly review meetings and ISP meetings and in addition notify the SC of any needed revisions between meetings if something should change with the individual. The Program Specialist Supervisor will be trained on this plan by 12/11/2020. The Program Specialist Supervisor will be responsible for this plan of correction. 2380.33(b)(2): [Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall complete an audit of Individual Assessments to ensure that information contained in the Individual Assessments is concurrent with the information contained in the Individual Support Plan. Discrepancies between the Individual Assessment and Individual Support Plan shall be communicated to the party responsible for revisions to the Individual Support Plan. Documentation of the Assessment audits and communication of discrepancies shall be kept. (DPOC by HDKP, HSLS on 12/23/2020)] 12/11/2020 Implemented
SIN-00156954 Renewal 06/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 had Tuberculin skin testing with negative results completed 3/9/17 then again 4/14/19. (Repeated Violation 6/25/18)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.A repeat TB test will be completed for Individual #1 by 7/5/19. In order to prevent this from happening again, a live spreadsheet has been developed which lists the most recent TB test date and changes color depending on how soon the test is due. This spreadsheet will be reviewed weekly by the ATF Director and the Administrative Assistant to determine when tests are due in the near future. The Administrative Assistant will prepare and send out a memo as a reminder to the residential manager and ATF Director for each individual at least 30 days prior to the due date of the test. As the TB tests are completed and read, a copy of the test results will be sent to the ATF Director and the Administrative Assistant so that the TB Test Spreadsheet can be updated with the most recent test date. If for any reason, an individual does not have a completed TB test within the 2 year period, that individual will not be permitted to attend the ATF until they can provide evidence of a recent negative TB test or a chest x-ray if their TB test was positive. A form has been developed to document the weekly monitoring of the spreadsheet by the ATF Director and the Administrative Assistant. The ATF Director and the Administrative Assistant will be responsible for this plan of correction. 07/05/2019 Implemented
SIN-00137225 Renewal 06/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The written fire drill record for the fire drills held on 05/01/18 at 09:50AM and 05/25/18 at 11:41AM did not indicate the exit routes used during the fire drills. This section 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.The staff who conducts the fire drill each month will provide the information regarding which exits were used to evacuate during the drill on the Fire Drill Record. The Director will train each of the staff who are authorized to conduct drills by 7/10/18. The documentation of the training will be kept in personnel files. The ATF Director will review the Fire Drill Record following each drill to determine if exit routes are listed and sign the form indicating the review. 07/20/2018 Implemented
2380.91(a)Individual #1's most recent annual fire safety instruction was 02/02/17.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Individual #1 received fire training on 6/26/2018. She had been absent on the original date of the fire training. When an individual is not present for the fire training, it will be provided for the individual on the day of their return to the ATF. The ATF Director will review all fire training and determine any who did not attend and provide the training on the date of the return of the individual to the ATF. All training sheets are stored in the individual file and in the Fire Drill Book. The Director will train the ATF Director regarding the Annual Fire Safety Instruction by 7/6/18 and retain the documentation of the training in the personnel file. [Immediately, the CEO or designee will develop and implement a tracking system to ensure all individuals are trained in required areas of fire safety upon admission and at least annually. At least quarterly, the ATF director shall audit the aforementioned tracking system and a 25% sample individuals' fire safety training documentation to ensure timely completion. Documentation of audits shall be kept. (AS 7/3/18)] 07/31/2018 Implemented
2380.111(c)(5)Individual #1 had a Tuberculin skin test completed on 07/01/15 and then again on 07/21/17. (Repeated Violation-7/10/17)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.Individual #1 will receive a Tuberculin skin test on 7/1/2018 with her annual physical. The ATF Director will be trained by the Director regarding this regulation by 7/6/2018. All participants will receive information regarding the requirement by way of memo to remind of the necessity of scheduling the physical including the Tuberculin skin test (every two years) to be completed by the regulation date. All current physicals will be reviewed to determine compliance. The ATF Director will maintain a schedule of the due dates for physicals. A memo is sent to indicate the need for the physical to be completed including the tuberculin test (every two years). [Immediately, upon completion and at least quarterly for 1 year, the ATF Director or designee shall review all individuals' physical examinations to ensure a Tuberculin skin testing is completed every 2 years. (AS 7/3/18)] 07/27/2018 Implemented
