| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Poisonous materials shall be kept locked or made inaccessible to individuals when not in use. At the time of the inspection, two areas where poisonous materials were stored were found to be unlocked and accessible. A maintenance closet located next to the cafeteria was unlocked and contained poisonous materials including bleach and Vital Oxide disinfectant. The cleaning crew closet/laundry room was unlocked and contained poisonous materials including Palmolive antibacterial dish detergent, Fantastic-brand spray cleaner and lemon quat cleaning and sanitizing liquid. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Via will purchase and install an automatic door closer (to go on the top of each door-laundry room and maintenance room) as well as a keyless key pad that allows rooms to remain locked at all times and entered with the use of a passcode. Screenshots of purchased items to be sent as additional documentation. |
12/16/2022
| Implemented |
| 2380.91(a) | Individual #2 completed annual fire safety training late. Individual #2 completed fire safety training on 8/20/2021, then not again until 10/26/2022. | 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. | Via's 2380 Program Specialist has been connected with Via's 2390 Program Director to discuss adopting the same schedule and tracking system that the 2390 program uses. The 2390 program offers the fire safety training at least four times annually, and asks that participants sign off on a specific tracker that allows Via to easily see that the training occurs minimally once per year. This tracker will be sent as documentation of this POC. |
12/12/2022
| Implemented |
| 2380.111(a) | Individual #1's annual physical examination was late. Individual #1 had a physical examination on 3/15/2021, then not again until 4/06/2022. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | As a result of this violation Via has developed a new initial and annual release form to be reviewed and signed upon intake and at annual ISP meetings. This form, which will be sent as additional documentation of correction, is intended to ensure it is communicated to Via ATF participants and responsible parties that annual physicals are required to be turned in, and that failure to turn in a thoroughly completed physical may result in the participant not returning to program until the thoroughly completed physical is turned in. |
12/15/2022
| Implemented |
| 2380.111(c)(10) | The annual physical examination record for Individual #1 completed on 4/06/2022 did not document medical information pertinent to diagnosis and treatment in case of an emergency (the area was left blank on the form). | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | As a result of this violation Via has developed a new process to ensure that program specialists track annual physicals with the use of our Electronic Health Record System. This process, which will be sent as additional documentation of correction, is intended to ensure all program specialists in both 2380 and 2390 programs are following the same steps to track, request, and review annual physicals. |
12/14/2022
| Implemented |
| 2380.21(u) | 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. Individual rights were reviewed and signed with Individual #1 on 2/28/2022, Individual #2 on 10/26/2022, and Individual #3 on 6/01/2022, but the rights statement that was reviewed and signed did not contain the following rights: 21c -- may not be reprimanded, punished or retaliated against for exercising their rights, 21d -- a court's written order that restricts an individual's rights shall be followed, 21e -- a court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order, 21f -- an individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order, 21g -- an individual has the right to designate a person to assist in decision-making and exercising rights on behalf of the individual, 21r -- an individual's rights shall be exercised so that another individual's rights are not violated, 21s -- the facility shall assist the affected individuals to negotiate choices in accordance with the facility's procedures for the individuals to resolve differences and make choices, and 21t -- an individual's rights may only be modified in accordance with 2380.185 to the extent necessary to mitigate a significant health and safety risk to the individual or others. | 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. | Upon discovery that Via's Civil, Legal and Human Rights initial and annual release form was not in line with the 2380 Individual Rights regulations the document was updated. It now contains the exact Individual Rights listed within the regulations, with additions for Via specific rights inclusion. The updated Civil, Legal and Human Rights form will be sent as documentation of the POC. |
12/07/2022
| Implemented |