Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238086 Renewal 01/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.53Egress and outside walkway located out of the 'Second Warehouse' had sticks, leaves and debris.Outside walkways shall be free from ice, snow, leaves, equipment and other hazards.The egress and outside walkway located out the second warehouse has been added to the monthly safety inspection checklist. The HART management team and safety and security officer had a meeting to discuss this plan. 02/02/2024 Implemented
2390.61· There is a surface hole in the middle closet door in the cafeteria. · The door located at the 'Second Warehouse' egress had a C-Clamp on the hinge and needs repaired. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The management team and safety and security discussed the surface hole in the middle door of the cafeteria. They also discuss the door located at the "second warehouse" egress which had a C-Clamp on the hinge in need of repair. This discussion took place on 1/31/24 and a date for the repair was made for 2/1/24. 02/01/2024 Implemented
2390.72(c)Upon entering the production area, to the far left where Individuals are packaging Utz, there is a work aisle between the Utz boxes and where Individuals stand while packing the boxes. In that area, the work aisle is not marked with lines that are at least 2 inches wide.Work aisles shall be marked with visible lines that are at least 2 inches wide. If visually handicapped clients are served, work aisles shall be marked with tactile guides.A meeting was held between the HART Center Executive Director, HART Center Safety and Security Office and management team on 1/31/24. There was an understanding that this is an area where product is not packed but in the area on the other side of the table. This is a work area and not a aisle way and the lines were scraped off the floor. 02/01/2024 Implemented
2390.82(b)Annual onsite fire safety inspection by the local fire department was conducted on 1/27/2022, then not again until 2/22/2023.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.The management team and safety and security officer met on 1/31/24 to discuss the importance of completing an annual onsite fire safety inspection by the local fire department. 02/07/2023 Implemented
2390.86-1There is no sign bearing the word "EXIT" leaving production area heading towards the cafeteria.Signs bearing the word ``EXIT¿¿ in plain legible letters shall be placed at exits.The management team met with the safety and security officer and discussed that there is no sign bearing the work "EXIT" leaving the production area heading towards the cafeteria. A plan of action for the correction of this violation was agreed upon to be fixed tomorrow 2/1/24. 02/01/2024 Implemented
2390.87Staff #4 was hired on 08/22/22 and did not receive initial fire safety until 10/27/22. Staff # 2 was hired on 01/18/23 and did not receive initial fire safety training until 01/31/23.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The management team and HR met on 2/1/2024 to discuss the importance of staff being trained on fire safety on their first day of employment during their orientation. Staff, and clients shall be instructed upon initial admission and reinstructed annually in general fire safety and in the use of fire extinguishers. 02/02/2024 Implemented
2390.21(u)Individual #1's first day was 5/8/2023 but individual rights were not reviewed and signed until 9/27/23.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.The rehabilitation manager and program specialist evaluator had a meeting to discuss the individual rights not being signed and reviewed. HART shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter. 02/01/2024 Implemented
2390.40(a)REPEAT from 1/27/23 - Staff # 1-4 do not have a training record which includes the source, content, dates, length, or persons attending. The Staff Orientation records do not include the source or length of the trainings.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.The management and staff meet two times weekly and every other week for training. Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. 02/02/2024 Implemented
2390.48(b)(2)REPEAT from 12/16/22 - Staff #2 was hired on 01/18/23 but did not receive orientation training in the identification of abuse.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The management and staff meet two times weekly and every other week for training. The prevention, detection and reporting of abuse, suspected and alleged in accordance with the Older Adults Protective Services and applicable protective services will be held during orientation and again during the annual training year. 02/02/2024 Implemented
2390.49(c)(1)Staff #3 did not receive training in person centered planning in the 21-22 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.The application of person-centered practices, community, integration, client choice and supporting clients to develop and maintain relationships will be incorporated into updated documentation to ensure compliance and prevent future occurrences. 02/02/2024 Implemented
2390.49(c)(2)REPEAT from 12/16/22 - Staff #3 did not receive training in the identification of abuse in the 21-22 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The staff will meet twice weekly and every other week to ensure the training and prevention, detection and reporting of abuse, suspected abuse, suspected and alleged abuse in accordance with the Older Adults Protective Services. 02/02/2024 Implemented
2390.49(c)(3)Staff #3 did not receive training in Individual Rights in the 21-22 training year. Staff #3 did not receive training in Positive Behavioral Supports in the 21-22 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.The staff will meet twice weekly and every other week for hours to receive training in Individual Rights and positive Behavioral Supports. HR and management met on 2/1/2024 and will continue to meet regarding areas of this training. 02/02/2024 Implemented
2390.49(c)(5)REPEAT from 12/16/22 - Staff #3 did not receive training in Positive Behavioral Supports in the 21-22 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with a client.The management team and HR met to discuss training and appropriate documentation in Positive Behavioral Supports in the training year. Staff will meet twice weekly and every other week for training time and to ensure compliance. 02/02/2024 Implemented
2390.49(c)(6)Staff # 1 informed that all staff are directed to read all Individual ISP's and it is documented that all staff have taken 15 minutes time to read each ISP (regardless of the length or intricacy of each ISP). Plan implementation and Staff knowledge of Individual Needs cannot be ensured. Staff # 4 was not trained on Individual # 1's ISP or Seen Plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with a client.Staff will continue to meet twice weekly and and every other week for training. Staff already met 2/2/2024 to discuss the implementation of the individual plan and to put down the exact time it takes to read the Individual Support Plan. Program Specialists will also met with staff to train and discuss the Individual support plan. 02/02/2024 Implemented
