Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00207149 Renewal 06/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #3's most recent hearing screening was completed 7/07/2020.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The hearing test for individual #3 is scheduled for 7/27/22. The program specialist will make a spreadsheet to track due dates for the annual physicals including the vision and hearing screenings. 08/01/2022 Implemented
2380.111(c)(7)Individual #3's physical examination completed 6/28/2021 does not include an assessment of the individual's health maintenance needs. This section was 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.Individual # 3¿s physical examination from 6-28-21 was obtained from the residential site with the health maintenance needs completed on 7-7-22. 08/08/2022 Implemented
2380.113(a)Program Specialist #1 had a physical examination completed 9/12/2019 and then again 10/01/2021.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.Program Specialist #¿1 physical was completed 10/1/2021, therefore it is current now. 08/08/2022 Implemented
2380.113(c)(2)Program Specialist #1 had a tuberculin skin test completed 9/12/2019 and then again 10/01/2021.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.Program Specialist #1¿s TB test was completed 10/1/2021, therefore it is current now. 08/08/2022 Implemented
2380.181(e)(4)Individual #1's assessment completed 7/07/2021 states she is unable to be in the facility or community without supervision and that she requires 24 hour supervision at home and in the community. Individual #1's individual support plan, last updated 6/13/2022, states she needs to be in line of sight when eating her meals at the day program. It states she must be unsupervised in the community, and that she can go into the community with staff and two other individuals. Individual #2's assessment completed 7/07/2021 states he is unable to be in the facility or community without supervision. Individual #2's individual service plan, last updated 5/17/2022, states he no longer attends a formal day program due to pandemic closure in March 2020, but that staff provided visual supervision when attending. It also states must be visually supervised at all times in the community due to medical concerns and safety issues. Individual #3's assessment completed 9/03/2021 states the individual is unable to be in the facility or community without supervision and that she needs 24 hour supervision at home and in the community. Individual #4's assessment completed 11/17/2021 states she is unable to be in the facility or community without supervision. Individual #4's individual support plan, last updated 6/24/2022, states the facility supervision is 1:4 to 1:6 and the community supervision is 1:2 or 1:3.The assessment must include the following information: The individual¿s need for supervision.Individual # 1, 2, 3 and 4's assessments will be updated by 8-1-22 to include more details about their supervision care needs. The assessment which is completed in our electronic medical record will be revised so that N/A will not available as a selection for areas that are required to be assessed. Also, the expanded text boxes which contain more details will be made required fields for completion. 08/08/2022 Implemented
2380.181(e)(5)Individual #1's assessment completed 7/07/2021 states the individual does not take medication at program and does not address the individual's ability to self-administer medications. Individual #1's individual support plan, last updated 6/13/2022 states the individual is not able to self-medicate. Individual #2's assessment completed 7/06/2021 states that he does not take any medications while at program. Individual #2's individual support plan, last updated 5/17/2022, states he is not self-medicating and relies on others to ensure correct medication dose, time, route, and obtain refills. Individual #4's assessment completed 11/17/2021 states she does not take medication at program. individual #4's individual support plan, last updated 6/24/2022 states she takes her own medication with staff physically getting her medications ready and handing them to her daily and that she doesn't pass medications on her own.The assessment must include the following information: The individual¿s ability to self-administer medications.Individual # 1, 2 and 4's assessment will be updated to address each individual's ability to self medicate by 8-1-22. The assessment which is completed in our electronic medical record will be revised so that N/A will not available as a selection for areas that are required to be assessed. Also, the expanded text boxes which contain more details will be made required fields for completion. 08/08/2022 Implemented
2380.181(f)Individual #4's assessment completed 11/17/2021, was sent to the plan team members on 11/17/2021, for the individual support plan meeting that occurred 12/01/2021.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 program specialist will complete a spreadsheet to address the citation in regards to the annual assessment being sent to plan team members less than 30 days prior to the meeting. The spreadsheet will be maintained electronically by the supervisor/program specialists. 08/08/2022 Implemented
