Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237238 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(ii)Individual #1's file did not contain information regarding identifying marks. There was a spot on the emergency information sheet for this information, but it 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.The individuals record includes the race, height, weight, color of hair, color of eyes and identifying marks. These items are noted on the individuals Emergency Information Sheet, also known as the Face Sheet. On 18 January 2024 the Director of Community Life Services retrained the Program Specialists, who are tasked with maintaining the individuals record to include the Individuals Face Sheet. The Program Specialists were retrained on the personal information that must be retained in the individuals record to include the individuals' identifying marks. The Program Director reminded the Program Specialists if the information is unknown or not applicable, the Program Specialist shall note this as unknown¿, UNK, N/A, or use any other standard indicator; however, the sections that note required information cannot be left blank. On 18 January 2024 the Program Specialist updated Individual #1¿s record to include Unknown for identifying marks. 02/02/2024 Implemented
SIN-00219787 Renewal 02/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drills for 3/10/22 and 9/14/22 were both missing the evacuation time.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.On 10 March 2022 the evacuation time was noted on the fire drill log, completed in 49 seconds. On 18 April 2022 and 14 September 2022, the evacuation time was not noted. Although the last twelve fire drill evacuation times have been no more than one minute and eighteen seconds, on average lasting less than a minute, the evacuation times could not be unequivocally verified. Facility management noted ¿unable to verify on the 18 April 2022 and 14 September 2022 fire drill logs. On 23 February 2023 facility management conducted a fire drill during the physical site inspection. Facility management noted the duration of evacuation time. 03/03/2023 Implemented
2380.89(e)All exits are being used for all fire drills. A discussion was held explaining the need to have individuals use alternate exits in case of a fire that blocks the usual exit. This allows for individuals to be aware of and comfortable using alternate exits.Alternate exit routes shall be used during fire drills.During fire drills the facility uses every exit of the building as occupants of the building will use the most accessible exit; because of this practice, the facility does not distinguish specific exits during fire drills, but note all exits used during the fire drill. During licensing it was discussed that alternate exits must be used during fire drills. It was further discussed that it may be best to identify specific locations used and develop a way to practice the use of alternate routes. On 22 February 2023 the facility Program Director instructed staff on the process for fire drills, including the use of orange cones to indicate the location of the fire and the need to evacuate the building using alternate routes as necessitated by the placement of the cone. On 23 February 2023 the facility management conducted a fire drill during the physical site inspection. The cone was used to indicate the fire and staff exited the building refraining from using the exits blocked by the ¿fire¿ (orange cone). The exits used during the fire drill was documented, as well as the location of the cone/fire. Evacuation routes not utilized during the fire drill, correlating with the placement of the cone where not documented as being used. 03/03/2023 Implemented
SIN-00199969 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)No fire drill was conducted in May 2021, the first month that the facility reopened to Individuals.An unannounced fire drill shall be held at least once a month.On May 10, 2021, the facility re-opened after being closed for over a year because of the March 2020 COVID-19 closure. Upon reopening an unannounced fire drill was not conducted. However, the facility did conduct an announced fire drill on June 10, 2021, within a month or 30 days of the facility reopening. A second fire drill was conducted on June 29, 2021, to account for the month of June as facility management at the time was confused by the language used in the regulation regarding the requirement to conduct a fire drill at least once a month. Unannounced fire drills have been conducted each calendar month from June 2021 forward. 06/10/2021 Implemented
2380.21(u)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 2/15/2022 annual inspection, Individual #1 and #2 were not informed of the individual rights as described in 2380.21.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The facility updated its Rights and Responsibilities packet to include the updated regulatory rights, effective 2/3/2020. The updated rights were provided and explained to individual #1 on 2/21/2022 and individual #2 on 2/21/2022. The facility has provided and explained the updated rights to all other program participants. On 2/18/2022 the Program Director, retrained Program Specialists on the requirement to inform and explain the regulatory rights to individuals they support. All Program Specialists were retrained by the Program Specialist Lead, on the updates to the individual rights packet on 3/03/2022. 02/21/2022 Implemented
2380.181(f)There is no record that Individual #1's 2/15/22 Assessment was sent to the entire ISP team, which includes Individual #1 and Individual #1's mother.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The facility sent Individual #1's assessment dated 2/15/2022 to all members of the ISP team to include: Individual #1 (2/22/2022), Individual #1 parent or guardian (2/22/2022), Individual #1 Supports Coordinator (2/15/2022), Individual #1 Communication services team (2/21/2022), and Individual #1 Behavioral Supports service team (2/22/2022). On 2/18/2022 the Program Director, retrained Program Specialists on the requirement to submit assessments to the individual's support team 30 days prior to an individual's plan meeting. The Program Director, provided a memo to the team on 3/04/2022. 02/22/2022 Implemented
SIN-00164907 Renewal 02/19/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Many individuals at the program are assessed to be unsafe with poisonous materials. During the 2/20/2020 physical site inspection multiple poisonous substances were located throughout the facility, unlocked and accessible to individuals. All the substances contained a label that stated to contact poison control center if ingested. Hillard Summer Fresh Air freshener was located in an unlocked cabinet in the women's hallway restroom. Two, large, Hillard non-acid restroom disinfectant were unlocked in first aid/laundry room.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The air freshener that was located unlocked in the bathroom was immediately locked on 2/20/20. The Program Manager placed a work order on 2/24/20 to have maintenance remove the dual cleaning detergent dispensers in the laundry room. On 4/7/20, the maintenance team notified the Assistant Director of LES that the dispensers had been removed from the laundry room wall (see attachment #27). All Direct Support Staff were retrained on 2380.53 to keep all poisons locked (see attachments #28 & 29). Any Direct Support Staff not present or on leave will be trained within 15 days of programs re-opening by the Program Specialists. The Program Specialists were retrained on 2380.53 on 3/4/20 during a Leadership Meeting (see attachment #3). Program Specialists who were not present will be retrained by the Director of LES within 15 days of programs re-opening. All Program Specialists are responsible to do a walk-through of all areas accessible to individuals prior to opening and after individuals leave the building daily to ensure all poisons are locked. They are also working in the group rooms between 8:30-11:00am daily and are to be monitoring the locking of poisons during those times. Departmental Directors will be responsible to complete random checks weekly for proper storage of poisons. 04/07/2020 Implemented
2380.84The agency had a fire safety inspection of the building on 2/8/18 and not again until 7/16/19, outside of the annual time frame requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.A fire safety inspection on 2/8/18 (see attachment #22) and the following inspection was on 7/16/19 (see attachment #23), which was late. The Director of LES contacted the fire safety inspector on 2/26/20 (see attachment #24-3 pages) to schedule a time to perform an inspection. The fire inspection of the building was completed on 3/10/20 (see attachment #25). The Director of LES is responsible for scheduling the annual fire inspection and has created a reminder alert in Outlook for 1/4/21 to make the 2021 inspection appointment (see attachment #26). The Director of LES is responsible for following recommendations as a result of the inspection within 15 days of programs re-opening. 03/10/2020 Implemented
2380.91(a)Individual #5's date of admission to the facility is 8/12/19 and he did not receive training on fire safety and all components described under 2380.91(a) until 8/13/19; after admission to the facility and outside the regulatory time frame requirement. Individual #3 has been attending the program for a few years and is required to have the fire safety training annually. She received fire safety training on 12/12/19 but there is no evidence she received fire safety training in 2018.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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.The Program Specialist is responsible for completing the fire safety training for an individual on their first day in program and Individual #5s fire safety was completed on the second day of program , 8/13/19 as per daily progress notes (see attachment #20). His first day was 8/12/19. The Program Specialist is responsible for completing a fire safety training log on the first day which indicates what must be completed according to regulations (see attachment #21). A new participant fire safety log was reviewed and retraining on its use was completed with all Program Specialist¿s on 3/4/20 during a Leadership Meeting (see attachment #3). All Program Specialists that were not present at the meeting will be trained within 15 days of our programs re-opening by the Director of LES. 03/04/2020 Implemented