2380.113(c)(3)Direct Service Worker #1's physical examination completed on 04/11/18 did not include a statement that the person is free of serious communicable diseases. This section was left blank.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.All physical exams for employees will include the statement that the person is free of communicable disease. The physical will be reviewed by the Administrative Assistant prior to the employee beginning to work or upon completion of the biannual physical. The Administrative Assistant will be trained by the Director regarding this requirement by 7/6/2018 and documentation of the training will be kept in the personnel file. The Director will review 25% of employee physicals to determine if completed with the statement that the employee is free of communicable disease and documentation of the review will be kept. 07/31/2018 Implemented
SIN-00117114 Renewal 07/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #3, date of admission 4/4/17 had a physical examination completed on 6/13/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The physical for this individual cannot be corrected as it is in the past. One month prior to the due date of the annual physical or one month prior to an admission, a memo will be sent as a reminder that the physical due date is approaching. The ATF Director will keep a checklist of all due dates of physicals and monitor the completion of the physical by the due date. The Acting Director will train the ATF Director and the Assigned Office staff regarding the physicals. [Within 30 days of receipt of the plan of correction, Director will completed aforementioned training. Documentation of the training shall be kept. At least quarterly for 1 year, the Director shall review the aforementioned checklist and correspondence memos and a 25% sample of completed physical examinations to ensure individuals' have a physical examination within 12 months prior to admission and annually thereafter.(AS 7/26/17)] 07/31/2017 Implemented
2380.111(c)(5)Individual #3, date of admission 4/4/17 had a Tuberculin skin testing with negative results completed on 6/16/17.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.This cannot be corrected for Individual #3 as it is in the past. One month prior to the due date of the annual physical or one month prior to admission, a memo will be sent as a reminder that the physical due date is approaching. The ATF Director will keep a checklist of all due dates of physicals and monitor that the Tuberculin skin testing results are included on all Admission physicals and those required every two years. The ATF Director and the Assigned Office Staff will be trained by 7/31/2017 by the acting Director.[Documentation of the training shall be kept. At least quarterly for 1 year, the Director shall review the aforementioned checklist and correspondence memos and a 25% sample of completed Tuberculin skin testing to ensure individuals' have a Tuberculin skin testing every 2 years.(AS 7/26/17)] 07/24/2017 Implemented
2380.111(c)(7)Individual #3's physical examination completed on 6/13/17 did not include health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was blank.The 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 #3 will have the physical examination reviewed by the physician who conducted it and an addendum will be added to include health maintenance needs, medication regimen and the need for blood work at recommended intervals. This will be completed by 8/10/17. The Residential Manager will be responsible for completion and will present the corrected physical to the ATF Director by 8/10/17. In the future, each physical will be reviewed by the ATF Director upon return for completion. Immediately, the ATF Director will review all physicals and determine if any are missing required information. The Acting Director will train the ATF Director and the Residential Managers by 7/31/2017. 07/24/2017 Implemented
2380.111(c)(8)Individual #3's physical examination completed on 6/13/17 did not include physical limitations of the individual. This section was blank.The physical examination shall include: Physical limitations of the individual.Individual #3 will have the physical exam reviewed by the physician who conducted it and an addendum will be added to include the physical limitations of the individual by 8/10/17. The Residential Manager will be responsible for completion and will present the corrected physical to the ATF Director by 8/1017. In the future, each physical will be reviewed by the ATF Director upon return for completeness. Immediately, the ATF Director will review all physicals and determine if any are missing required information. The Acting Director will train the ATF Director and the Residential Managers by 7/31/17. 07/24/2017 Implemented
2380.111(c)(11)Individual #3's physical examination completed on 6/13/17 did not include special instructions for the individual's diet. This section was blank.The physical examination shall include: Special instructions for an individual's diet.Individual #3 will have the physical exam reviewed by the physician who conducted it and an addendum will be added to include the special instructions for the individual's diet by 8/10/17. The Residential Manager will be responsible for completion and will present the corrected physical to the ATF Director by 8/10/17. In the future, each physical will be reviewed by the ATF Director upon reception for completion of all parts which are required by regulation. Any which are lacking information will be returned for completion. The Director will keep documentation of the reception of the physical and its completeness. Immediately, the ATF Director will review all physicals and determine if any are missing required information. If so, the Director will advise the responsible person that the Addendum must be completed by 8/10/17 . The ATF Director will be trained by the Acting Director by 7/31/17. 07/24/2017 Implemented