SIN-00189754 Renewal 07/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 had a Tuberculin skin test by Mantoux method on 04/24/19, no further testing was provided at inspection to measure compliance with this regulation. [ Repeat Violation - 10/04/19]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.111c5 Individual #1 removed from program until TB screening complete. TB screening schedule 7/21/21 and will be read on 7/23/21 with an anticipated return date to programming on 7/26/21. (Immediately, the program specialist will check all individuals to assure a current TB screening. The program specialist will develop a master spread sheet of all program individuals, tracking all required administrative tasks including the completion of a Tuberculin skin test in a timely manner. Review spreadsheet monthly/two months in advance and follow up with assigned staff to insure completion. Train all staff to review current Physical/TB policy. Documentation of monthly review and actions taken to complete requirements. Families and residential providers will be forwarded a copy of our policy for review. 07/21/2021 Implemented
SIN-00163723 Renewal 10/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 had a Tuberculin skin test completed on 4-25-19, and the prior Tuberculin skin test was completed 3-31-17.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.POC 2380 111 (c) (5) Program Specialist and or Back up Specialist will review all program participants physical forms 2 months prior to annual physical due date. Program Specialist will review Turberculin Skin Testing dates to ensure that it is completed within the designated 2 year time frame. After review the Program Specialist will send out the annual physical forms to be completed within the indicated time frame. and document on the monthly documentation form. [Immediately, the CEO or designee shall develop a tracking system for all Individuals' Tuberculin skin testing and follow aforementioned notification procedures to ensure timely completion of Tuberculin skin testing. Within 30 days of receipt of the plan of correction, upon hire and upon changes in procedures, the CEO or designee shall educate all staff persons responsible for notification and review of individuals' Tuberculin skin testing, of their responsibilities to ensure tuberculin skin testing for all individuals is completed timely. Documentation of training shall be kept. (DPOC by AES, HSLS on 10/17/19)] 10/16/2019 Implemented
SIN-00143447 Renewal 10/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(d)There was not a written procedure for fire safety monitoring in the event the fire alarm is inoperative.There shall be a written procedure for firesafety monitoring in the event the fire alarm is inoperative.55 PA Code Chapter 2380.87 (d) Correction: Mercy Behavioral Health Fire Alarm/Inoperative Policy Number 4.02 was replaced into binder ATF program policy binder with fire drill log. [Within 30 days of receipt of the plan of correction and continuing at least annually, the CEO or designee shall educate all staff person in the current procedures for fire safety monitoring in the event the fire alarm is inoperative. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 10/31/18)] 10/17/2018 Implemented
2380.186(a)The program specialist did not complete an ISP review for Individual #1 that included the date of 3/22/18. The program specialist did not complete an ISP review for Individual #1 for October 2017 through December 2017. The program specialist did not complete an ISP review for Individual #2 that includes the dates of 10/19/17 through 10/24/17.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.55PACode Chapter 2380.186(a) 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 Program Specialist Reviewed previous reviews and found that a conflict of dates due to carryover goals from the previous year ISP that resulted in miscounts of the days that the quarterly was due. Correction: As of 10/17/18 The Program Specialist will ensure the quarterly is completed, signed and dated by all parties the day of the review by having the backup program specialist as a completion. This process will ensure that two Program Specialist will have viewed the for document completion accuracy. check [At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of ISP reviews to ensure timely completion to encompass all timeframes. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 10/31/18)] 10/17/2018 Implemented
2380.186(b)The ISP review for Individual #1 for the review period 4/1/18 to 6/30/18, was signed by the Individual and Program Specialist on 9/5/18. The ISP review for Individual #1 for the review period 6/22/18 to 8/30/18 was not when signed by the individual; therefore, compliance could not be measured. The ISP review for Individual #1 for the review period of 3/23/18 to 7/10/18 was not signed by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.55 PA Code Chapter 2380.186(b) Correction: The Program Specialist Reviewed previous reviews and found that a conflict of dates due to carryover goals from the previous year's ISP for individuals #1 and #2 that resulted in miscounts of the days that the quarterly was due. Correction: As of 10/17/18 The Program Specialist will ensure the quarterly is completed, signed and dated by all parties the day of the review by having the backup program specialist as a completion. This process will ensure that two Program Specialist will have viewed the for document completion accuracy. [At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of ISP reviews to ensure the program specialist and individual sign and date the ISP reviews, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 10/31/18)] 10/17/2018 Implemented
