Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00091340 Renewal 03/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility did not have an annual onsite firesafety inspection by a firesafety expert in 2014 and 2015.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.Community Living and Learning, Inc. will be using JAWCO Fire Inc. to complete all fire safety and on-site fire safety inspections for the agency. JAWCO Fire Inc. will come out to the Adult Training Facility by June 30, 2016 to complete annual fire safety training and do the fire safety inspection.[On site Fire safety inspection was completed on 6/15/15, all fire safety hazards/recommendations were addressed and will be kept on site as required. CEO will develop and implement a tracking system to ensure onsite fire safety inspections by a fire safety expert are completed annually as required. Documentation of tracking system shall be maintained. (AS 6/24/16)] 06/30/2016 Implemented
2380.111(c)(10)Individual #1's physical examination, completed on 1/5/16, does not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical for Individual #1 was taken back to the doctor who wrote none on the "note special information pertinent to diagnosis and treatment in case of an emergency" line of the physical form. The ATF coordinator and the Executive Director will both look over individual's physical forms to ensure accuracy. [Immediately, the ATF and Executive Director will review all Individuals' current physical examinations for required information including medical information pertinent to diagnosis and treatment in case of an emergency. Upon completion of initial and annual physical examinations and prior to entering into each individuals' record the ATF Coordinator and Executive Director will review physical examinations to ensure all required information is included. Documentation of all reviews shall be kept. (AS 4/27/16)] 04/14/2016 Implemented
SIN-00079429 Renewal 03/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)The two most recent fire safety trainings for Staff person #1 were completed on 9/10/13 and on 10/21/14. The two most recent fire safety trainings for Staff person #2 were completed on 8/4/13 and on 10/21/14.(f)  Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Community Living & Learning Adult Training Facility Program Specialist will ensure that Fire Safety training is scheduled at least 2 months in advance. Program Specialist will ensure that the Program Director is aware of the scheduled date as well as the prior year date to make sure that it is within the regulated annual time frame. Program Director will make sure that the Fire Safety training in followed through with by the Program Specialist. The Program Specialist will be in charge of administering the fire safety training and ensuring that all documentation is completed yearly. Fire Safety training has already been scheduled for the 2015 year on October 16th, 2015. All individuals had their Fire Safety training on 10-21-2014 and this date will be within the regulated time frame. Any individual not in attendance that day will be trained in fire safety the following Monday as Fridays and Mondays are the days that almost 100% of the individuals who attend the day program are scheduled for. Program Director will be present for this training and the training will be carried out by the Program Specialist. Both Program Director and Program Supervisor will sign off on training records to ensure that all individuals have had the training. 07/02/2015 Implemented
2380.91(a)The two most recent fire safety instructions with Individual #1 and Individual #2 were completed on 9/10/13 and 10/21/14.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.Community Living & Learning Adult Training Facility Program Specialist will ensure that Fire Safety training is scheduled at least 2 months in advance. Program Specialist will ensure that the Program Director is aware of the scheduled date as well as the prior year date to make sure that it is within the regulated annual time frame. Program Director will make sure that the Fire Safety training in followed through with by the Program Specialist. The Program Specialist will be in charge of administering the fire safety training and ensuring that all documentation is completed yearly. Fire Safety training has already been scheduled for the 2015 year on October 16th, 2015. All individuals had their Fire Safety training on 10-21-2014 and this date will be within the regulated time frame. Any individual not in attendance that day will be trained in fire safety the following Monday as Fridays and Mondays are the days that almost 100% of the individuals who attend the day program are scheduled for. Program Director will be present for this training and the training will be carried out by the Program Specialist. Both Program Director and Program Supervisor will sign off on training records to ensure that all individuals have had the training. 07/02/2015 Implemented
SIN-00057447 Renewal 04/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff Person #1's most recent physical examination was completed on July 12, 2013, the prior physical examination was completed on January 19, 2011; 2 years and 6 months apart. (a)  A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.the Program Director will give each staff an annual written reminder as to when their next physical and Mantou test is due. The staff will then be responsible for making the appointment and having the forms completed and submittd by the due date. According to current policy staff who do not complete their physicals by the due date are suspended and are given 10 days to complete the physical or their employment is terminated. 04/14/2014 Implemented
2380.115(1)The facility's written emergency medical plan did not include the hospital or source of health care that will be used in an emergency. The facility shall have a written emergency medical plan listing the following: (1)  The hospital or source of health care that will be used in an emergency.A paragraph was added to the current emergency plan to include the name of the hospital. EMERGENCY MEDICAL TREATMENT PLAN In the event an individual requires emergency medical care, Community Living and Learning, Inc. will have the individual taken to Indiana Regional Medical Center by either ambulance or agency vehicle. If the individual is on an outing outside of Indiana County, they will be transported to the closed emergency medical treatment facility by ambulance or agency vehicle. 04/14/2014 Implemented
SIN-00043258 Renewal 12/05/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.122(a)The 18 Ventolin HFA inhaler for Individual #1 does not have a pharmaceutical label. Paritally Implemented, Adquated Progress 3/22/13 - CLG(a)  The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician.1. On a daily basis there will be one staff designated to review all medications when an individual arrives at the Adult Training Facility. 2. Staff will ensure each medication is in the original container and labeled correctly with all pharmaceutical information needed. 3. If an individual arrives at the ATF with a medication that does not meet the criteria for ODP Med Administration, staff will notiify the individual's caretaker immediately to rectify the situation. 4.No medications will be administered unless they meet the criteria for ODP Med Administration. One Direct Care Staff person will be assigned each morning by the Supervisorto check in all medications. A checklist will be followed to ensure that all necessary supplies needed to administer medications accurately are available. If medications or supplies are not available the ATF Supervisor will be notified, immediately. The ATF Supervisor will review the checklist on a monthly basis to ensure all medications and supplies meet regulations. 12/31/2012 Implemented
2380.173(8)(iv)Individual #2's plan team members were not given the option to decline the 3 month ISP review. Paritally Implemented, Adquated Progress 3/22/13 - CLG(8)  Documentation of ISP reviews and revisions under §  2380.186 (relating to ISP review and revision), including the following: (iv)   Notices that the plan team member may decline the ISP review documentation. The Program Specialist will hand deliver a letter of declination to each team member at the annual ISP update. Responses to the letter will be filed in the individual's file. The Program Specialist will insure that all team members receive the letter of declination if they do not attend the ISP. (see faxed documentation)Also, the Program Specialist was trained on ISP declination options on 3/14 & 15/13. Program Director and ATF Progam Specialist will ensure the declination letters are sent to team members and document sent dates. 12/31/2013 Implemented
SIN-00241944 Renewal 04/04/2024 Compliant - Finalized
SIN-00223356 Renewal 04/25/2023 Compliant - Finalized
SIN-00204875 Renewal 05/11/2022 Compliant - Finalized
SIN-00187891 Renewal 05/25/2021 Compliant - Finalized
SIN-00170763 Renewal 02/11/2020 Compliant - Finalized
SIN-00149932 Renewal 02/12/2019 Compliant - Finalized
SIN-00130532 Renewal 03/06/2018 Compliant - Finalized
SIN-00112114 Renewal 04/11/2017 Compliant - Finalized