SIN-00218609 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(b)-2Staff were not completing different locations within the facility for the hypothetical fire location, they were only switching between exit doors.Hypothetical locations of the fire shall be different for each drill.The HART Center will hold monthly fire drills. During these monthly fire drills HART will choose a different hypothetical location of the fire which will encompass a variety of locations within the building. These locations will include but not be limited to offices, cafeteria, work floor and warehouse areas. The safety and security officer will be responsible for the ongoing monitoring and documentation of this practice. 02/07/2023 Implemented
2390.87There were several clients/consumers (13) who did not receive annual fire safety training. 7 clients had training in March of 22 but not in 11/21 or 10/22. 4 clients had training in October of 22 but not in 11/21 or 3/22. 2 clients had training on 11/21 but not in 10/22 or 3/22.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The HART Center safety and security office will schedule the local fire company yearly, in October, to have a person from that fire department come to the facility to give a fire safety training to all staff and clients. The safety and security officer will also schedule a day yearly, in March, for all staff and clients to view a fire safety video. The safety & security officer and program specialists will also utilize the following 15 days after these yearly scheduled trainings to ensure that all staff and clients who were absent from the scheduled trainings to view the fire safety video. The rehabilitation manager will ensure that all new staff and clients will view the fire safety video within the fist 15 days of their start date. All of these trainings will encompass general fire safety and use of fire extinguishers. 02/07/2023 Implemented
2390.103HART does not have an emergency medical plan.A 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. (2) The method of transportation to be used.(3) Written consent from the client, parent or guardian for emergency medical treatment.(4) The staffing plan during the emergency.All clients will be distributed a yearly personal data sheet to complete. An emergency medical plan will be added to this document. When the personal data is returned the program specialists will review all of the information to ensure its accuracy. The program specialists will also review and discuss with clients all of the information to include the emergency medical plan which includes the source of health care that will be used in an emergency, the method of transportation to be used, the consent for emergency medical treatment and the staffing plan during an emergency. 02/07/2023 Implemented
2390.104(4)Individuals #1 and #2 on the emergency procedure card, there was a space labeled "diagnosis", but it was left blank. Individual #4 had a diagnosis of MH on his emergency information card but he does not have a MG diagnosis.Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency.The rehabilitation manager met with the program specialists to discuss and train the importance of carefully reviewing emergency procedure cards, personal data sheets and spaces labeled diagnosis. The rehabilitation manager will meet weekly with program specialists to ensure to discuss, review and ensure accurate documentation with this plan. 02/07/2023 Implemented
2390.124(2)Individual #1 does not have the full address for the parent/legal guardian on the emergency procedure card, they only have written "CSG". The full address needs to be added because CSG has several homes, and it needs to be clarified if the address should be the address at where individual #1 lives or the CSG office location.Each client's record must include the following information: The name, address and telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency.The rehabilitation manager met with program specialists to review, discuss and teach the importance of ensuring that the full address, name, telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency are correct on documentation. The rehabilitation manager will continue to meet weekly with program specialists discuss and monitor the importance of this information. The rehabilitation manager will also meet on a daily basis as needed to ensure continued compliance. 02/07/2023 Implemented
2390.151(e)(3)(i)The assessment dated 7/5/22 for individual #2 has 3 different piece rate amounts. Under Motor & Communication Skills it states an average piece rate of $2.82/hour. Under Acquisition of Vocational Function Skills it states an average piece rate of $2.56/hour and under Vocational Skills it states an average piece rate of $4.18/hr.The assessment must include the following information: The client's current level of performance and progress in the following areas: Acquisition of vocational functioning skills.The rehabilitation manager met with program specialists to discuss the importance of the annual assessment to include client's current level of performance and progress in the Acquisition of vocational skills. The rehabilitation manager will meet weekly with program specialists to discuss, teach, monitor and review assessments and accuracy of said document in order maintain compliance. 02/08/2023 Implemented
2390.21(d)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A court's written order that restricts a client's rights shall be followed.A court's written order that restricts a client's rights shall be followed.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss a court's written order that restricts a client's rights shall be followed and to ensure continued compliance. 02/07/2023 Implemented
2390.21(e)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A court-appointed legal guardian may exercise rights and make decisions on behalf of a client in accordance with the conditions of guardianship as specified in the court order.A court-appointed legal guardian may exercise rights and make decisions on behalf of a client in accordance with the conditions of guardianship as specified in the court order.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss a court-appointed legal guardian may exercise rights and make decisions on behalf of a client in accordance with the conditions of guardianship as specified in the court order. 02/07/2023 Implemented
2390.21(f)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A client who has a court-appointed legal guardian, or who has a court order restricting the client's rights, shall be involved in decision-making in accordance with the court order.A client who has a court-appointed legal guardian, or who has a court order restricting the client's rights, shall be involved in decision-making in accordance with the court order.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss the continued compliance with the consumer rights policy. 02/07/2023 Implemented
2390.21(g)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A client has the right to designate persons to assist in decision-making and exercising rights on behalf of the client.A client has the right to designate persons to assist in decision-making and exercising rights on behalf of the client.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss the continued compliance with the consumer rights policy. 02/07/2023 Implemented