2380.186(d)There was not documentation that the ISP review for Individual #1 for the review period 12/21/17 to 3/21/18 was sent to the plan team members; therefore, compliance could not be measured.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.55 PA Code Chapter 2380.186 (d)Correction: Program Specialist with designated staff will conduct quarterly peer review of quarterly goals to ensure that all quarterlies within 90 days of the last review. After the review one staff and both Program Specialist will sign off on a quarterly chart audit form. [At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of correspondence documentation showing that the program specialist provide all individuals' ISP reviews to the plan team members as required and documentation is available upon request by the Department. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 10/31/18)] 10/17/2018 Implemented
SIN-00123036 Renewal 10/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)The program specialist did not date the September 2017 monthly documentation of Individual #1's participation and progress toward outcomes. The program specialist shall be responsible for the following:  Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.The Program Specialist immediately signed off and dated the monthly document form. The program specialist reviewed and trained each ATF team/staff on the completion of the this form and the policy of the form. At the end of the month, Program Specialist will use a monthly and/or quarterly audit form to ensure that the required signature area is completed. All charts will be reviewed monthly and again quarterly by program Specialist. [Documentation of all chart audits shall be kept. (AS 1/19/18)] 10/19/2017 Implemented
2380.111(a)Individual #1 had physical examination completed 3/2/16 and then again on 4/15/17. Individual #2 had physical examination completed 4/13/16 and then again on 5/8/17. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist will review outing going program participants physical form; which are sent out 60 days before the annual physical is due to determine the exact date it should be signed off and returned by the physician.. Each incoming physical will be reviewed by program specialist for completeness and immediately, follow-up if there are any questions are not filled in. All follow-up pre and follow-up call will be documented on the critical information form. [Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking and notification system to ensure timely completion of individuals' physical examinations. (AS 1/19/18)] 10/23/2017 Implemented
2380.111(c)(4)The physical examination completed 5/8/17 for Individual #2 did not include the a vision and hearing screening. These section indicated "unable to assess." The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialist will review all incoming physicals with the quarterly audit checklist. If there is any omitted and or questionable entries Program Specialist will follow up with family, physician or both for clarification of the information entry or omission in question. Program Specialist will request a written, signed and dated clarification by the physician. If needed Program Specialist will involve the Supports Coordinator of the Program Participant. All communication will be documented on the critical information form. [Within 30 days of receipt of the plan of correction, the CEO or designee shall train all staff persons who are involved in the audit of physical examination documentation of the required information as per 2380.111(a)-(d) and that required areas of the physical examination shall not be left blank. Documentation of trainings and audits shall be kept. (AS 1/19/18)] 10/23/2017 Implemented
2380.111(c)(10)The physical examination completed 1/31/17 for Individual #3 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.Program Specialist will review outing going program participants physical form; which are sent out 60 days before the annual physical is due to determine the exact date it should be signed off and returned by the physician.. Each incoming physical will be reviewed by program specialist for completeness and immediately, follow-up if there are any questions are not filled in. All follow-up pre and follow-up call will be documented on the critical information form. If necessary, the Program Participant(s) Supports Coordinator will be consulted to assist with the attainment of completed physical form. [Within 30 days of receipt of the plan of correction, the CEO or designee shall train all staff persons who are involved in the audit of physical examination documentation of the required information as per 2380.111(a)-(d) and that required areas of the physical examination shall not be left blank. Documentation of trainings and audits shall be kept. (AS 1/19/18)] 10/23/2017 Implemented
2380.173(1)(iv)Individual #1's record did not include religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Immediately the program specialist completed the omitted religious affiliation onto the ATF Information Documentation form. On 10/19/17, the program specialist reviewed the corrected form with the team of individual #1 and reviewed all program charts to ensure that all forms were completely filled out. . Additionally, Program Specialist will have an assigned primary counselor to review each individual record to ensure that the records include all personal information including; The race, height, weight, color of hair, color of eyes, identifying marks and religious affiliation. The Site Supervisor and/ or Back - Up Program Specialist will review all forms on a quarterly basis and within 1 week for all new program participants to ensure that All staff will be trained on Policy of Information Sheet form MMR #900 by 10/19/17. Each staff will sign off on the training form once trained. 10/19/2017 Implemented