2380.113(a)CEO #1 who comes into direct contact with the individuals had a physical examination completed on 9/23/14 then again 11/29/16.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.The Assigned Office Staff will keep a list of due dates for each employee physical and forward a memo to the staff at least one month before it is due. All staff will be advised that they will contact the Assigned Office Staff with the date of the scheduled physical examination. The Assigned Office Staff will confirm that the employee completed the physical with the medical agency that performs the physicals for ARS. The Assigned Office Staff will be trained by the Acting Director by 7/31/2017. The Acting Director will review at least 25% of the physicals each quarter for one year. 07/24/2017 Implemented
2380.113(c)(2)CEO #1 who comes into direct contact with the individuals had a Tuberculin skin testing with negative results completed on 9/25/14 then again 12/1/16.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.The Assigned Office Staff will keep a list of due dates for each employee physical and forward a memo at least one month before it is due indicating that the physical examination and the Tuberculin Skin testing are due. All staff will be advised of the need to contact the Assigned Office Staff of the date of the scheduled physical examination and Tuberculin skin testing. The Assigned Office Staff will confirm the employee completed the exam and Tuberculin skin testing with the medical agency that performs physicals for ARS. This staff will be trained by the Acting Director by 7/31/2017 07/24/2017 Implemented
2380.155(d)Individual #1's restrictive procedure plan was not signed and dated by the chairperson of the restrictive procedure review committee and the program specialist. The restrictive procedure plan had a creation date of 9/17/13.The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.The ATF Director met with the Behavior Specialist and the Program is being reviewed and updated. The Acting Director will train the Program Specialists regarding the need for the plan to be signed and dated prior to the use of a restrictive procedure. The Restrictive Committee will be asked to review the plan and the chairperson will sign it. The Acting Director will train the Committee regarding the review prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months. [Immediately and at least semiannually, the chairperson and the program specialist shall review all restrictive procedures for all individuals to ensure restrictive procedures are be implement as per 2380.155(a)-(g). Documentation of reviews shall be kept. (AS 7/27/17)] 07/24/2017 Implemented
2380.155(e)(5)Individual #1's restrictive procedure plan did not include a target date for achieving the outcome.The restrictive procedure plan shall include: A target date for achieving the outcome.The Behavior Specialist is working with the ATF Director/Program Specialist to review and update the plan. A target date will be including for the achievement of the outcome. The Acting Director will train the Program Specialists regarding the need for inclusion of a target date. All future restrictive plans will include a target date upon the initiation of the plan.[Immediately and at least semiannually, the chairperson and the program specialist shall review all restrictive procedures for all individuals to ensure restrictive procedures are be implement as per 2380.155(a)-(g). Documentation of reviews shall be kept. (AS 7/27/17)] 07/24/2017 Implemented
2380.155(e)(8)Individual #1's restrictive procedure plan did not include the name of the staff person or staff position responsible for monitoring and documenting progress with the plan.The restrictive procedure plan shall include: The name of the staff person or staff position responsible for monitoring and documenting progress with the plan.The ATF Director and the Behavior Specialist are working to review and update the Plan. All Program Specialists will be trained regarding the need to include the name of the staff person or staff position responsible for monitoring and documenting progress with the plan by the Acting Director. All future plans will be reviewed by the ATF Director to ensure this information is included prior to initiation.[Immediately and at least semiannually, the chairperson and the program specialist shall review all restrictive procedures for all individuals to ensure restrictive procedures are be implement as per 2380.155(a)-(g). Documentation of reviews shall be kept. (AS 7/27/17)] 07/24/2017 Implemented
2380.181(a)Individual #4's most recent assessment was completed 1/20/16.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.The updated assessment for the individual was completed on 7/17/2017. The ATF Director will monitor the current assessment dates of completion. The Director will train all Program Specialists regarding the required completion time frame for each assessment by 7/31/2017. The Director will review the assessments upon completion to verify it meets the regulation. A Checklist will be maintained by the ATF Director to verify the completion of each assessment. The ATF Director and all program specialists will be trained by 7/31/17. 07/24/2017 Implemented