2380.111(c)(3)Individual #4's 3/14/19 physical examination form does not include a list of his immunizations as recommended by the Centers for Disease Control.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #4s current physical was from an outside agency and did not state his most recent immunizations. The Program Specialist contacted Individual #4¿s physician on 2/24/20 and received on 3/5/20 the most recent immunization dates. The record indicated that Individual #4 received the Tdap immunization on 3/3/16 (see attachment #19-2 pages). In accordance with the CDC guidelines, this immunization is due to be renewed by 3/3/26 and this date maintains that Individual #4 was in compliance during this physical year. The Program Specialists were retrained by the departmental directors at a Leadership meeting on 3/4/20 regarding the use of outside physicals. They were directed to only accept Excentia Human Services physical forms starting on 3/5/20 (see attachment #3). All Program Specialists who were not present will be trained within 15 days of programs re-opening by the Director of LES. The Program Specialists will be responsible for reviewing all individual physical forms immediately upon receiving them to detect any missing information and request it from the appropriate source. The departmental directors will be responsible for reviewing all physicals within 5 days of being received by the Program Specialists as indicated on the physical review checklist (see attachment #18). 03/04/2020 Implemented
2380.111(c)(10)All individuals' physical examination documents review by licensing during the 2/19/2020 inspection stated, "seizure disorder, speech impediment, gait disorder, phobia to needles/apparel/hospital or institution" as information contained within the regulatory requirement of medical information pertinent to diagnosis and treatment in case of an emergency. However, not every individual, who's physical examination contained this information, had the listed diagnoses and phobias.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.All Excentia Human Services annual physical forms were not uniform in the section for medical information pertinent to the diagnosis and treatment in case of an emergency. The examples listed in the section did not have parenthesis around them on all forms and could be mistaken for actual emergency medical information. The Director of Quality and Training updated the Excentia Human Services annual physical and implemented it on 3/24/20. The section for medical information pertinent to the diagnosis and treatment in case of an emergency was updated with parenthesis around the list of examples (see attachment #17). All Program Specialists are responsible for utilizing this form for internal and external individuals in all programs as of 3/24/20 as instructed by the Director of Quality and Training and was reviewed at the Leadership Meeting (see attachment #3). All Program Specialists who did not attend will be trained by the Director of LES within 15 days of programs re-opening. The departmental directors are responsible to review all individual physicals within 5 days of being received by the Program Specialists as added to the physical review checklist (see attachment #18). 03/24/2020 Implemented
2380.173(1)(ii)Individual #5's record states he does not have any identifying marks. However, the photograph in his record reveals deep ridges in the skin on his scalp.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.Individual #5s Emergency Face sheet did not indicate any identifying marks. Upon observation, it was evident Individual #5 had deep ridges in the scalp. The Program Specialist corrected Individual #5 Emergency Face sheet on 2/24/20, with the addition of deep ridges in scalp and a scar under right eye to the Identifying Marks section (see attachment #16). The Program Specialists were retrained on the Emergency Face Sheet on 3/4/20 at a Leadership Meeting and the importance of having identifying marks listed to identify an individual should an emergency arise (see attachment #3). Program Specialists were instructed to review and correct any other individuals Emergency Face sheets that may be missing information on 3/4/20. Due to the programs closure, the completion date will be within 15 days re-opening. Program Specialists that were not in attendance will be retrained by the Director of LES within 15 days of programs re-opening. 03/04/2020 Implemented
2380.181(e)(8)Individual #1's current, 6/14/19 assessment does not address his ability to evacuate during a fire drill. The assessment stated that he is in the community most of the time and it's unclear how he would respond during a fire drill. He has not been assessed for evacuation at this facility and has been attending since 2017.The assessment must include the following information: The individuals ability to evacuate in the event of a fire.Individual #1 completes programming in the community and has not been present at the facility during a fire drill, therefore his assessment did not reflect his ability to evacuate at program. Due to the closure of LES programs on March 17th, and receiving the LIS on March 18th, Individual #1 did not have the chance to participate in a facility fire drill. The Program Specialist sent to the ISP team an addendum to Individual #1s annual assessment to indicate his ability to evacuate a facility as indicated by his residential program on 4/2/20 (see attachments #14 & #15). The addendum also indicates that upon reopening of the facility, there will be a plan for Individual #1 to participate in the next facility fire drill. The plan at this time will be for Individual #1 to be brought to the facility during a specific time period when a fire drill will be initiated. At this time, we do not have a date that it will be completed, but it will occur within the first 15 days of re-opening. The Program Specialists were retrained by the departmental directors at a Leadership meeting on 3/4/20 to create a plan for all community-based individuals to return to the facility on a minimum of once every 12 months to participate in a fire drill (see attachment #3). This completion date will also be within 15 days of re-opening. All Program Specialists not present will be retrained by the Director of LES within 15 days of programs re-opening. The Program Specialists were instructed on 3/4/20 to create addendums to any individuals assessment that does not indicate their ability to evacuate during a fire drill and this completion date will be within 15 days of re-opening. 03/04/2020 Implemented
2380.21(j)Per Individual #2's Seizure Protocol developed 12/13/18 by the agency, The PAI Corporation, "If at any time {Individual #2} appears to be turning blue or having respiratory distress, immediately call 911 to get assistance." Per 1/14/2020 Progress Note written by agency staff, Staff #4, "{Individual #2} had a severe seizure. Staff was able to pull off the road. It lasted approximately 45 seconds. Her lips turned blue, her face was ash in color. Staff administered {Individual #2's} bracelet to {Individual #2's} chest, where {Individual #2's} patch was. {Individual #2's} breathing labored and {Individual #2} had foam coming out of {Individual #2's} mouth. After the seizure, {Individual #2} fell into a deep sleep." Staff neglecting to provide the medically necessary services as outlined in the individual's Seizure Protocol in her record, put the individual's health and safety at risk.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Staff #4 did not follow Individual #2s seizure protocol as written and failed to notify 911 when Individual #2 was exhibiting signs of distress that were outlined as requiring emergency action. The Director of LES created a signature sheet on 2/24/20 for staff to sign upon reading and understanding her seizure protocol prior to working with Individual #2 (see attachment #12). Direct Care Staff working with Individual #2 were retrained on Individual #2s seizure protocol by the Program Specialist and documented their acknowledgement of the training on the signature sheet provided beginning on 2/24/20. A seizure chart was created by the Assistant Director of LES and implemented on 2/24/20 to identify individual symptoms of any future seizures and to assist staff in following Individual #2s seizure protocol (see attachment #13). The Program Specialist is responsible for training all staff on Individual #2s seizure protocol prior to working with them and to maintain documentation of the staff¿s training with the signature sheet. The Direct Care Staff is responsible for following the seizure protocol, filling out the seizure chart and contacting the Program Specialist with any reports of seizure activity. The Program Specialist is responsible for reviewing the seizure log immediately following a seizure to ensure the protocol is followed as well as maintaining monthly documentation of any seizure activity and relaying it to the ISP team. The Program Specialists were trained on the signature sheet and new procedure on 3/4/20 at a Leadership meeting as well as the procedure for incident reporting should any medical neglect be observed (see attachment #3). Program Specialists that were not present will be trained by the Director of LES within 15 days of programs re-opening. The Director/Assistant Director of LES is responsible for reviewing all reports of seizure activity to ensure appropriate action was taken. 03/04/2020 Implemented