SIN-00103290 Renewal 11/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)On 11/9/16 at approximately 1:20 PM, the cabinet under the sink in the kitchen was unlocked and contained the following poisonous materials: Clorox Clean Up, Clorox Spray, and Dawn Dish Detergent. All of the containers stated "if swallowed contact poison control." Individual #1's assessment dated 7/29/16 indicates s/he is not safe around poisons. Individual #2's assessment dated 7/1/16 indicates s/he is not safe around poisons. Individual #3's assessment dated 6/9/16 indicates that s/he is not safe around poisons. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All poisonous materials are locked in the cabinet beneath the kitchen sink. The key for entry is inaccessible to individuals. All staff will be trained and/or retrained on the lock protocol on an annual basis as part of the annual unit safety training. Each staff will acknowledge training completion by signing the poisonous material sign off form. see attached form [Immediately, all staff persons shall be educated in the procedures to ensure all poisonous materials are locked. All staff shall check the cabinet used for locking cleaning supplies and other poisonous materials to ensure it is locked at all time and check through out the facility to ensure no poisonous materials are accessible in the facility throughout the normal course of their daily duties. (AS 12/2/16)] 11/25/2016 Implemented
2380.111(c)(1)The physical examination for Individual #1, dated 6/28/16, did not include previous medical history. (Repeated violation, 11/5/15 et al)The physical examination shall include: A review of previous medical history.In order to prevent reoccurrence, [{individuals without a formal medical summary will have a compilation developed by the assigned counselor which will be extracted from their Individual Support Plan and physical. The information categories will be the following; Developmental Information, Current Health Status, General Health and Safety, Physical Assessment , Social/Emotional and adapted self help. The Program Specialist will review and update at the time of the received annual physical. The Program Specialist and Program Counselor(s) will sign and date upon completion and reviewed at the ISP meeting with the interdisciplinary team.}NOT ACCEPTABLE (AS 12/2/16)] [Immediately, the Director shall review and educate the program specialist(s) as to the required information in individuals' physical examination as per 2380.111(c)(1)-(11). Documentation of the training shall be kept. Individual #1's physical examination was updated with "N/A" for previous medical history. Immediately and upon completion of physical examinations, the program specialist shall review all individuals physical examinations to ensure all required information is included. At least quarterly for 1 year, the Director shall review all newly completed physical examinations to ensure all required information is included. Documentation of all audits shall be kept. (AS 12/2/16)] 11/25/2016 Implemented
2380.111(c)(7)The physical examination for Individual #3, dated 6/1/16, did not include an assessment of health maintenance needs, medication regime, and the need for blood work at recommended intervals. 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.In order to avoid reoccurrence of blank spots on the physical form ,each physical form will be reviewed by the program specialist and assigned counselor for completeness. Incomplete physicals will be returned to the families, care provider, staff and /or doctor to complete.[Immediately, the Director shall review and educate the program specialist(s) as to the required information in individuals' physical examination as per 2380.111(c)(1)-(11). Documentation of the training shall be kept. Immediately, the program specialist shall contact the completing physician and have the physical examination updated with an assessment of health maintenance needs, medication regime, and the need for blood work at recommended intervals for Individual #3. Immediately and upon completion of physical examinations, the program specialist shall review all individuals physical examinations to ensure all required information is included. At least quarterly for 1 year, the Director shall review all newly completed physical examinations to ensure all required information is included. Documentation of all audits shall be kept. (AS 12/2/16)] 11/25/2016 Implemented