2390.21(i)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A client has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the client's choice, and practice no religion.A client has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the client's choice and practice no religion.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss the continued compliance with the consumer rights policy. 02/07/2023 Implemented
2390.21(j)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A client may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.A client may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss the continued compliance with the consumer rights policy. 02/07/2023 Implemented
2390.21(l)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A client has the right to make choices and accept risks.A client has the right to make choices and accept risks.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss the continued compliance with the consumer rights policy. 02/07/2023 Implemented
2390.21(t)Client Rights for Individual #'s 1, 2, 3, 4, and 5 do not include: A client's rights may only be modified in accordance with § 2390.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the client or others.A client's rights bay only be modified in accordance with § 2390.185 (Relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.An addendum to the consumer rights policy was discussed and reviewed with individual's #1,2,3,4 and 5. The rehabilitation manager met with program specialists to discuss the importance of this documents. The rehabilitation manager will meet weekly with program specialists to discuss the continued compliance with the consumer rights policy. 02/07/2023 Implemented
2390.40(a)Training records for staff attending fire safety was not on their individual training logs.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.HART Center HR will coordinate and work with safety and security officer to ensure compliance that all staff are trained in October by the local fire department and March with a fire safety video. Safety and security will meet with the rehabilitation manager monthly to ensure continued compliance with records of orientation and training of fire safety. 02/07/2023 Implemented
2390.152(c)Employment info in the 7/5/22 assessment and the 11/2/22 ISP do not match. Section 2 of the assessment states "for now, Allen wants to work in the HART center ···". In the ISP under Employment/Volunteer Information it states that he would like to work at Home Depot or Lowes inside stocking shelves. Also, in the ISP under the Know and Do section, it states " Allen is no longer interested in competitive employment."The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.the rehabilitation manager met with program specialists to discuss the importance that the individual plan shall be initially developed, revised annually when a client's needs change based upon a current assessment. The rehabilitation manager will meet weekly with program specialists to read, review, discuss, train as necessary and monitor the individual plan and how it shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment in order to ensure continued compliance. 02/08/2023 Implemented
2390.153(b)Individual #1 did not have a Direct service worker present at the ISP meeting held on 12/30/21At least three members of the individual plan team, in addition to the client and persons designated by the client, shall be present at a meeting at which the individual plan is developed revised.The rehabilitation manager will meet with program specialists to ensure compliance of direct service workers being present at ISP meetings. 02/01/2023 Implemented
SIN-00216649 Unannounced Monitoring 11/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.48(b)(2)Throughout the investigatory process it was identified staff interviewed gave conflicting responses as to their orientation training provided at the HART Center. Staff stated that they never had training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, the Adult Protective Services Act, and applicable protective services regulations or they may have or couldn't remember. A few staff interviewed stated that they never even heard of the terms "Incident Management" and "EIM". All staff interviewed did respond stating they would contact their supervisor if they suspected abuse or neglect.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Prior to working alone with clients, and within the 30 days after hire staff shall complete the orientation of the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Staff will be rained in the Incident Management Manual that ensures that safeguards are in place t protect the health, safety and rights of anyone receiving services and support through the H.A.R.T. Center. The training encompasses and ensures recognition of abuse and neglect, including prevention, detection and reporting. The Incident management manual is part of the orientation and orientation checklist. 01/04/2023 Implemented
2390.48(b)(4)Throughout the investigatory process it was identified staff interviewed gave conflicting responses as to their orientation training provided at the HART Center. Staff stated that they never had training on recognizing and reporting incidents or they may have or couldn't remember. A few staff interviewed stated that they never even heard of the terms "Incident Management" and "EIM". All staff interviewed did respond stating they would contact their supervisor if they suspected abuse or neglect.The orientation must encompass the following areas: Recognizing and reporting incident.Prior to working alone with clients, and within the 30 days after hire staff shall complete the orientation of recognizing and reporting incidents. Training on recognizing and reporting suspected abuse, neglect, abandonment or exploitation to include the ODP incident management will be ensured. 01/04/2023 Implemented
2390.49(c)(2)Throughout the investigatory process it was identified staff interviewed gave conflicting responses as to their annual training provided at the HART Center. Staff stated that they never had training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, the Adult Protective Services Act, and applicable protective services regulations. or they may have or couldn't remember. A few staff interviewed stated that they never even heard of the terms "Incident Management" and "EIM". All staff interviewed did respond by stating they would contact their supervisor if they suspected abuse or neglect.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff are trained yearly on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. To ensure this training, staff will read, discuss and sign the Incident Management Manual regarding reporting suspected abuse, neglect, abandonment or exploitation document and ODP incident management. An excel spreadsheet is utilized as an additional documenting system to the instructions to ensure training. 01/04/2023 Implemented
2390.49(c)(4)Throughout the investigatory process it was identified staff interviewed gave conflicting responses as to their annual training provided at the HART Center. Staff stated that they never had training on recognizing and reporting incidents or they may have or couldn't remember. A few staff interviewed stated that they never even heard of the terms "Incident Management" and "EIM". All staff interviewed did respond by stating they would contact their supervisor if they suspected abuse or neglect.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff are trained yearly on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. To ensure the training, staff will read, discuss and sign recognizing and reporting incidents. An excel spread sheet is utilized as an additional documenting system to the instructions to ensure training. 01/04/2023 Implemented