2380.123(e)Individuals at the program require the use of an Epinephrine auto-injector as a potentially life-saving device ordered by their physicians. Per the CEO (Chief Executive Officer) designee at the time of the 2/19/2020 inspection, the auto-injectors continue to be stored in a locked bag that is not readily accessible to staff who administer the medication. Occasionally the locked bag is stored in the locked trunk of the car when traveling and completely out of reach of the staff who are to administer the medication.Epinephrine and epinephrine auto-injectors shall be stored safely and kept easily accessible at all times. The epinephrine and epinephrine auto-injectors shall be easily accessible to the individual if the epinephrine is self-administered or to the staff person who is with the individual if a staff person will administer the epinephrine.A standard protocol regarding the accessibility of epinephrine and epinephrine auto-injectors was not being utilized causing these medications to be in locked containers which were not allowing them to be immediately available to individuals if needed. The Director of LES created a protocol on 3/24/20 outlining the need for individuals¿ who are prescribed epinephrine and epinephrine auto-injectors to be easily accessible at all times, and taking into account the location of their storage as to not risk others safety (see attachment #10). Due to closure of Life Enrichment Programs on 3/17/20 due to COVID-19, physical written approval was unable to be acquired. Email confirmation of approval for epinephrine and epinephrine auto-injectors to be included in medication administration training was given by the Director of Quality and Training on 4/3/20 (see attachment #11-2 pages). Program Specialists will be responsible for identifying the appropriate location of the epinephrine and/or epinephrine injectors based on each individuals needs/abilities and will implement the change on the first day of the re-opening of LES programs and the medication remains in those locations by completing daily checks when staff return to the building. They are also responsible to inform the Supports Coordinator and ISP team and have the information added to the individuals ISP. Program Specialists will be fully trained within 15 days of programs re-opening. 04/07/2020 Implemented
2380.129(a)Staff #2 initialed Staff #1's annual medication administration training with a re-certification date of 3/29/19 to pass medications. However, recorded on the annual practicum summary sheet, two of the required medication administration record reviews were listed as being completed by Staff #1's "previous employer." If a staff transfers with any completed medication training approved by the Department, the current employing agency still must complete the entire medication annual practicum summary sheet prior to allowing the staff to administer mediations. The annual practicum summary was not completed in its entirety by the employing agency, The PAI Corporation, prior to allowing Staff #1 to administer medications. Staff #1 has been administering medications to individuals in the program, without certification to do so, since her date of hire on 9/17/18. Additionally, another one of the required medication administration reviews was not completed prior to the 3/29/19 recertification date documented by Staff #2; it was completed on 4/14/19. Therefore, at the time of the 3/29/19 annual medication administration training recertification documentation, Staff #1 only had one out of the two required medication administration reviews completed correctly for the previous year and both required medication observations.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).The Program Specialist contacted Staff #1 and they ceased to administer medications as of 2/21/20 and that they have not given medication in any form from 2/21/20- present. Life Enrichment Services was closed indefinitely on 3/17/20 and Staff #1 was unable to complete a full medication training due to its cancellation resulting from the COVID-19 guidelines. With the indefinite closure of programs and suspension of all face-to-face, non-essential trainings, Staff #1s Program Specialist/supervisor will be responsible for ensuring that she is enrolled in the next available agency training upon re-opening, and that Staff #1 will not administer any medications to any individuals until an entire medication training, observations and record reviews are completed by a certified medication trainer and reviewed by the departmental director. The requirements for staff transferring medication administration certification from an outside agency has been reviewed with all Excentia medication trainers, including Staff #2, on 2/27/20 by medication trainer and Assistant Director of LES. This was confirmed through email with all trainers (see attachment #9-5 pages). All medication trainers are responsible for adhering to the procedure for outside transfer of medication administration records as of 2/27/20. 02/27/2020 Implemented
2380.156(a)There is no evidence that staff were trained in the plan specific techniques or procedures documented in Individual #4's behavior support plan that is in effect at the program.A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.The documentation of staff training of Individual #4¿s behavior support plan was completed by Behavior Specialists in daily progress notes (see attachment #7-4 pages), but no formal document was signed by staff that the plan was reviewed. The Behavior Specialist created an Excentia Human Services staff signature sheet on 2/24/20 that is specific to everyone with a behavior support plan. The Behavior Specialist retrained all staff working with Individual #4 on the behavior support plan on 2/24, 2/25 & 2/26/20 and they signed the staff training signature sheet (see attachment #8). All staff who work with other individuals with behavior support plans were also retrained by the Behavior Specialist and signed a staff training signature sheet as of 3/1/20. Program Specialists were trained on this new procedure on 3/4/20 at a Leadership meeting (see attachment #3). Program Specialists who were not present will be trained within 15 days of programs re-opening by the Director of LES. All Program Specialists are responsible for contacting a behavior specialist to train new staff prior to working with an individual on the individuals behavior support plan and indicating that this was completed by collecting their signature on the staff training signature sheet. This will be monitored by the Behavior Specialist during monthly meetings. 03/04/2020 Implemented
2380.181(b)Individual #1's current Individual Support Plan (ISP) stated that as of 7/15/2019, a 1:1, staff to individual ratio, was an approved service being provided at the day program and in the community with day program staff during day programming hours. According to the individual's 6/14/19 assessment, "{the individual} is supervised in a 1:2-1:3 ratio in the community and a 1:2-1:6 ratio in the facility." Another assessment was never complete to show the change in need for staffing at the facility and in the community with the facility. An addendum to his assessment was found in his record but it wasn't created until 7/17/19, after the date of implementation of the 1:1 staff to individual ratio which was 7/15/19, and no evidence of the addendum being send to team members.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.The Program Specialist responsible for Individual #1s documentation sent out an addendum on 7/17/19 to indicate the change in supervision from 1:2-1:3 community and 1:2-1:6 in the facility (see attachment #1) to a 1:1 staffing ration in both settings as this was the date the change was entered in Individual #1s ISP. The service change was entered into the ISP on 7/17/19, yet also indicates that 1:1 service began on 7/15/19. (see attachment #2 -2 pages) On 3/4/20, the Director and Assistant Director of LES retrained Program Specialists on the importance of sending an addendum to the ISP team when any major changes to an individuals ISP occur prior to the change and reviewed the utilization of our existing addendum format (see attachment #3-2 pages). All Program Specialists that were not present will be trained within 15 days of programs re-opening A second addendum (see attachment #4) explaining the discrepancy of a 7/17/19 addendum disseminated 2 days following the actual start date of 1:1 services being 7/15/19 was completed and sent to the ISP team on 3/25/20 by the Program Specialist (see attachment #5) upon receiving our formal LIS. All future service changes as of 3/25/20 will be monitored through a service change form by the departmental directors to ensure all dates are aligned (see attachment #6). 03/25/2020 Implemented
SIN-00146164 Renewal 12/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The lower hinge on the right cabinet door to the left of the kitchen sink is broken.Floors, walls, ceilings and other surfaces shall be in good repair.The lower hinge was loose and was tightened with a screw driver immediately upon discovery. The cabinet is now in working condition. 12/19/2018 Implemented
2380.111(a)Individual #5 had a physical exam completed on 6/7/17 and not again until 8/1/18. Individual #6 had a physical exam completed 4/6/17 and not again until 4/30/18.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialists were retrained on following applicable due dates. A due date spreadsheet controlled by the Program Specialists will now be checked and reviewed by the Program Manager and Associate Director to ensure regulatory due dates and time frames are being met. 01/04/2019 Implemented
2380.111(c)(4)Individual # 11 11/21/18 physical does not include vision or hearing screening. Individual #4 7/02/18 physical states that a hearing screen was not completed due to, "MR and minimally verbal" which is not an acceptable reason to not have the screening completed. Individual #8 has no record of a vision or hearing screen in the record.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialists were retrained on physical examination requirements and all physical examination documents have been updated for consistency including the medical examination form, medical examination checklist, and yearly physical exam reminder letter for families and providers. The physical examination forms for individuals #11, #4, and #8 have all been updated with information from the physicians to include vision and hearing screening information. 01/16/2019 Implemented
2380.111(c)(5)Individual #5 had a TB test with negative results read on 6/23/16 and not again until 8/03/18. Individual #6 had a TB test with negative results read on 4/08/16 and not again until 8/29/18The 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.Program Specialists were retrained on applicable due dates and physical examination requirements. In addition, all physical examination documents have been updated for consistency including the medical examination form, medical examination checklist, and yearly physical exam reminder letter for families and providers. 01/16/2019 Implemented