2380.111(c)(10)The physical examination for Individual #1, completed on 6/28/16, did not include information pertinent to diagnosis and treatment in case of an emergency. The physical examination for Individual #2, dated 11/5/15, did not include information pertinent to diagnosis and treatment in case of an emergency. The physical examination for Individual #3, dated 6/1/16, did not include information pertinent to diagnosis and treatment in case of an emergency. (Repeated violation, 11/5/15 et al)The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.In order to avoid reoccurrence of blank spots on the physical form ,each physical form will be reviewed by the program specialist and assigned counselor for completeness. Incomplete physicals will be returned to the families, care provider, staff and /or doctor to complete.[Immediately, the Director shall review and educate the program specialist(s) as to the required information in individuals' physical examination as per 2380.111(c)(1)-(11). Documentation of the training shall be kept. Individual #1's physical examination was updated with "N/A" for medical information pertinent to diagnosis and treatment in case of an emergency. Individual #3's physical examination was updated with to include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination was updated with to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and upon completion of physical examinations, the program specialist shall review all individuals physical examinations to ensure all required information is included. At least quarterly for 1 year, the Director shall review all newly completed physical examinations to ensure all required information is included. Documentation of all audits shall be kept. (AS 12/2/16)] 11/25/2016 Implemented
2380.173(1)(v)The record for Individual #1, admission date 3/18/15, did not include date on the photograph. The record for Individual #4, admission date 10/21/87, did not include a date on the photograph.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.In order to avoid reoccurrence, counselors will review and audit each others charts for accuracy on quarterly basis. Each audit will be completed with the use of the 2380 audit check off list. The program specialist will review each audited chart with counselor upon completion. [Individual #4 had a photograph dated 4/2015 entered in the record. Individual #1 had a photograph dated 3/2015 entered in the record. Immediately, the director shall educate the program specialist(s) as to what is required in each individual's record as per 2380.173 (1)-(11). Documentation of the trainings shall be kept. Immediately and at least quarterly, the Program Specialist(s) shall review all individual records to ensure all required information is present including a current, dated photograph. Documentation of record audits shall be kept. (AS 12/2/16)] 11/25/2016 Implemented
2380.181(e)(10)The assessment for Individual #1, dated 7/29/16, did not include a lifetime medical history. The assessment for Individual #2, dated 7/1/16, did not include a lifetime medical history. The assessment for Individual #3, dated 6/9/16, did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.[{In order to prevent reoccurrence, individuals without a formal medical summary will have a compilation developed by the assigned counselor which will be extracted from their Individual Support Plan and physical. The information categories will be the following; Developmental Information, Current Health Status, General Health and Safety, Physical Assessment , Social/Emotional and adapted self help. The Program Specialist will review and update at the time of the received annual physical. The Program Specialist and Program Counselor(s) will sign and date upon completion and reviewed at the ISP meeting with the interdisciplinary team.}NOT ACCEPTABLE DOES NOT ADDRESS THE VIOLATION (AS 12/2/16)][Immediately, the Director of ID and the program specialist shall review the currently used assessment document to ensure all the required information is present and determine if the current information is needed to serve the individuals in the Adult training facility and develop an assessment that meets the requirements and serves the individuals. Individuals #1, #2 and #3 assessments were updated to include a lifetime medical history. Immediately, the program specialist(s) shall review all individuals' assessments to ensure they include all required information including lifetime medical history and shall update immediately as needed. At least quarterly, for 1 year the director shall review all assessments completed that quarter to ensure all individual are assessed in all required areas and the information is in the assessment as required including life time medical history. Documentation of all audits shall be kept. (AS 12/2/16)] 11/25/2016 Implemented
SIN-00086316 Renewal 11/05/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #1's most recent physical examination, dated 8/26/15, did not include a review of previous medical history.The physical examination shall include: A review of previous medical history.For individual #1 as well as other clients moving forward Mercy ATF program will be sure to use our own Annual Physical form (emailed to Jared on 12/2/2015) or another state licensed agency¿s form which will include the section for previous medical history. .[CEO or designee will immediately obtain the required missing information from the physical examination for Individual #1. CEO or designee will review all individuals' most recent physical examinations for completeness and obtain what is missing as needed. CEO or designee will review all new physical examination forms to ensure all required information is present, the reviews will be completed prior to filing in the individuals' record. Required elements of physical examinations will be obtained as needed. Documentation of reviews will be maintained by the CEO or designee. (AS 12/22/15)] 12/03/2015 Implemented