2390.49(c)(5)Throughout the investigatory process, the majority of staff interviewed stated they have never read an Individual's Service Plan (ISP) or SEEN/Behavioral Plan. The HART management have stated through interviews that their staff do read individual ISP's; however, currently The HART Center needs to keep a better system of documenting this.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with a client.Staff are trained annually on the safe and appropriate use of behavior supports. To ensure this training, staff read, discuss, ask questions and sign documents of this topic. A better system of documenting this process has been restructured on an excel spreadsheet and is now utilized in the documenting system to staff instructions to ensue training. 01/04/2023 Implemented
2390.49(c)(6)Throughout the investigatory process, the majority of staff interviewed stated they have never read an Individual's Service Plan (ISP). The HART management have stated through interviews that their staff do read individual ISP's; however, currently The HART Center needs to keep a better system of documenting this.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with a client.Staff are trained annually on the implementation of the individual's plan. Staff read, discuss and sign that the Individual Support Plan and SEEN plan have read as well as attended the staffing/ISP meetings. A spreadsheet has been restructured and is utilized as an additional documenting system to ensure compliance. 01/04/2023 Implemented
SIN-00151030 Renewal 06/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.124(12)REPEAT from 3/29/18 annual inspection: Individual #7's physical examination form stated he has an allergy to latex in which he gets a rash but has no other allergies. Individual #7's emergency procedure card in his record stated "allergies: none." According to the Individual Support Plan (ISP), there is a known latex allergy with a known skin rash reaction and takes medications for seasonal allergies. The ISP also states that Individual #7 requires a "CPAP (Continuous Positive Airway Pressure) mask that is not plastic, as he is allergic." This is not noted on any other document in the Individual's record. Repeat 3/29/18: Individual #8's information sheet indicates allergy to Penicillin, white ash & dust mites. The updated ISP 10/15/18 indicated allergies to Seasonal, Dust mites & cockroaches.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.The Program Specialists and rehabilitation manager met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss and fix content discrepancy of individual #7 and #8's records. The discussion and importance of matching information on all documents, for example, the emergency card, ISP, physical, assessment was confirmed. The importance of of documenting per family, per doctor also noted. A weekly meeting will be held to make sure of continued compliance of this and all other regulations. The program specialists feel comfortable asking questions on a daily basis to their supervisor if they have concerns. 06/17/2019 Implemented
2390.151(e)(4)Individual #7's 12/21/18 assessment did not include an assessment of the individual's supervision levels out in the community with staff. The assessment did not address the unsupervised time that is assessed to have while at the facility during breaks and lunches. The assessment must include the following information: The client's need for supervision.The Program Specialists and rehabilitation manager met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss, review and fix this violation and individual #7's assessment to include the need for supervision. The assessments will state the need for supervision and will add a line for supervision during breaks and lunch. The purpose of these meetings was to further explain each part of the violation and ensure compliance. A weekly meeting will be held to make sure of compliance and discuss this and all other regulations. The program specialists feel comfortable asking on a daily basis to their supervisor if they have any concerns. 06/17/2019 Implemented
2390.151(e)(5)REPEAT from 3/29/18 annual inspection: Individual #7's 12/21/18 assessment states that "he needs supervision to fill his medication boxes" and that "he could self-administer medications if needed and they were measured out for him." According to self-administration requirements under 6400.169(a)(1)-(3), the individual must be able to know how much medication is to be taken. As described in the assessment, the individual requires medications to be measured, thus making him unable to be self-administering of his own medications. This was not accurately assessed in the 12/21/18 assessment. The assessment must include the following information: The client's ability to self-administer medications.The program specialists and rehabilitation manager met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss, review and fix assessment information on individual #7's assessment. Each assessment will include the ability to self-administer medications. The assessments will indicate the individuals ability to self medicate or not and they will be specific. The purpose of these meetings was to further explain each part of the violations and ensure compliance. A weekly meeting will be held to make sure of continued compliance of this and all other regulations. The program specialists feel comfortable asking questions of a daily basis to their supervisor if they have any concerns. 06/17/2019 Implemented
2390.151(e)(9)REPEAT from 3/29/18 annual inspection: Individual #7's 12/21/18 assessment did not include medical limitations of having a latex allergy and seasonal allergies. According to individual #7's Individual Support Plan (ISP), is diagnosed with Moderate Intellectual disability, Down's Syndrome, Gout, Hypothyroidism, Asthma, Sleep Apnea, requires the use of a hearing aid, and has a ventricular septal defect that required repair at ages 5 months and 20 years old. Individual Marshall's 12/21/18 assessment only states he has a diagnosis of Down's Syndrome, a thyroid condition and sleep condition, a shattered knee cap, and a hearing impairment.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.Each individual assessment will include documentation of the client's disability to include functional and medical limitations. This documentation will match in ISP and Annual Assessment and the diagnosis will be kept up to date. The program specialists met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss, review and fix individual #7's documentation of disability, including functional and medical limitations. The purpose of the meetings was also to ensure, discuss and explain this violation. There will be weekly meetings to make sure of compliance with this and all other regulations. The program specialists feel comfortable asking questions on a daily basis to their supervisor if they have concerns. 06/17/2019 Implemented