2380.181(f)The program specialist provided Individual #2's assessment, completed 6/6/17 to the supports coordinator and residential manager on 6/13/17 for the annual ISP meeting on 7/6/17.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 situation cannot be corrected for Individual #2's assessment. In the future, the assessment will be completed at the time of the 2nd 90 day review and provided to the SC, or plan lead, as applicable, and plan team members upon its completion, or, at least 30 calendar days prior to the ISP meeting. The assessment will be forwarded to the Assigned Office Staff to send out. The ATF Director will monitor all assessment dates and verify in documentation the transmittal of the assessment to the necessary parties. The Program Specialists, ATF Director and Assigned Office Staff will be trained by 7/31/17 by the Acting Director. 07/24/2017 Implemented
2380.186(d)The program specialist provided Individual #2's ISP review documentation, completed 11/6/16 to plan team members including supports coordinator and the residential manager on 12/20/16.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.This citation cannot be corrected for this individual as it occurred in the past. The process for providing ISP Review documentation will include the following: 1. The program specialist will forward the ISP review documentation to the Assigned Office Staff within three days of the completion of the review; 2. The Assigned Office Staff will forward the information to plan team members within 5 days of the review date; 3. When the review information is returned to the program specialist, the date of the review and the date of the transmittal letter will be reviewed to ensure its correctness. The Acting Director will train the ATF Director, Program Specialists by 7/31/2017. All Program Specialists will give the ISP review information to the ATF Director within 3 days of the meeting. The Director will forward the review information to the Assigned Office Staff within 5 days and that staff will record the date the information was sent out to determine its compliance with regulations. 07/24/2017 Implemented
SIN-00092570 Renewal 07/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(d)The center section piece of the lid on the garbage receptacle in the ladies room on the first floor was missing; leaving the receptacle uncovered. Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.The garbage receptacle has been replaced with one with a complete lid. The ATF Director will designate a staff to monitor the receptacles and report any without a complete lid so that it can be replaced immediately. [Immediately and continuing at least monthly, a designated staff person shall complete a physical site monitorings to include trash receptacle are covered as required. The director shall train responsible staff person on procedures on addressing areas of physical site when needed. Documentation of monitoring and repairs shall be kept and reviewed by the director at least quarterly. (AS 9/12/16)] 09/15/2016 Implemented
2380.89(e)The front and back exits were used in all the monthly fire drills held from 6/10/15 to 7/22/16. There are four exits from the facility.Alternate exit routes shall be used during fire drills.All exit doors for the ATF will be numbered with the number visible on each door. Each month, the fire drill report will include the door numbers that were used for exiting. The ATF Director or his designee will be responsible to alternate the doors available for use during the drill each month. [Immediately, the Director shall develop and implement policies and procedures to ensure all requirements of fire drills are met including alternating exit routes and train staff responsible for conducting fire drills as to the policies and procedures. At least quarterly the Director shall review fire drill documentation to ensure all requirements are being met. Documentation of training, policies and procedures and reviews shall be kept. (AS 9/12/16)] 09/29/2016 Implemented
2380.111(c)(1)The physical examination completed on 12/15/15 for Individual # 1 did not include a review of previous medical history.The physical examination shall include: A review of previous medical history.A physical examination is scheduled for 9/1/2016 for Individual #1 and the physical form will include a review of previous medical history. All individuals who will be admitted to the Program will use the physical form provided by this agency and the ATF Director will review and ensure the information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including medical history. Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(4)The physical examination completed on 12/15/15 for Individual #1 did not include a vision and hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.A physical examination is scheduled for 9/1/16 for Individual #1 and the physical will include the vision and hearing screening. All individuals who will be admitted to this program will use the physical form provided by this agency and the ATF Director will review and ensure the required information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including vision and hearing screening. Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(5)The physical examination completed on 12/15/15 for Individual #1 did not include a Tuberculin skin test.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.A physical examination is scheduled for Individual #1 on 9/1/2016 and will include a Tuberculin skin test and the results will be documented on the form. All individuals who will be admitted to the program will use the physical form provided by the agency and the ATF Director will review and ensure the information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including Tuberculin skin testing . Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(7)The physical examination completed on 12/15/15 for Individual #1 did not include an assessment of Individual #1's health maintenance needs.