Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210338 Renewal 08/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Executive Director #1 conducts weekly visits with the individuals. Their most recent physical exam was completed on 10/19/16.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Executive Director already received her physical and is talking to her oncologist about receiving her TB test. This may have to be a chest x-ray because with her medical condition she can't have certain things injected into her body. She will get a physical and TB test every 2 years as per the regulations. 11/30/2022 Implemented
2380.113(c)(2)Direct Service Worker #2's most recent tuberculin skin test via Mantoux method was read with negative results on 2/24/21. However, the medical credentials of the interpreter were not provided.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.We have updated our physical form to clearly show the name and title of the medical professional reading the TB test. 09/08/2022 Implemented
SIN-00157159 Renewal 06/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility had a fire safety inspection completed 2/1/18 and then again 4/11/19.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.Joy Yoder, Director of HR, Federal Programs and Finance, will email Ron Garner, head of Maintenance, 3 months prior to the date of expiration of the fire safety inspection. Ron Garner will make sure that the inspection is scheduled and executed in a timely manner before the expiration date. Email and written request will be used to document the requests and Ron will document the time and date of the request. [Immediately and upon hire of new staff of the aforementioned positions, the CEO or designee shall educate the aforementioned staff persons of their responsibilities to ensure timely completion of the facilities fire safety inspection. Documentation of the training shall be kept. Upon completion of the annual fire safety inspection, the CEO or designee shall review the documentation from the fire safety inspection to ensure timely completion of the fire safety inspection and all required information as specified in 2380.84 is maintained and available for review upon request by the Department. (DPOC by AES,HSLS on 6/25/19)] 01/11/2020 Implemented
SIN-00116340 Renewal 06/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)The physical examination dated 4/26/17 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physician has completed the missing sections of the physical for individual #1. The physical form includes a statement requiring all sections of the physical to be completed. The client handbook also states that any clients without required physical examinations, will be out of compliance with the program regulations will be suspended until required documentation is received. The program specialist shall be responsible for ensuring all portions of the physical examination are completed within the required time frame for all individuals, effective immediately. When physical forms are submitted with incomplete sections, physicians will be contacted for the required missing information. [Immediately and upon completion and submission, the program specialist shall review all individuals' current physical examination to ensure all required information is included and there are not any areas of required information left blank. Missing information will be obtained by the program specialist as needed. Documentation of review shall be kept. (AS 7/7/17)] 06/29/2017 Implemented
2380.113(a)Direct Service Worker #1, date of hire 8/22/16, had a physical examination completed 10/7/16. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.The HR Director and Program Specialist have reviewed this regulatory requirement. For DSP#1, an updated physical will be required within the 2 year renewal period. For all new hires and rehires of former staff, a physical examination will be required before the hiring process is completed and employment can begin. The HR Director will be responsible for ensuring the physical is completed before hire, effective immediately, for all applicable staff. The HR Director will also be responsible for ensuring that physicals are continued after hire every 2 years. [Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure all staff person who come direct contact with the individual or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, have a physical examination within 12 months prior to employment and every 2 years thereafter. At least quarterly, for 1 year the CEO or designee shall review the tracking system to ensure timely completion of staff persons' physical examinations. (AS 7/7/17)] 07/06/2017 Implemented
2380.113(c)(2)Direct Service Worker #1, date of hire 8/22/16, had a Tuberculin skin test completed 10/10/16. The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.The HR Director and Program Specialist have reviewed this regulatory requirement. For DSP#1, a TB test will be required within the 2 year renewal period. For all new hires and rehires of former staff, a TB test will be required before the hiring process is completed and employment can begin. The HR Director will be responsible for ensuring that a TB test is included in initial physical examinations before hire, effective immediately, for all applicable staff. The HR Director will also be responsible for ensuring that the TB test with negative results is provided every 2 years, and that if a TB test is positive, an initial chest x-ray with results is noted.[Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to document staff persons' physical examinations including Tuberculin skin testing to ensure all staff persons who come direct contact with the individual or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, have a physical examination including Tuberculin skin testing within 12 months prior to employment and every 2 years thereafter. At least quarterly, for 1 year the CEO or designee shall review the tracking system to ensure timely completion of staff persons' physical examinations including Tuberculin skin testing. (AS 7/7/17)] 07/06/2017 Implemented