2380.111(c)(7)Individual #7 most recent physical dated 10/11/18 did not contain a response regarding "recommendations" on section "health maintenance needs"; this cannot be left 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.Program Specialists were retrained on applicable due dates and physical examination requirements. In addition, all physical examination documents have been updated for consistency including the medical examination form, medical examination checklist, and yearly physical exam reminder letter for families and providers. The physical examination form for individual #12 has been updated with information from the physicians to include health maintenance needs, medication regimen, and the need for blood work at recommended intervals. 01/17/2019 Implemented
2380.173(1)(ii)Individual #12 eye color is listed on the face sheet as brown, but individual's actual eye color is Hazel and appears blue in the photo and in person.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 document for Individual #12 was updated to reflect his appropriate eye color. 12/26/2018 Implemented
2380.173(9)Individual #12-Allergies on the physical form state, "adhesive bandages, seasonal, and Zosyn" but the face sheet, most recent ISP dated 9/6/18, and most recent assessment dated 4/10/18, all only indicates allergy to "Adhesive bandages". Individual #9-Physical dated 04/18/18 stated no known food or drug allergies, ISP dated 11/08/18 has seasonal allergies.Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The face sheet document for individual #12 was updated to reflect all applicable allergies listed in the physical and ISP. 12/26/2018 Implemented
2380.176(a)A quarterly review was left unattended in an unlocked closet in the first room to the left upon entering from the bus pickup/drop-off zone.Individual records shall be kept locked when they are unattended.The quarterly report that was discovered to be unlocked and unattended was immediately placed in the appropriate file and locked. Direct Support Professionals working within the room where the unlocked document was found were retrained immediately. All Direct Support Professionals were retrained during a team meeting on the applicable regulation, protected health information, and Excentia¿s policy stating that all individual records shall be kept locked when unattended. In addition to retraining, a work order was placed and completed to fix the locks on the lockers where the document was found. 12/19/2018 Implemented
2380.181(a)Individual #11 Assessment completed on 09/13/17 and not again until 10/03/18.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.Program Specialists were retrained on following applicable due dates. A due date spreadsheet controlled by the Program Specialists will now be checked and reviewed by the Program Manager and Associate Director to ensure regulatory due dates and time frames are being met. 01/04/2019 Implemented
2380.181(d)Individual #5 assessment dated 10/11/2018 was not signed by the program specialist (name was typed in).The program specialist shall sign and date the assessment.Program Specialists were retrained on providing applicable signatures and dates on all necessary documentation. The assessment for individual #5 was signed by the Program Specialist immediately after discovery. 01/17/2019 Implemented
2380.186(d)Individual #11 08/14/18 ISP review is not documented as being sent to team members.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.Program Specialists were retrained on following applicable due dates and providing required signatures and dates on all necessary documentation. A due date spreadsheet controlled by the Program Specialists will now be checked and reviewed by the Program Manager and Associate Director to ensure regulatory due dates and time frames are being met. The quarterly report for individual #11 was sent to the ISP team on 12/19/18 to immediately rectify the missing date. 01/17/2019 Implemented
SIN-00121890 Renewal 12/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(b)(4)Video recording in hallways and in each program room and there wasn't a sign posted by any camera stating that video recording was taking place.The facility shall develop and implement civil rights policies and procedures. Civil rights policies and procedures shall include the following: Informing individuals on their right to register civil rights complaints.Jeff Kepeck, Director of Life Enrichment Services will post Signs stating there are video cameras recording will be placed by each camera. Individuals and legal guardians will be informed there are video cameras in the facility. An addendum will be added to the LIFE ENRICHMENT SERVICES INDIVIDUAL RIGHTS, RESPONSIBILITIES, RESTRICTIONS, AND RESOURCES packet to inform families and guardians of this information. Program Supervisors/Program Supervisors will ensure individuals are informed of the use of cameras. They will also document the date each individual has received this information. A letter will be sent home to inform all legal guardians of the cameras. Lauren Ward, Assistant Director, will be responsible to draft the letter and send it to legal guardians. Supporting Documents: Acknowledgement form for the individuals who have been informed there are cameras in the rooms (attachment 18).Picture of a surveillance notification sign posted near one of the cameras (attachment 19). Signs have been posted in each program room and near each camera in the hallways. A copy of the addendum to include with the LIFE ENRICHMENT SERVICES INDIVIDUAL RIGHTS, RESPONSIBILITIES, RESTRICTIONS, AND RESOURCES packet (attachment 20). A copy of the letter being sent out to legal guardians to inform them of the cameras in the facility (attachment 21). 12/20/2017 Implemented
2380.36(a)Staff #1 DOH was 9/5/17 and not trained in daily operations at facility until 9/20/17.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.Orientation training documents will be updated for the Independent U Program to include dates and signatures for all trainings required prior to working with individuals. Lauren Ward, Assistant Director, will train all Supervisors on the new orientation training documents. Program Supervisors will be responsible to conduct the Orientation Training. In addition, all Life Enrichment Service new hires will receive training on Daily Operations and Facility Policies and Procedures prior to their first day of Program Orientation by a member of Human Resources. Supporting Documents: Supervisor Training on New Employee Orientation Agenda and Signature Sheet (attachment 15). Updated Life Enrichment Services Department New Employee Orientation Training Log (attachment 16). Human Resources updated Orientation for New Employee Life Enrichment Services training log (attachment 17). 12/20/2017 Implemented
2380.91(c)Individual #4, #6, and #1 came to the new building on 6/5/17 and didn't receive fire safety training at new location. Individual #2 had fire safety on 3/4/16 and again on 4/28/17.A written record of firesafety training, including the content of the training and individuals attending, shall be kept.All Individuals currently served in the Independent U Program will receive training their first day back to program starting 12/15/2017. Program Supervisors will provide the fire safety training and document the content of the training and the individual¿s in attendance. Content of the training will include general firesafety, evacuation procedures, responsibilities during fire drills, and the designated meeting place outside the building or within the fire safe area in the event of an actual fire. All new participants will receive the same fire safety training upon their initial admission. Program Specialists will be responsible to ensure all individuals receive fire safety training at initial admission and annually. Supporting Documents: Program Specialists Plan of Correction Training Agenda and Signature Sheet (attachment 1). Fire Safety Training Sign in Sheets for Independent U Participants from 12/15/2017-12/21/2017 (attachment 14). 12/21/2017 Implemented
2380.173(1)(ii)Individual #4's record did not contain 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.Julie Webb, Program Specialist Supervisor, will train all Program Specialists will be retrained to understand what classifies an identifying mark. All Program Specialists will review face sheets to ensure identifying marks are accurately identified on the face sheets. Supporting Document: Program Specialists Plan of Correction Training Agenda and Signature Sheet (attachment 1). #4's updated face sheet with appropriate identification of identifying marks (attachment 10). 12/20/2017 Implemented
2380.173(9)Individual #1 ISP stated to follow a diabetic, low fat, low cholesterol diet. The 10/31/17 physical stated to follow consistent carbohydrate , low fat, low cholesterol diet.Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Specialists Supervisor, Julie Webb, will train all Program Specialists to clarify any discrepancies with the PCP and communicate all content discrepancies between physicals and ISP¿s through the quarterly ISP reviews and email communication to the supports coordinator. The Physical Exam Checklist Document will be revised to include procedure for cross referencing physical information and the ISP. #1's Supports Coordinator will be asked to update the diet information in the ISP. #1's next ISP Review will include the updated diet information. Supporting Documents: Program Specialists Plan of Correction Training Agenda and Signature Sheet (attachment 1). Email to #1's Supports Coordinator to update the diet information in his ISP (attachment 11). Revised Physical Exam Checklist Document (attachment 12).#1's Diet changes added to the next ISP Review (attachment 13). 12/20/2017 Implemented
2380.181(a)Individual #4, #6, and #1 came from Prince St location and transferred their assessments. Records no documentation that their assessments were reviewed upon transfer to location on 6/5/17.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.Independent U Program Specialists will review assessments to ensure all content is accurate and relevant to the service they are receiving since moving to the at the 1810 Rohrerstown Road location on June 5th, 2017. Program Specialists will explain any discrepancies or if there are no discrepancies since the move in the next ISP review. Supporting Document: Next ISP Review for #4, #6, and #1 stating the assessment has been reviewed since the move. Any discrepancies will be included in the ISP Review. (attachment 9). Supporting Document: Next ISP Review for #4, #6, and #1 stating the assessment has been reviewed since the move. Any discrepancies will be included in the ISP Review. 12/20/2017 Implemented