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.A physical examination is scheduled for 9/1/2016 and the physical form will include an assessment of health maintenance needs for this individual. All individuals who will be admitted to the program will use the physical form provided by this agency and the ATF Director will review and ensure the information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including health maintenance. Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(8)The physical examination completed on 12/15/15 for Individual #1 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual.A physical examination is scheduled for this individual on 9/1/2016 and the physical form will include the physical limitations. All individuals who will be admitted to the program will use the physical form provided by the agency and the ATF Director will review and ensure the information is provided prior to admission. [Individual #1 had a physical examination completed on 9/1/16 to include all required information including limitations of the individual. Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(9)The physical examination completed on 12/15/15 for Individual #1 did not include allergies or contraindicated medication.The physical examination shall include: Allergies or contraindicated medication.Individual #1 has a physical scheduled for 9/1/2016 and the physical form will include allergies or contraindicated medication as needed. All individuals who will be admitted to the program will use the physical form provided by this agency and the ATF Director will review and ensure that the information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including allergies or contraindicated medication. Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(10)The physical examination completed on 12/15/15 for Individual #1 did not include 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.Individual #1 has a physical scheduled for 9/1/2016 and the physical form will include information pertinent to diagnosis and treatment in case of an emergency. All individuals who will be admitted to the program will use the physical form provided by the agency and the ATF Director will review and ensure that the information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including emergency medical information. Within 30 days of receipt of the plan of correction, Director or supervisor will update the agency physical examination for to include "medical information pertinent to diagnosis and treatment in case of an emergency." Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.111(c)(11)The physical examination completed on 12/15/15 for Individual #1 did not include special instructions for an individual's diet.The physical examination shall include: Special instructions for an individual's diet.A physical is scheduled for this individual on 9/1/2016 and the physical form will include special instructions for the diet. All individuals who will be admitted to the program will use the physical form provided by the agency and the ATF Director will review and ensure the information is included prior to admission.[Individual #1 had a physical examination completed on 9/1/16 to include all required information including special instructions for an individual's diet. Within 30 days of receipt of the plan of correction, the Supervisor or director shall review with the program specialist the required information of physical examinations as per 2380.111(a)-(11) and sign and date upon review. Within 2 weeks of receipt of the plan of correction and prior to entering into the individuals' record, the program specialist shall review individuals' physical examination to ensure all required information is present. Documentation of all reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.173(1)(ii)The records for Individual #1 and 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.The Face Sheet has a place on it for Identifying Marks identified on it. The Face Sheets for both Individual #1 and #2 now has the identifying marks added. All other Face Sheets will be reviewed by the Director to ensure they are complete. The Program Staff will be trained regarding this requirement. [Individual #1 and Individual #2s' records were updated to include "none" for identifying marks. Immediately and continuing at least quarterly, the program specialist(s) shall review all individual records to ensure all required person information is present and will update as needed. At least quarterly the Director shall review a 25 % sample of individual records to ensure all required information is present. Documentation of all review shall be kept. (AS 9/12/16)] 09/15/2016 Implemented
2380.181(a)Individual #1, date of admission 1/13/16 had an initial assessment completed on 5/16/16.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.The ATF Director will ensure that the initial assessment is completed within one year prior to or 60 calendar days after admission to the facility. The Director will alert the responsible Program Specialist regarding the due date for the completion of the initial assessment and will review the assessment at least two weeks prior to the due date. The Program Staff will be trained on this regulation.[Within 30 days of receipt of the plan of correction, the Director shall develop and implement policies and procedures to include a tracking system and train the program specialist(s) to ensure all individuals' assessments are completed within the required timeframes. The Director shall review a 25% sample of assessments to ensure timely completion. Documentation of policies and procedures, tracking system, trainings and reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