2390.151(e)(13(ii)REPEAT from 3/29/18 annual inspection: Individual #7's 12/21/18 assessment did not include his progress over the last 365 calendar 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.Each individual assessment will include the individuals progress over the last 365 calendar days and current level in the area of motor and communication skills, in particular individual #7's motor and communication skills. This section of the assessment will also show progress, maintenance or regression. The program specialists and rehabilitation manager met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss, review and fix this violation. The purpose of the meetings was also to make sure and explain the violation and to ensure that it was fixed and completed. The program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. There will be continued weekly meetings to make sure of continued compliance with this and all other regulations. 06/17/2019 Implemented
2390.153(1)Repeat- 3/29/18 ISP- Individual #7's ISP updated on 11/28/18 the following outcome ended on 1/8/19 and there is no new outcomes in place- Earn Money.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Services provided to the client and expected outcomes chosen by the client and client's plan team.Each ISP, including annual updates and revisions including individual #7 will include services provided and expected outcomes. The program specialists met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss, review and fix this violation. Program specialists will continue to meet weekly with their supervisor to discuss and ensure continued compliance. Additionally, program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. 06/17/2019 Implemented
2390.156(c)(2)Repeat- 3/29/18: Individual #7's ISP reviews dated 4/15/19,1/7/19,10/15/18,7/18/18 does not indicated what community participation that Individual #7 participated in. It has the same statement on all ISP reviews. REPEAT from 3/29/18 annual inspection: Individual #8's 12/21/18, 9/24/18, 6/28/18, and 4/4/18 Individual Support Plan (ISP) reviews do not include a review of community participation services with the HART center or community participation events and outings that were offered to the individual, but declined. The reviews contain the same sentence regarding outings that have occurred throughout the year. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Each individual ISP review will include community involvement as it relates to the HART Center. They will be kept up to date and indicate participation or not and what is offered. Individual #7's and #8's ISP reviews were corrected. The program specialists met on 6/6/19, 6/7/19, 6/10/19 and 6/11/19 to discuss, fix and review this plan. A weekly meeting will be held to discuss and ensure continued compliance with this and all other regulations. Additionally, the program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. 06/17/2019 Implemented
SIN-00127749 Renewal 03/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(b)A blanket was not available in the first aid room.The first aid area shall have a bed or cot, a blanket and a first aid kit.The first aid area in the facility will have a bed, a blanket and a first aid kit. The safety and security staff will check daily on the first aid room to make sure that the first aid room has a blanket. There will be monthly safety and security meetings to make sure of continued compliance of this regulation. See attached picture of fixed violation. 04/12/2018 Implemented
2390.81The back exit in the community shop was blocked by a chair. A metal pole was blocking the stairway. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.All hallways and exits from rooms and from the facility will be unobstructed. The metal pole was removed from the blocked stairway. The safety and security officer will perform weekly checks of the facility and particularly regarding this stairway to make sure of continued compliance. The safety and security officer will also hold monthly safety committee meetings to make sure this regulation remains fixed and continues to stay in compliance with this regulation. See attached picture regarding this fixed violation. 04/12/2018 Implemented
2390.124(12)Individual #2's Individual Support Plan (ISP) indicated she attended the program Monday thru Friday. The ISP also indicated she was working to increase her days at the program, up to 3 days. Individual #2's physical exam indicated an allergy to Lorazepam. The ISP doesn't indicate any allergies. Individual #1's assessment indicated a 1:15 staff ratio with constant supervision. The ISP indicated 5 hours of supervision at a 1:15 ratio. Individual #1 attends the program for 5.5 hours. The half hour unsupervised time was not reflected in any plan.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Each individual record will include documentation when a content discrepancy in the ISP, the annual update or revision. The Program Specialists and rehabilitation manager met 4/2-6,9&10/18 to discuss and fix individual #1 and #2's content discrepancy in the ISP. The purpose of the meetings was also to further explain each part of the violations and to make sure that it was fixed. A weekly meeting will be held to ensure continued compliance with this and all other regulations. All files were reviewed and will continue to be read and reviewed in order for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(a)Individual #4 was admitted to the program on 8/17/15. An assessment was not completed until 8/18/17. Individual #6 was admitted to the program on 7/25/17. An assessment was not completed until 9/28/17.Each client 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.Each individual will have a written assessment with 1 year prior to or 60 calendar days after admission to the facility, with an updated assessment annually thereafter. Program Specialists and rehabilitation manager met on 4/2-6,9&10/18 to ensure that individual #4's assessment was fixed according to this code. The purpose of these meetings was also to further explain each part of the violation and to ensure that it has been fixed. The program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to ensure continued compliance with this regulation. A form has also been put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(d)Individual #4's 8/18/17 assessment and Individual #5's 3/12/18 assessment was not signed and dated by the program specialist.The program specialist shall sign and date the assessment.Each individual Program Specialist will sign and date the assessment. Program Specialists and the rehabilitation manager met 4/2-6,9&10/18 to correct individual #4 and #5's assessment regarding signatures and dates. The purpose also of these meetings was to further explain each part of the violations and to ensure that they have been fixed. Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to ensure continued compliance with this regulation. A form was also put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(2)Individual #3's 8/7/17 assessment did not include her dislikes.The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.Each individual assessment will include the likes, dislikes and interest of the individual, including vocational interests. Program Specialists and the rehabilitation manager met on 4/2-6,9&10/18 to fix individual #3's assessment and to include her dislikes. The additional purpose of the meetings was to further explain each part of the violation codes and to ensure that it was fixed and completed. Furthermore, Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have an concerns. A weekly meeting will be held to ensure continued compliance with this regulation. A form was developed to use for what is necessary for compliance. See corresponding attachment with code violation and code violation fixed. 04/12/2018 Implemented