2380.185(b)Individual #8's ISP indicated he needed to be repositioned throughout the day. He had two repositioning logs however most of the days were blank and didn't indicate if he was repositioned. The log, quotes, Change position after, end quotes. was blank from 5/12/17, 5/23/17, 5/26/17 to 5/29/17, 6/16/17 to 7/9/17,The ISP shall be implemented as written.Excentia has implemented a new electronic documentation system called Foothold Awards. Staff working directly with #8 were re-trained on documenting his health and safety protocols and procedures as well as using Foothold to document Health and Safety Protocols for all individuals on 12/19/2017 by the department Director, Jeff Kepeck. Additionally, all Life Enrichment Services direct support professionals will be re-trained in documenting health and safety protocols and procedures at the next all staff meetings on January 10th and January 24th. Since 12/04/2017 by Program Supervisors. Program Specialists are responsible to run daily reports on participant goals and health protocols/procedures to ensure staff are accurately completing and documenting these plans. Supporting Documents: Training agenda and signature page from 12/19/2017 (attachment 7). #8's daily documentation for repositioning from 12/12/2017-12/18-2017 (attachment 8). 12/19/2017 Implemented
2380.186(a)Individual #4, #8, #7 and #6's ISP reviews not completed within 15 days after last date of review period. The review period was June - August 2017 but review not completed until 9/22/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Julie Webb, Program Specialist Supervisor, will train all Program Specialists to complete and review all ISP Reviews with the individual within 15 days of the last review period. Supporting Documents: Program Specialists Plan of Correction Training Agenda and Signature Sheet (attachment 1). #2's ISP review completed and reviewed within 15 days of the last review period (attachment 2). 12/20/2017 Implemented
2380.186(c)(1)Individual #8's ISP review dated 8/8/17 didn't review community outing with friends goal but stated there was staff turnover and not chance to work on 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.Since 12/04/2017, Program Specialists are responsible to run daily reports on individual participation and progress to ensure we are providing services according to the ISP. Program Specialists will also be re-trained to ensure outcome progress is explained in the ISP Review by stating regression, maintenance, or progress on the outcome since the last review. #8's monthly schedule has been updated to include community outings so he has multiple opportunities to work on his goal. Supporting Documents: Copy of #8's monthly schedule with opportunities to work on his goal(attachment 3). New Procedure to review outcomes daily to ensure staff are working on outcome progress and documenting the progress accordingly (attachment 4). Program Specialist Training agenda and signature sheet (attachment 1). #8's ISP review with documentation of goal progress (attachment 5). 12/20/2017 Implemented
2380.186(c)(2)Individual #8's ISP review dated 8/8/17 didn't review if he has seizures that quarter. There was a seizure protocol in his ISP.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialists Supervisor, Julie Webb, will re-train all Program Specialists to ensure health and safety protocols are reviewed and reported on during each ISP Review. The Program Specialist Supervisor, Julie Webb, will review individual files at least twice per month to assist with accuracy of reporting. Supporting Document: Program Specialists Plan of Correction Training Agenda and Signature Sheet(attachment 1). #8's ISP review with seizure documentation (attachment 6). 12/20/2017 Implemented
SIN-00102601 Renewal 10/24/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(18)Staff #15 was not trained in Individual # 7's need for Thick-It. Staff # 15 indicated that she thought individual #7 got nectar-thick liquids. Staff # 15 placed 3 unleveled and unfull scoops of Thick-It into Individual #7's cup. The label for Thick-It instructs 3-3 1/2 level scoops with juice for nectar thick liquids.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.Staff #15 received disciplinary action for this episode (attachment 29). Moving forward, the Program Specialists have constructed reference cards which indicate the level of thickening for the daily working file for each person who uses it. In addition, despite the impression given by staff #15, she as well as all other ADS staff has indeed had training in Dysphasia and meal modifications as well as the use of Thick-it. Attachment 30 is a report of all ADS staff who have had Dysphasia training. 12/02/2016 Implemented
2380.53(a)In Room B's bathroom cabinet, Wasp/Hornet killer, hand sanitizer and dutch apple air freshner were stored in a cabinet with a key left in the cabinet lock. In Room D, Linen Breeze air freshner was left in an unlocked cabinet in the changing room. Dutch Apple Air Freshner was left in the Men's bathroom. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Attachment 27 a, b and c are photos showing that items are put away in locked cabinets and keys are replaced in their secure locations. Moving forward, all staff had retraining on 11.30.16 at a staff meeting and signed off on a statement committing to locking items (attachment 28) 12/02/2016 Implemented
2380.70(d)The first aid kit did not include tape. 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.Attachment 26 is a photograph of the first aid kit including tape. Each group also has a first aid kit in their rooms and a backpack first aid kit to take on outings. All kits will be checked monthly on the Physical Site Checklist 10/26/2016 Implemented
2380.89(a)A fire drill was held on 11/30/15 and not again until 01/29/16. An unannounced fire drill shall be held at least once a month.Attachment 24 shows a fire drill for November 2016. Supervisors have been instructed to conduct each monthly drill by the 15th of each month. Attachment 25 shows the schedule of which manager is responsible for each months drill. The Assistant Director will follow up by the 15th of each month to verify that a drill was conducted. 12/02/2016 Implemented
2380.89(c)The evacuation time was left blank on the 01/29/16 fire drill log. 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.Attachment 24 shows the fire drill evacuation time. The administrative assistant will review the fire drill logs each month to verify that all areas are complete. 12/02/2016 Implemented
2380.91(a)Individual # 2's fire safety training was late. Dates of fire safety training were 03/09/15 and 05/23/16.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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.Supervisors and Program Specialists were retrained in this requirement and signed off their understandings (attachment 23). Verification will be made through the Program Specialists for new enrollees and at the annual ISP meetings. 12/02/2016 Implemented
2380.111(c)(5)Individual # 8's physical exam dated 05/12/16 did not include results from a 05/08/15 TB 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.Attachment #19 shows the corrected physical exam for individual #8. Moving forward Attachment 20 shows a physical exam since inspection which included this information. Retraining of Program Specialists has occurred 11.28.16. Quarterly peer file reviews will be implemented this new inspection year. 11/28/2016 Implemented
2380.111(c)(7)Individual # 1's physical exam dated 11/12/15 did not include an assessment of his/her 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.Attachment 21 is the corrected copy of individual #1¿s physical exam. Retraining has occurred for this Program Specialist on 11.28.16 which included a checklist for reviewing physical exams (attachment 2). Attachment 22 provides an example of a correctly done physical since inspection. 11/30/2016 Implemented
2380.111(c)(10)Individual # 1's physical exam dated 11/12/15 did not include information pertinant to diagnosis and treatment. Area was left blank on form. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.As stated above, retraining occurred for this Program Specialist (attachment 2). The corrected physical exam is included (attachment 21) and an example of a physical since inspection is found in attachment 22. Physicals will be an area reviewed in quarterly peer file reviews. 12/02/2016 Implemented
2380.123(a)Individual # 6 was prescribed Thick-It. Staff # 15 used the Thick-It for Individual # 6 to prepare a drink for Individual #7.Prescription medications shall only be used by the individual for whom the medication was prescribed.Both staff #15 and her Supervisor received disciplinary action for their failure to follow proper procedures. All staff have been retrained in this requirement. (see attachment 18) 12/02/2016 Implemented
2380.173(1)(v)Individual # 9's record included a photo dated 08/13/07. Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Attachment 16 shows the updated photo for individual #9. Moving forward, a chart (attachment 17) has been constructed and will be maintained by each Program Specialist showing dates photos are due. 11/28/2016 Implemented
2380.176(a)In room A, a shred container contained individual records that were unlocked. In room C, the daily med log and monthly admin notebook was left unlocked on a bookshelf. The notebook contained medication evals and personal information for 4 individuals. Petty cash logs were unlocked and stored in a burlap basket. In Room D, face sheets, medication evaluations and health protocols were unlocked. Individual records shall be kept locked when they are unattended.All groups have implemented the procedure of taking documents for shredding immediately to the shredder thereby avoiding their collection where they are not kept confidential. Attachment 14 shows a photo of groups A, C and D which lack confidential information. All other items with private information has been locked. All Excentia staff were trained by the HR Director in the confidentiality/HIPPA policy on 11.10.16 (attachment 15) 12/02/2016 Implemented
2380.181(d)The program specialist did not sign the 07/20/15 assessment for Individual # 2. The program specialist shall sign and date the assessment.The Program Specialist signed the assessment (attachment 7), participated in retraining and will participate in quarterly peer file review. An example of a signed assessment since the inspection is attached (attachment 8). 12/02/2016 Implemented