SIN-00092496 Renewal 05/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's physical examination, completed 3/24/16, did not include a vision and hearing screening. The physical examination shall include: Vision and hearing screening, as recommended by the physician.A letter has been sent out and calls have been made requesting completion of vision and hearing screening sections of physical for individual #1. The physical form has been revised to include a statement requiring all sections of the physical must be completed. The client handbook will be revised to state that any clients without required physical examinations, including vision and hearing screenings, will be out of compliance with the program regulations will be suspended until required documentation is received. The program specialist shall be responsible for ensuring all portions of the physical examination are completed within the required time frame for all individuals.[Individual #1's physical examination dated 3/24/16 was updated on 4/7/16 to include vision and hearing screenings. Immediately, all individuals' current physical examinations shall be reviewed by the program specialist to ensure all required information is included including vision and hearing screenings and missing information will immediately be obtained. Prior to entering in individuals' records, physical examinations shall be review by the program specialist to ensure all required information is included including vision and hearing screenings and missing information will immediately be obtained. (AS 6/8/16)] 06/05/2016 Implemented
2380.111(c)(5)Individual #1 had a Tuberculin skin test completed on 2/25/14 and then again on 4/13/16. The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.A letter has been sent out requiring all clients to complete a TB test with negative results every 2 years, including Individual #1. The client handbook will be revised to state that any clients without required physical examinations, including timely TB tests, will be out of compliance with the program regulations and will be suspended until required documentation is received. The program specialist will be responsible for ensuring that the TB test with negative results is provided every 2 years, and that if a TB test is positive, an initial chest x-ray with results is noted.[Within 30 days of receipt of the plan of correction, the Executive Director will develop and implement and train staff on policies and procedures and a tracking system to ensure physical examinations with all required information including Tuberculin skin testing is completed within required time frames. At least quarterly, the program specialist will review the tracking system to ensure Individual are notified timely to ensure completion of physical examinations within the required timeframes. Documentation of tracking system and reviews shall be kept. (AS 6/8/16)] 06/05/2016 Implemented
2380.181(f)Individual #1's assessment, completed 10/6/15, was not sent to all plan team members, specifically the companion services and home and community habilitation services provider.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The most recent assessment has been sent to the missed plan team members for individual #1. Moving forward, each assessment will be delivered to all of the individual's team members for all individuals served. The program specialist has been remediated on this responsibility and shall be responsible for ensuring that the assessment is provided to all team members included on each individual's ISP. [Within 30 days of the receipt of the plan of correction, the Program Specialist will review all individuals' ISPs, invitation letters and other documentation to ensure all individuals' plan team members are provided the current assessment as required. Correspondence documentation that assessments are provided to all plan team members shall be kept and reviewed by the Executive Director or designated staff person to ensure the program specialist provided the assessment to all individuals' plan team members as required. Documentation of reviews shall be kept.(AS 6/8/16)] 06/05/2016 Implemented
SIN-00045507 Renewal 02/06/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)On 2/6/2013, the was no documentation to indicate Individual #1 had a physical completed on an annual basis. Physicals were completed on 7/18/2011 and not again until 8/13/2012. (Partially Implemented-Adequate Progress; CEM; 5-7-13)(a)  Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.***60 days, prior to the due date of the consumer's physical the administrative assistant will send a notice to the family/group home as a reminder. Placed in effect 3/15/13 ***The staff has been instructed to be aware of the need for proper dates for physicals and for the Mantoux TB testing, and will work with the administrative assistant to make sure that the reminder letter as well as the dates of the returned physical is in compliance. ***Ultimately the Director of Clelian Center is responsible for seeing that proper dates are in order. The Program Specialist will inform the Director if the physical has not been completed and returned by the date specified. The consumer will not be permitted to attend the program and will have to re-apply with proper documentation in order to attend the program. 04/03/2013 Implemented
SIN-00228999 Renewal 08/08/2023 Compliant - Finalized
SIN-00192237 Renewal 09/01/2021 Compliant - Finalized
SIN-00177311 Renewal 10/06/2020 Compliant - Finalized
SIN-00136490 Renewal 06/13/2018 Compliant - Finalized
SIN-00074157 Renewal 05/20/2015 Compliant - Finalized
SIN-00060108 Renewal 06/04/2014 Compliant - Finalized