2380.111(c)(3)Individual #1's most recent tetanus and diphtheria immunizations were 9/22/1989 as documented on physical examination dated 8/26/2015.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 had her tetanus and diphtheria shot on 11/24/2015 ¿ emailed a copy to Jared on 12/2/2015[CEO or designee will review all individuals' most recent physical examinations for completeness and obtain what is missing as needed. CEO or designee will review all new physical examination forms to ensure all required information is present, the reviews will be completed prior to filing in the individuals' record. Required elements of physical examinations will be obtained as needed. Documentation of reviews will be maintained by the CEO or designee. (AS 12/22/15)] 12/03/2015 Implemented
2380.111(c)(10)Individual #1's most recent physical examination, dated 8/26/15, did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.¿ For individual #1 as well as other clients moving forward Mercy ATF program will be sure to use our own Annual Physical form (emailed to Jared on 12/2/2015) or another state licensed agency¿s form which will include the section for medical information pertinent to diagnosis and treatment in case of an emergency. [CEO or designee will immediately obtain the required missing information from the physical examination for Individual #1. CEO or designee will review all individuals' most recent physical examinations for completeness and obtain what is missing as needed. CEO or designee will review all new physical examination forms to ensure all required information is present, the reviews will be completed prior to filing in the individuals' record. Required elements of physical examinations will be obtained as needed. Documentation of reviews will be maintained by the CEO or designee. (AS 12/22/15)] 12/03/2015 Implemented
2380.181(f)Individual #2's assessment, dated 3/27/15, was not sent to all plan team members.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Moving forward individual #2¿s summer camp will be included when disseminating items to the entire team, the documents were faxed to Mainstay the assessment dated 3/27/15 and emailed Jared with the fax cover sheet and a critical revision form.[Program specialist will immediately review all individuals' records to ensure the most recent assessments were sent to the entire team as required and will send as needed. Documentation of record reviews and coorespondence will be maintained. Program Specialist will review ISPs and invitation letters and other relevant documents to ensure the entire team is sent the assessments for all individuals. (AS 12/22/15) 12/03/2015 Implemented
2380.186(d)Individual #2's ISP review documentation, dated 10/29/15, 7/29/15 and 2/22/15, was not sent to all plan 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.Moving forward all individuals including individual#2¿s- summer camp will be included when disseminating items to the entire team, faxed documents to Mainstay for 10/29/15, 7/29/15 and 2/22/15 and emailed Jared with the fax cover sheet and a critical revision form. [Program specialist will immediately review all individuals' records to ensure the last 3 quarterlies were sent to the entire team as required and will send as needed. Documentation of reviews and coorespondence will be maintained. Program Specialist will review ISP and invitation letters and other relevant documents to ensure the entire team is sent the quarterly reviews for all individuals. (AS 12/22/15) 12/03/2015 Implemented
SIN-00066242 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(a)The three month reviews for Individual #1 were completed on 4/4/14 and 7/25/14.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.Supervisor will use her outlook calendar reminder action to create a reminder for each individual. the reminder will present itself the firt monday of every month for those folks that she must complete a review for. it will remind her on a quarterly basis, based on the isp date. it will have no end date.the prompt will help ensure completion of this task. 12/20/2014 Implemented
SIN-00051725 Renewal 09/19/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)The facility is not alternating the exit routes during fire drills. The fire drill record listed " all exits" as being used during every monthly fire drill from 10/4/12 through 09/10/13.(e)  Alternate exit routes shall be used during fire drills.All staff will be required to denote which exits were used in each fire drill and not to state "all exits"unless all are used. [The Director will audit the fire drill log monthly to ensure that the exit routes have been alternated and that it is clearly depicted on the fire drill log. (CHG 11/14/13)] 11/01/2013 Implemented
2380.90(b)The door leading to the vocational area where there is an exit to a side street does not have an exit sign to indicate the direction of travel.(b)  If the exit or way to reach the exit is not immediately visible to the individuals, access to exits shall be marked with visible signs indicating the direction of travel.We have placed a Fire Exit sign above arch way that was sited by monitors. done 10/21/2013 11/01/2013 Implemented
2380.181(d)The annual assessment for Individual #1, dated 8/12/13, was not signed by the program specialist.(d)  The program specialist shall sign and date the assessment.A Program Specialist will review all forms that require the position's signature, review for accuracy and sign. [The assessment for Individual #1 will be signed by the program specialist. The program specialist will audit all assessment forms to ensure that they contain the required information. The Director will audit a sample of individual records monthly to ensure that they contain all of the required information. (CHG 11/14/13)] 11/01/2013 Implemented
SIN-00225018 Renewal 05/25/2023 Compliant - Finalized