2380.181(e)(3)(i)The assessments dated 05/12/16 and 09/15/16 did not include information about Individual #1's acquisition of functional 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.The program Specialist provided individual #1 and his team with an addendum to his assessment (attachment 9). As above ¿ retraining occurred, quarterly peer file reviews will be conducted and an example of an accurate assessment is included (attachment 8). Another corrective addendum for individual #4 is included as well (attachment 10) 11/30/2016 Implemented
2380.181(e)(3)(iv)The 09/15/16 assessment for Individual # 4 did not include information pertaining to his/her needs with or without assistance from others. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others.In the above listed addendum, the Program Specialist provided individual #4 and his team with the necessary information (attachment 10). In addition retraining was given and a process for quarterly peer file reviews has been implemented. An example of an assessment since inspection including this information is also attached (attachment 11) 12/02/2016 Implemented
2380.181(e)(8)The assessment dated 05/12/16 did not include information about Individual #1's ability to evacuate in the event of a fire. The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.Attachment 9 provided individual #1 and his team with the missing information. Moving forward, since inspection, 2 examples of assessments which include this information are included (attachment 8 and 11) 12/02/2016 Implemented
2380.181(e)(9)The assessment dated 05/12/16 did not include information about Individual #1's diagnosis. The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.As above, Attachment 9 shows the corrective information. Retraining was provided 11.28.16 (attachment 2). Attachments 8 and 11 show assessments since inspection which include this information. 12/02/2016 Implemented
2380.181(e)(13)(vi)The assessment dated 05/12/16 did not include information about Individual #1's current level 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.As above, Attachment 9 shows the updated information shared with individual #1¿s team. Attachments 8 and 11 occurred since inspection and include this information. 12/02/2016 Implemented
2380.181(f)Individual # 1's 05/12/16 assessment was sent to the team on 05/23/16 for a 06/13/16 Indvidual Support Meeting (ISP). Individual # 3's 11/19/15 assessment was sent to the team on 11/19/15 for a 12/3/15 ISP meeting. 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).Two examples of assessments since inspection are included. Attachments 12 and 13 show that this time frame was met (as does Attachment 8). Program Specialists have been retrained 11.28.16 (attachment 2) and will participate in quarterly peer file reviews for accuracy. 12/02/2016 Implemented
2380.183(4)Individual # 5's 09/23/16 assessment indicated 3 minutes of unsupervised time in the bathroom and classroom. If he/she goes to bathroom located in the hallway, eyesight supervision is required. Eyesight supervision was not indicated in the Individual Support Plan. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.The Program Specialist gave a list of changes/content discrepancies for individual #5¿s ISP to his SC at his meeting which was held 10.25.16 (attachment 6). The Program Specialists participated in retraining of requirements on 11.28.16 and will participate in quarterly file reviews moving forward. 11/28/2016 Implemented
2380.186(a)Individual # 1's date of admission was 03/28/16. His/her Individual Support Plan (ISP) review was not completed until 09/01/16.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.An initial meeting was conducted for individual #1 (attachment 1) but a report was not constructed or mailed out. The Program Specialist has done so since the inspection. The Program Specialists met with the Associate Director on 11.28.16 to be retrained in these requirements (attachment 2). Excentia staff will conduct random peer reviews of files throughout the year. The Associate Director will review the documents and requirements for all new admissions. 11/28/2016 Implemented
2380.186(c)(1)The 08/09, 05/08, 02/13 and 11/29 quarterly reviews did not include progress towards the health and safety outcome on the 09/01/16 Individual Support Plan (ISP) for Individual #2. Individual 1's Individual Support Plan (ISP) outcome of health and safety did not include progress toward outcome on the 09/01/16 review. 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.The Program Specialist constructed addenda for the information missing in the 4 quarterly reviews for individual #2 (attachment 3). The above named retraining which occurred on 11.28.16 included retraining of the requirements of the content of all services in quarterly reviews. Moving forward staff will conduct random peer reviews of quarterly reports for completeness. The Program Specialist also constructed an addendum for individual #1 (attachment 4) to share the missing information with the team. 11/28/2016 Implemented
2380.186(c)(2)Individual # 1's Social, Emotional, Environmental, Needs (SEEN) plan was not reviewed on his/her 09/01/16 Individual Support Plan (ISP) review. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialist provided the team members for individual #1 with an addendum (attachment 5) for the missing information. Moving forward, Program Specialists have been retrained on 11.28.16 (attachment 2) and will be conducting random peer reviews of files each quarter. 11/28/2016 Implemented
SIN-00084387 Renewal 10/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16According to the witness statements Individual #1 had been choking while drinking juice, staff person #3 put on gloves to try to sweep Individual #1's mouth for any objects and encouraged him to continue to cough- nothing came out, then for 3 min the Heimlich was attempted by staff person #3 but she felt she wasn't doing something right, so she asked staff person #5, Individual #1's face had turned blue. Staff #5 was pushed out of the way for improper technique by staff person #6 who continued to attempt the Heimlich. Food particles and small amount of blood was noticed by staff person #3 who was continuing to sweep Individual#1's mouth. A large piece of ham was retrieved approx. 3 inches long and Individual #1's breathing & color returned to normal per the Reportable Incident report. This incident happened at 11:27am and Individual #1's mother was not notified until 12:45pm via phone and 911 was not called and no medical treatment was sought for this incident.The policy and proceedure for emergency medical treatment for PAI was not followed. This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview This episode was not one of abuse occurring at the facility. This episode of choking was investigated prior to the inspection to determine whether or not neglect occurred in providing adequate supervision and was found not confirmed for neglect. All staff throughout the program have reviewed and signed a feeding protocol which was put in place on October 7, 2015 which defines a procedure to assure food is prepared to the appropriate consistency and that staff follow the necessary supports for each individual. The protocol also requires staff to call 911 when someone begins to choke to assure help is available if further assistance beyond back blows and abdominal thrusts is needed. In addition to instruction in the protocol, all program staff will receive training in dysphagia which is conducted by the agency nurse and all staff will be retrained in care for conscious choking victims by American Red Cross Certified trainers in the agency. 11/27/2015 Implemented
2380.33(b)(18)All staff were not trained after the incident on 9/28/15. Staff person #7- a room supervisor trained some of the staff . Staff person #9 was not trained as well as the other staff in the facility. The only staff trained that day was staff in the room during the incident. There was no sign off sheet that those staff where trained. Staff person #7 had with a sheet that had typing on it with what she said she reviewed but she had written the staffs names on it and signed it 10/6/15 the day I had asked if any training had been completed. I had also asked if the 2 staff -#4 & #5 who had attempted the Heimlich, but did not do it properly if they were being retrained in CPR. I was given another sheet with typing on it that only staff person #5 was scheduled for re-training on Oct 13 & 14th. When asked why staff person #4 wasn't scheduled, staff person #7 didn't know. I had asked if the PS #1 knew it was her responsibility per regulation to make sure all staff were trained- she did not know this. The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.All staff have subsequently received the training and the program specialist collaborated on the content. Moving forward, whenever there are needs for training staff in the content of health and safety needs relevant to an individual, both the supervisor and the program specialist will participate in the process. In our structure the supervisors have responsibility for staff performance issues, and the program specialist will provide the information on the individual's supports. 11/13/2015 Implemented
2380.36(f)Staff person #2 was not trained annually by a fire safety expert. There was no fire safety training for staff person #2 in 2014. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Beginning with the second half of our last training year, that is, from January 2015 - June 2015, the Training Coordinator was assigned the responsibility to schedule all employees for fire safety training and track their completion of it. Staff person #2 did receive Fire Safety training in this period. The Training Coordinator has send out the schedule for this training year, July 1, 2015 to June 30 2015 and will use the same process to track completion. 11/05/2015 Implemented
2380.111(c)(9)Individual #2's physical exam listed no allergies, but the Face sheet stated that Individual #2 had air borne allergies.The physical examination shall include: Allergies or contraindicated medication.Individual #2's physician verified that Individual #2 does not have any allergies. The face sheet was corrected. During the instructional meeting with program specialists on November 4, 2015, program specialists were informed of the need to maintain consistent information as stated above between the ISP, ISP reviews, physical exams and also on the face sheets. Face sheets will be included in the four month sample reviews conducted by the Lead Program Specialist or Director. 11/04/2015 Implemented