2390.151(e)(3)(iv)Individual #2's 3/13/18 assessment did not include her personal needs. The assessment must include the following information: The client's current level of performance and progress in the following areas: Personal needs with or without assistance from others.Each individual assessment will contain current level of performance and progress in meeting own personal needs with or without assistance from others. Program Specialists and rehabilitation met on 4/2-6,9&10/18 to fix and assure compliance with individual #2's current level of performance and progress with personal needs with or without assistance from others. In addition, the purpose of these meetings was to further explain each part of the violations and to ensure that is has been fixed. Additionally, Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to ensure continued compliance with this regulation. A form has been put into place to utilize what is necessary for compliance. See corresponding attachment with code violation and code violation fixed. 04/12/2018 Implemented
2390.151(e)(5)Individual #3's 8/7/17 assessment, Individual #4's 8/18/17 assessment, Individual #5's 3/12/18 assessment, and Individual #6's 9/28/17 assessment did not include his/her ability to self administer medications. The assessment must include the following information: The client's ability to self-administer medications.Each individual assessment will include the individuals progress toward self- administration of medications if the individual is not able to self-administer medication. Program Specialists and the rehabilitation manager met on 4/2-6,9&10/18 to fix individual #3, #4, #5 and #6's assessment regarding ability to self-administer medications. The purpose of the meetings was also to further explain each part of the violation and to ensure that it was fixed. In addition, the program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. Weekly meetings will be held to ensure continued compliance with this regulation. A form has also been put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(7)Individual #2's 3/13/18 assessment and Individual #4's 8/18/17 assessment did not include her ability to move away from heat sources.The assessment must include the following information: The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Each individual assessment will include the individuals understanding of the danger of heat sources and ability to sense and move away from heat sources quickly. The Program Specialists met 4/2-6,9&10/18 to fix individual #2 and #4's assessment regarding the individuals knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. In addition, the purpose of these meetings was to further explain each part of the violations and to ensure that it was fixed. Additionally, the program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to ensure continued compliance with this and all other regulations. A form was also put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(9)Individual #2's 3/13/18 assessment did not include documentation of disability.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.Each individual assessment will include the individuals disability, including functional and medical limitations. The Program Specialists and the rehabilitation manager met on 4/2-6,9&10/18 to discuss and fix individual #2's assessment regarding documentation of the individuals disability, including functional and medical limitations. The purpose also of these meetings was to further discuss and explain each part of the violations and to ensure that is was fixed. The Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to make sure of continued compliance with this and all other regulations. A form was developed to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(10)Individual #2's assessment and Individual #3's assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.Each individual will include a lifetime medical history in their assessment. Program Specialists and rehabilitation manager met 4/2-6,9&10/18 to discuss and fix individual #2 and #3's lifetime medical history in their assessments. In addition, the purpose of the meetings was to further explain each part of the violations and to make sure that it was fixed. Also, program specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to also make sure of continued compliance with this and all other regulations. A form was put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(13)(i)Individual #2's 3/13/18 assessment did not include progress over the past year in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Each individual assessment will include the individuals progress and growth in the area of health. The Program Specialists and rehabilitation manager met on 4/2-6,9&10/18 to discuss and fix individual #2's progress over the last 365 calendar days and current level in the area of health on the assessment. The reason for the meetings was to also further explain each part of the violations and to make sure that it has been fixed. The Program Specialists feel comfortable discussing and asking questions on a daily basis if they have concerns. A weekly meeting will be held to ensure continued compliance with this and all other regulations. A form was developed to utilize what is necessary for continued compliance. See attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(13(ii)Individual #2's 3/13/18 assessment did not include progress over the past year 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.Each individual assessment will include the individuals progress and growth in the area of motor and communication skills. The Program Specialists and rehabilitation manager met 4/2-6,9&10/18 to discuss and fix individual #2's individual progress over the last 365 calendar days and current level in the area of motor and communication skills. The purpose of the meetings was also to make sure and explain each part of the violations and to ensure that that it was fixed and completed. The Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. There will be weekly meetings to make sure of continued compliance with this and all other regulations. A form was developed to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(13)(iii)Individual #2's 3/13/18 assessment and Individual #5's 3/12/18 assessment did not include progress over the past year 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.Each individual annual assessment will include the progress and growth in the area of personal adjustment. The Program Specialists and rehabilitation manager met 4/2-6,9&10/18 to discuss and fix individual #2 and #5's progress over the last 365 calendar days and current level of in the area of personal adjustment. The purpose of these meetings was to also further explain each part of the violations and to make sure that it was fixed. In addition, Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to make sure of continued compliance with this and all other regulations. A form was put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(e)(13(iv)Individual #5's 3/12/18 assessment did not include progress over the past year 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.Each individual annual assessment will include progress and growth in the area of socialization. The Program Specialists and rehabilitation manager met on 4/2-6,9&10/18 to discuss and fix individual #5's progress over the last 365 calendar days and current level in the socialization section of the assessment. The purpose of these meetings was also to further explain each part of the violations and make sure that it has been fixed. The Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to make sure of continued compliance with this and all other regulations. A form was put in place to use what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.151(f)Individual #2's 3/13/18 assessment was not sent to her family.