2380.181(f)The program specialist did not provide the Individual #'2 assessment, dated 2/5/16 to the plan team members. 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 assessment will be provided to all team members within the required time frame. The ATF Director will monitor the dispersal of the assessments so that they go out on time. All program specialists will be trained regarding this requirement. [Within 30 days of receipt of the plan of correction, the Director shall develop and implement policies and procedures to include maintaining corresponding documentation and train the program specialist(s) to ensure the program specialist provides all individuals' assessments to all individuals' plan team members. The Director shall review a 25% sample of assessments to ensure timely completion. Documentation of policies and procedures, correspondence, trainings and reviews shall be kept.(AS 9/12/16)] 09/15/2016 Implemented
SIN-00077894 Renewal 07/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)The physical examinations completed 9/3/14 and 9/4/13 for Individual #2 did not include a tuberculin skin testing. 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.The ATF Director will be responsible to review each physical examination as it is completed and review the results of the Tuberculin skin testing and if positive, acquire the initial chest x-ray with results noted. This information will be stored in the individual's record. The Director and the Program staff have been trained regarding this issue.[As per conversation with the Director on 8/28/15, the IDP Supervisor reviewed all physicals in the individuals' records for all required elements in physical examination documentation including Tuberculin skin testing and addressed as needed. (AS 8/28/15)] 08/07/2015 Implemented
2380.186(e)The program specialist did not notify the plan team members of the option to decline the ISP review documentation for Individual #1.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Each Program Specialist will maintain a checklist of all documents required including the Declination Form. The signed request from the Team members will be stored with ISP documents in the record. The declination forms which were missing have been obtained and are now in the record. All Program Specialists have been trained regarding this plan..[As per conversation with the Director on 8/28/15, the IDP Supervisor reviewed all individuals' records for declinations forms and addressed as needed. (AS 8/28/15)] 08/07/2015 Implemented
SIN-00066030 Renewal 07/21/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)The most recent physical examinations for Individual #1 were completed on 6/11/13 and 7/3/14.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The appointment for the physical for #1 will be completed by the ATF staff in conjunction with his mother as assigned by the ATF Director at least one month prior to its expiration date. [Program Specialists will be educated on the requirement for physical examinations. The CEO will audit a sample of individual records monthly to ensure regulatory requirements have been met including the annual physical exam. (CHG 8/22/14)] 08/20/2014 Implemented
2380.111(c)(5)The most recent Tuberculin skin tests for Individual #1 were completed on 6/5/12 and 7/1/14.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.The ATF Director will advise the physician regarding the need for the Tuberculin skin test at the time that the test is required. ATF staff will be assigned to acquire the test during the physical exam appointment. [Program Specialists will be educated on the requirement for physical examinations. The CEO will audit a sample of individual records monthly to ensure regulatory requirements have been met including the the physical exam requirement fro Tuberculin skin testing. (CHG 8/22/14)] 08/20/2014 Implemented
2380.173(1)(ii)The records for Individual #2 and Individual #3 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.Each Face Sheet has been reviewed and updated when missing identifying marks for the individual. It will be reviewed at each Team meeting to ensure it is current and the Program Specialist will update it as needed. The program specialists have been trained regarding the needed information. 08/20/2014 Implemented
2380.173(1)(iv)Individual #2's record did not include religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.Each Face Sheet has been reviewed and updated with regard to Religious affiliation for each individual. It will be reviewed at each team meeting to ensure it is current and the Program Specialist will update it as needed. The Program Specialists have been trained regarding the needed information. 08/20/2014 Implemented
SIN-00049690 Renewal 03/26/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)On March 26, 2013, the following hazards were observed: 1. The toilet seat on the toilet located in the third bathroom to the left of the main entrance, was loose. 2. There was a hole in the floor of Program Area 1 measuring 2 feet long and 1 foot wide. 3. An area rug covering a hole in the floor of Program Area 1 has a loose rubber border which could pose a tripping hazard.(b)  Floors, walls, ceilings and other surfaces shall be free of hazards.1. The toilet seat was repaired and is functioning properly. 2. The flooring for the ground floor has been replaced by new tile. 3. The flooring for the ground floor has been replaced with new tile. The area rug has been removed. [The program specialist will complete a physical site audit one time per month of the facility to ensure floors, walls, ceilings, and other surfaces do not contain any hazards. (CHG 6/10/13)]. 04/22/2013 Implemented
SIN-00230739 Renewal 09/20/2023 Compliant - Finalized
SIN-00211776 Renewal 09/22/2022 Compliant - Finalized