2380.113(a)Staff person #2 annual physical was late- 10/24/12- 8/26/15A 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.Human Resources Manager and Human Resources Generalist reviewed the requirement of the regulation on 8/26/2015 when the error was noticed. Once the error was recognized, the employee was sent immediately for her physical and TB test that day. The error occurred because of an error in data input by a former HR employee and when this was recognized, the HR Generalist audited all employee physical due date spreadsheets for any other errors. None were found, and moving forward the HR Generalist or HR Manager run reports each month for upcoming physicals due. 11/05/2015 Implemented
2380.113(c)(2)Staff person #2 was later with the bi-annual Tuberculin skin testing- 10/26/12-8/28/15The 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.As stated above, the HR Manager and HR Generalist recognized this error in August during file audits. All additional employees' records were reviewed, as was the regulation with sign-off by these two HR staff. Moving forward reports are run every month for upcoming employee due dates. 11/05/2015 Implemented
2380.173(7)There was no current ISP in the record for Individual #4. Each individual¿s record must include the following information:  A copy of the current ISP.The current ISP for individual #4 was obtained and placed on file along with the signature sheet. All program specialists were directed to review their files as stated above to assure the current ISPs and signature sheets are on file. Also as stated above, in the four month sampling of files, the Lead Program Specialist and or Director will include these items to monitor. 11/30/2015 Implemented
2380.173(9)The ISP & ISP reviews for Individual #4 stated there was a plan of support and the annual assessment for Individual #4 stated there was no plan of support. Individual #4 does have a plan of support. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The annual assessment for Individual #4 was corrected through an addendum which was sent to the team. This was not a content discrepancy of the ISP, but rather an error on our part in our assessment. All Program Specialists met on November 4, 2015 to be re-instructed on their responsibilities to assure consistent and accurate information across all documents (ISP, ISP reviews, physical exams and assessments) for individuals to assure their safety and needed supports. In the four month sampling by the Lead Program Specialist and or Director, we will specifically monitor the consistency of the content. 11/04/2015 Implemented
2380.176(a)The Individual records were found to be unlocked in each room. They were found to be kept unlocked on a bookshelf in each room. Individual records shall be kept locked when they are unattended.Locking cabinets were purchased and delivered on October 28, 2015. All will be assembled and placed in the rooms for the records by November 20, 2015. 11/20/2015 Implemented
2380.184(b)Individual #4's signature sheet for the annual ISP was missing from the record and was unable to be found. At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting.Individual #4's signature sheet for the annual ISP was obtained and placed on file. All Program Specialists will review their files by November 20, 2015 to assure they have both the current ISP and the signature page from the most recent meeting. Any missing documents will be obtained and placed on file by November 30, 2015. Moving forward, the Lead Program Specialist and or Director will sample files for review every four months and will included verifying the signature sheet and current ISP are on file. 11/30/2015 Implemented
2380.185(b)Individual #1's ISP, annual physical and annual assessment where not followed by staff. Individual #1's food is to be cut into bite size pieces before being served to him. This was not followed on 9/28/15 due to the size of ham that was recovered after Individual#1 was done choking. Staff person #4 documented the size of ham that was found to be approx. 3-3 ½ long. Staff person #8 was the staff who reported prepared Individual#1's lunch that day-per witness statements that were obtained. There were also pieces of ham found bigger than bite size still not consumed in the container. The ISP shall be implemented as written.On October 7, 2015 a protocol for eating and feeding was put in place; reviewed and signed by all program staff throughout the building. Among other things, the protocol requires staff to verify the requirements of each individual and to assure the food items are prepared accordingly before presenting the food to the individual. The protocol is available to all staff to refer to. Supervisors, Program Coordinators, Program Specialists and the Director will monitor during snacks and meals to assure the protocol is being followed. 11/04/2015 Implemented
2380.186(a)The 6/15 ISP review for Individual #5 was missing from the record and could not be located. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.The 6/15 ISP review for Individual #5 will be sent to the team. Each Program Specialist will review their records to assure that there are no other missing ISP reviews and will report this information to the Director by November 6, 2015. Moving forward, the Lead Program Specialist will review a sampling of records every four months to assure that the quarterly ISP reviews were completed, sent to the team and are on file. 11/06/2015 Implemented
2380.186(c)(2)Individual #6 SEEN plan was not reviewed in the ISP reviews. Individual #7's dental protocol to brush teeth after lunch and plan of support to walk 2x's a day was not reviewed in the ISP reviews. Individual #5 seizure plan was not reviewed 9/14/15, 3/9/15 & 12/13/14. Individual #4 seizure protocol and SEEN plan was not reviewed on the ISP reviews.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Individual #6's SEEN plan (Excentia calls this a Plan of Support) was indeed reviewed in the ISP reviews and this was pointed out to the inspector on the date of the inspection. ISP reviews which were missing information, Individual #7's dental and walking protocols, Individual #5's seizure plan, and Individual #4's Seizure protocol and Plan of Support (SEEN) will be amended and the information will be sent to the respective teams. Program specialists will review all files for items missing from ISP reviews and send any necessary addenda to respective teams by November 30, 2015. Moving forward, the Lead Program Specialist and or Director will review a sample of ISP reviews every four months to assure all necessary information is addressed in the reviews. All Program Specialists met on 11/4/2015 for training on the completeness of ISP reviews. 11/30/2015 Implemented
2380.186(d)The ISP review for Individual #7 was not sent to team members 30 days after the meeting. The ISP review was completed 3/3/15 not sent till 4/23/15. The ISP review 8/11/15 for Individual #4 was not sent to team members. 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.Overall, ISP reviews with individuals will be completed between the Program Specialists and Program Coordinators of each group within 3 days of the report being completed. In so doing, Individuals will sign-off and the documents can be sent to the rest of each team in a more timely manner, no later than 30 days from the date of the review. The ISP review for Individual #4 will be edited for completeness and sent to the team. 11/20/2015 Implemented
SIN-00068328 Renewal 09/17/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)A ceiling tile was knocked out of the ceiling in the physical development room. The tile was replaced during inspection. Floors, walls, ceilings and other surfaces shall be in good repair.Supervisor, L. VanAulen replaced the ceiling tile during the inspection, 9/17/2014. (Attachment #16) Going forward, each month DSPs will receive training in the requirements of the physical site during monthly unit meetings. All staff have been notified of their responsibility in not only recognizing, but also remedying violations. Management will monitor the condition of surfaces during routine visits through the building and during monthly Physical Site Checks. 10/17/2014 Implemented
2380.58(b)A broken table was laying on the floor, near an exit, in the community room. Floors, walls, ceilings and other surfaces shall be free of hazards.Director, R. Giberson removed the table from the program area at the time of the inspection. The same day, 9/16/2014, Supervisor, K. Budovec removed the broken table from the building for disposal. (Attachment #15) Going forward, each month DSPs will receive training in the requirements of the physical site during monthly unit meetings. All staff have been notified of their responsibility in not only recognizing, but also remedying violations. Management will monitor the condition of surfaces during routine visits through the building and during monthly Physical Site Checks. 10/17/2014 Implemented
2380.82A chair was blocking an exit door in Room B. Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Supervisor, L. VanAulen has coached all staff in the group to be mindful of individuals¿ moving chairs and to be certain to keep any items away from the path of egress. (Attachment #14). The Monthly Physical Site Checklist for October shows that at the time of that check, all paths of egress were clear. Management will make routine visits through the building to monitor paths of egress. 10/17/2014 Implemented
2380.111(c)(3)The physical examination for Individual #2 included adult immunizations (tetanus/diphtheria) that were last given on 5/13/2003. These immunizations must be updated every 10 years.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Program Specialist, M. Mosebach contacted the parent of Individual #2 and requested updated information on a td/DT immunization for the individual. The PCP sent verification that it was done October 24, 2013. There have not been any individuals who have needed Tetanus/Diphtheria immunizations since the inspection; However, two examples of updates which occurred this calendar year are attached to show the compliance of every 10 years. (Attachment #13). Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/17/2014 Implemented