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 Program Specialists and rehabilitation manager met on 4/2-6,9&10/18 to discuss and fix assessment on individual #2's assessment not sent to her family. Each individual will have documentation that the individual and all plan team members are informed of the results of the assessment at least 30 calendar days prior to the ISP, ISP Annual Update meeting or ISP plan revision. The purpose of these meetings was to further explain each part of the violations and to make sure that it was fixed completely. A weekly meeting will be held to make sure of continued compliance of this and all other regulations. The Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. See Corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.152(d)(2)Individual #6 was admitted to the program on 7/25/17. An Individual Support Plan (ISP) was not created until 12/19/17.The plan lead shall develop, update and revise the ISP according to the following: The initial ISP shall be developed within 90 calendar days after the client's admission date to the facility.Each individual program specialist will develop the ISP for each individual based on the assessment within 90 calendar days of the individuals admission date. Program Specialists and rehabilitation manager met 4/2-6,9&10/18 with the purpose of fixing individual #6's ISP plan regarding this violation and to further explain each part of the violation and to ensure that it has been fixed. A weekly meeting will be held to ensure continued compliance with this regulation. Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A form was also utilized that includes what is necessary. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.152(d)(5)Individual #2's Individual Support Plan (ISP) and Individual #6's ISP were not sent to team members.The plan lead shall develop, update and revise the ISP according to the following: Copies of the ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision), shall be provided as required under §  2390.157 (relating to copies).Each individual will have supporting documentation that copies of the plan, plan annual update, and plan revision were sent as required. Program Specialists met with the rehabilitation manager on 4/2-6,9&10/18 to discuss and fix individual #2's compliance with this regulation. The purpose of these meetings was to further explain each part of the violation and to ensure that it was fixed. Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to ensure continued compliance with this regulation. A form was also put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.153(1)Individual #2 did not have an outcome in the Individual Support Plan (ISP) between 6/20/17 and 9/18/17.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Services provided to the client and expected outcomes chosen by the client and client's plan team.Each individual will have an ISP, ISP Annual update and ISP revision which includes services provided to the individual and expected outcomes chosen by the individual and the individuals ISP team. Program Specialists and rehabilitation manager met on 4/2-6,9&10/18 with the purpose of discussing, ensuring, explaining and fixing Individual #2's outcome in the ISP. Weekly meeting will be held to ensure continued compliance with this regulation. A form has also been put in place to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.153(5)Individual #4's Individual Support Plan (ISP) and Individual #5's ISP did not include the social, emotional, environmental needs (SEEN) plan. Individual #2's SEEN plan in the ISP did not include her PTSD diagnosis or how staff should assist her during times of distress.A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Each individual will have a completed ISP, Annual update and ISP revision and include information regarding a protocol to address social, emotional and environmental needs of the individual, if a medication is prescribed to treat symptoms of a diagnosed psychiatric illness. Program Specialists and rehabilitation manager met on 4/2-6,9&10/18 to have a discussion and explanation of individual #2, 4 and 5's SEEN plan. The purpose of the meetings was also to fix the violations and develop a form to use that includes what is necessary. Weekly meetings will be held to ensure continued compliance with this regulation. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.153(7)(i)Individual #2's Individual Support Plan (ISP) did not include her potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.Each individual ISP, ISP Annual update and ISP revision will include information regarding the assessment of the individuals potential to advance in vocational programming. Program Specialists and the rehabilitation manager met on 4/2-6,9&10/18 to discuss and fix individual #2's potential to advance in vocational programming in the ISP. The purpose of these meetings was to further explain each part of the violation and to ensure that it has been fixed. Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. A weekly meeting will be held to ensure continued compliance with the regulation. A form was developed to utilize what is necessary for compliance. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.153(7)(ii)Individual #2's Individual Support Plan (ISP) did not include her potential to advance in competitive employment.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.Each individual will ISP, ISP Annual upgrade and ISP revision will include information regarding the assessment of the individual's potential to advance in their vocational programming towards competitive community-integrated employment. Program Specialists and rehabilitation manager met on 4/2-6,9&19/18 to fix individual #2's potential to advance in competitive employment section of the ISP. The purpose of the meetings was also to further explain each part of the violation and to ensure that it has been fixed and completed. A weekly meeting will continue to be held to ensure continued compliance with the regulation. See corresponding attachment with the code violation number and code violation number fixed. 04/12/2018 Implemented