2380.111(c)(5)The TB test for Individual #2 was not completed in the regulatory timeframe. The past TB test was given in January of 2011. An exact date was not available. The testing was not completed again until April 25, 2014. 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 physical exam for individual #2 did show a current TB test having been placed on 4/22/2013 and read negative 4/25/2013. A copy is attached as is a recent example for another individual whose recent physical shows that the TB test was done within the two year time frame. (Attachment #12). Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/06/2014 Implemented
2380.173(7)A current copy of the ISP was not included in the records of Individual #4 and Individual #8.Each individual's record must include the following information:  A copy of the current ISP.Program Specialists, L. Gray and S. Getz each obtained copies of the current ISPs for these individuals and showed them to the inspectors the next day. Going forward, Program Specialists will file the current ISP or copies of all correspondence with Supports Coordinators requesting same when ISPs are not received within 30 days of the ISP review meetings or of the individual¿s starting to attend. The Assistant Director has also given Supervisors the HCSIS access role of ISP reviewer so they too can obtain copies of the ISPs for DSPs. 10/16/2014 Implemented
2380.181(e)(5)The assessment for Individual #7 did not include his ability to self-administer medications. The assessment must include the following information: The individual's ability to self-administer medications.Program Specialist, L. Gray sent an addendum to the assessment for Individual #7 to his team on 10/17/2014 which addressed his ability to be self medicating. (Attachment #11) Going forward, the Assistant Director amended the Assessment document to include the question whether or not the individual takes medication at ADS or at home and instructed the Program Specialists to address Self Administration even if the individual does not take medications at the day program. 10/17/2014 Implemented
2380.181(e)(12)The assessment for Individual #1 did not include recommendations for training, vocational programming, and competitive-integrated employment. A recommendations section was included in the assessment, however, it didn't identify the recommendations for this specific area. The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program Specialist, J. Webb sent an addendum on 10/17/14 to Individual #1¿s team addressing recommendations for this section (Attachment #7). Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/17/2014 Implemented
2380.181(e)(13)(ii)The assessments for Individuals #1, #3, and #7 did not include progress over the last 365 days in motor and communication skills. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Program Specialists sent addenda to the individuals¿ teams on 10/17/14 to address the area of Progress and Growth in Motor and Communication skills (Attachments #7, #9, and #11). Going forward, the Assistant Director amended the Assessment document to include the area for Progress and Growth in Motor skills and will be responsible to audit files quarterly to assure requirements are met. 10/17/2014 Implemented
2380.181(e)(13)(iii)The assessments for Individuals #2, #3, #4, and #7 did not include progress over the last 365 days in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Program Specialists sent addenda to the individuals¿ teams on 10/17/14 to address the area of Progress and Growth in Personal Adjustment. (Attachments #8, #9, #10, and #11) Going forward, the Assistant Director amended the Assessment document to include the area for Progress and Growth in Personal Adjustment. 10/17/2014 Implemented
2380.181(e)(13)(iv)The assessments for Individuals #1, #2, and #3 did not include progress over the last 365 days in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialists, J. Webb, M. Mosebach and S. Getz have constructed addenda for each individual¿s assessments and sent to the teams on 10/17/14 (Attachments #7, #8, #9) addressing Progress and Growth in Socialization. Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/17/2014 Implemented
2380.181(e)(13)(v)The assessments for Individuals #1, #2, and #3 did not include progress over the last 365 days in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.Program Specialists, J. Webb, M. Mosebach and S. Getz have constructed addenda for each individual¿s assessments and sent to the teams on 10/17/14 (Attachments #7, #8, #9) addressing Progress and Growth in Recreation. Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/17/2014 Implemented
2380.181(e)(13)(vi)The assessments for Individuals #1, #2, and #3 did not include progress over the last 365 days 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 Specialists, J. Webb, M. Mosebach and S. Getz have constructed addenda for each individual¿s assessments and sent to the teams on 10/17/14 (Attachments #7, #8, #9) addressing Progress and Growth in Community Integration. Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/17/2014 Implemented
2380.185(b)Individual #4's ISP indicates he is to be repositioned every 2 hours. The documentation logs show that he was repositioned once daily. There were 5 days in July 2014 and 8 days in August 2014 when Individual #4 attended program and no documentation was completed to indicate he was repositioned. The ISP for Individual #2 indicates he is to have Diastat, for a diagnosed seizure disorder, available to him while at day program. There was no Diastat available at the program should he need it. There is no seizure protocol in place that tells staff when it is appropriate to administer the Diastat and when it is appropriate to call 911. In the seizure documentation, a seizure took place on 6/26/14 lasting 2 minutes. The details of the seizure include Individual #2 having a blue color, being unconscious, unresponsive, eyes rolled up, stiff extremeties, and difficulty breathing. When questioned, the program specialist relays that she is not typically made aware of when seizures happen. 911 was not called in this situation. The ISP for Individual #9 indicates she should have Bendadryl available for her to take on outings at day program because of a reaction to bug bites and bee stings. Bendadryl was not available. The ISP shall be implemented as written.Program Specialist, L. Gray restructured the documentation method in Care Tracker to require documentation every two hours for Individual #4 on 9/23/2014. Since then, Supervisor, M. Bourassa trained all DSPs of the group on the necessity and process of changing his position. Documentation is attached (Attachment #3). Going forward, Supervisors and Program Specialists will monitor the documentation required for supports listed in the ISP. If there is failure by DSPs to document supports, the Supervisors will initiate disciplinary action. Program Specialist, M. Mosebach contacted Individual #2¿s mother and obtained the Diastat. In addition, M. Mosebach constructed the appropriate protocol with information from Mother and PCP. The protocol was put into place on 10/16/14. Supervisor, M. Bourassa instructed DSPs on the protocol. M. Bourassa interviewed the DSP who documented the seizure on 6/26/14. His clarification of the event (which was witnessed by another supervisor) is attached. The DSP simply chose from pre-populated options for the report and knew at the time they were not completely accurate for the occasion. (Attachment #4) Supervisor, L. VanAulen obtained Benadryl for Individual #9 and has instructed DSPs on its use. (Attachment #5) Going forward, in addition to quarterly file audits the Assistant Director will be responsible for Monthly MAR reviews to assure there are no missed medications, adequate protocols are in place, and appropriate refills are obtained immediately. 10/17/2014 Implemented
2380.186(c)(1)Individual #3 had an outcome to exercise in her ISP. This outcome was not being reviewed in her ISP reviews. 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 for individual #3, S. Getz contacted the Supports Coordinator on October 7, 2014 to notify that Excentia was listed in error as responsible for this outcome. Individual #3 only performs this exercise routine at home. The ISP was corrected on 10/8/2014 (Attachment #2). Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. 10/08/2014 Implemented
2380.186(e)The option to decline the ISP review documentation was not offered to Individual #9 or her plan team members.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Program Specialist, M. Mosebach corrected the quarterly document for Ind. #9 to include the option to decline the review. Two quarterlies after the inspection are included in the attachment as well to show that this option is included for every report. (Attachment #1). The correction was done 10/10/14. All Program Specialists proof read their reviews to assure this option was included by 10/14/14. Going forward, in addition to the oversight of the Program Specialists, the Assistant Director will be responsible to audit files quarterly to assure requirements are met. (Attachment #17) 10/14/2014 Implemented
SIN-00042523 Renewal 11/01/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Staff #1 transferred into the Life Enrichment program on August 27, 2012. He did not receive orientation training relevant to his new position.(a)  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.A meeting was held with Kim Hubric, Director of Human Resources, to ensure that all employees received the appropriate training. Also, supervisors were reminded to make sure that their new employees received the proper orientation. This training was completed with Staff #1 on 11/1/2012 and 11/5/2012. Fully Implemented 11/05/2012 Implemented
2380.186(c)(2)Indivdiual #1's ISP reviews did not include progress made on her Plan of Support.(c)  The ISP review must include the following:  (2)  A review of each section of the ISP specific to the facility licensed under this chapter.The ISP review requirements were gone over with the Program Specialists at the end meeting for licensing on 11/2/2012. The specific program specialist whose case this was had a seperate meeting with her supervisor to discuss the specific individual on 11/2/2012. Fully Implemented 11/02/2012 Implemented
SIN-00183362 Renewal 02/16/2021 Compliant - Finalized
SIN-00054901 Renewal 10/30/2013 Compliant - Finalized