2390.156(a)An Individual Support Plan (ISP) review was completed for Individual #4 on 5/19/16 and not again until 8/18/17. 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.Program Specialists met with the rehabilitation manager for two hours on each of the following days-4/2-6,9&10/18. Licensing violations were discussed and fixed. The purpose of these meetings was to further explain each part of the violations and to insure that individual #4's reviews are held when the individuals needs change which impact services as specified in the current ISP. The violation was fixed and in the future weekly meetings will be held to insure continued compliance with this regulation. All other files have been reviewed and will be checked monthly. In addition, random files will be pulled and checked in detail during weekly rehabilitation meetings. See corresponding attachment with code violation number and code violation number fixed. 04/11/2018 Implemented
2390.156(c)(1)Individual #1's 3/5/18 Individual Support Plan (ISP) review did not include progress toward his earning money outcome. ISP reviews for all individuals did not include a review of the ISP outcome for the prior three months. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.Individual #1's violation was discussed, reviewed and fixed. Program specialists met with the rehabilitation manager on each of the following days- 4/2-6,9&10/18. Licensing violations were discussed and fixed. A form is in use that includes what is necessary to insure that this violation does not occur in the future. Weekly rehabilitation meetings also will be held to insure continued compliance with this violation which includes monthly documentation of the individuals participation and progress during prior 3 months toward ISP outcomes that are supported by the services provided licensed under this chapter. See corresponding attachment with code violation number and code violation number fixed. 04/11/2018 Implemented
2390.156(c)(2)Individual #2's Individual Support Plan (ISP) reviews did not include a review of the social, emotional, environmental needs plan. The ISP reviews for Individual #1 and #2 did not review their community involvement. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Individual #2's social, emotional, environmental needs plan as it relates to the review of each section of the ISP specific to the facility licensed under this chapter was discussed and violations were fixed. Program specialists met with rehabilitation manager on 4/2-6,9&10/18 to discuss, review and fix relevant violation. The purpose of these meetings was to further explain this violation and to ensure that it has been completed and fixed. Weekly meetings will be held to make certain continued compliance. See corresponding attachment with code violation number and code violation number fixed. 04/11/2018 Implemented
2390.156(d)There was no documentation that the Individual Support Plan (ISP) reviews were sent to plan team members for all individuals reviewed. 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 and rehabilitation manager met 4/2-6,9&10/18. Licensing violation of providing documentation to support that the Program Specialist provided the ISP review documentation and recommendations to the SC/Plan lead and plan team members within 30 days of the ISP review meeting was discussed, reviewed and fixed. The purpose of the meetings was to further explain the violation and to ensure that it was completed and fixed. Weekly meetings will be held to ensure continued compliance with this regulation. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.156(e)Individual #2's family and case manager did not receive the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The Program Specialists and rehabilitation manager met on 4/2-6,9&10/18. The purpose of the meetings was to explain, discuss, plan and fix documentation to support that the Program Specialist notified the Plan Team members of the option to decline the ISP review documentation. The violation on individual #2's team member to receive this option to decline was fixed. Weekly meetings will be held to ensure, to review files, discuss and check for continued compliance of this regulation. See corresponding attachment with code violation number and code violation number fixed. 04/12/2018 Implemented
2390.159(4)(i)Individual #6's vocational evaluation completed during the period of 7/25/17 and 9/28/17 was not signed by the Individual #6.If the facility provides vocational evaluation, the following apply: The facility shall ensure the client and the client's parent, guardian or advocate, as applicable, are informed of the results of the evaluation. The client and the client's parent, guardian or advocate, as applicable, shall sign a statement acknowledging receipt of the evaluation results.The rehabilitation manager and evaluator met on 4/2-3/18. The violation of ensuring there is a signed statement that the client and the client's parent, guardian or advocate, as applicable, are informed of the results of the evaluation was discussed. In the future, meetings will be held monthly to check files and insure compliance. This violation was fixed and all other files were reviewed as well. See corresponding attachment with code violation number and code violation number fixed. 04/11/2018 Implemented
SIN-00102676 Renewal 11/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.18(a)-2The facility had an unusual incident on 11/2/16 involving law enforcement and it was not reported. The facility shall send copies of the report to the Regional Office of Mental Retardation and the funding agency within 24 hours after the event occurs. A copy of unusual incident reports shall be kept on file by the facility. Rehabilitation manager, Mary Krumrine, contacted the county office for additional advise from Adrian Redding concerning this violation. The correction was made on 12/5/16 by placing the report in to the appropriate system. A copy of the report was also placed on file. All future occurrences will placed into the system within 24 hours after the event. This violation was fixed. Please see attachment #7 as it relates to 18a. 12/05/2016 Implemented
2390.32(c)Staff #1 does not have qualifications for the CEO position. A chief executive officer shall meet one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years of work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years of work experience in administration or the human services field.The executive director, Craig Clabaugh, completed the waiver form with supporting documents for this violation. The H.A.R.T. Center board contacted/talked to the state licensing representatives and wrote letters of recommendation. The county commissioner, Steve Warren, was also contacted and made aware of Craig's many qualities for this position. Craig Clabaugh plans to contact and meet with James Richards from the state concerning the waiver with supporting documents. Please see attachments # 1 for this correction. 12/19/2016 Implemented
2390.81The donation door exit was blocked by 3 boxes of decorations.  Stairways, hallways and exits from rooms and from the facility shall be unobstructed.Rehabilitation manager, Mary Krumrine, and Executive Director, Craig Clabaugh met with all staff on 11/30/16 to discuss the importance not blocking the donation door exit. The importance of safety was further explained. The rehabilitation manager and executive director will continue to meet monthly with staff to stress the importance of exits being unobstructed. This violation was fixed by removing the carts. Please see attachment #5 picture of the cleared area. 12/19/2016 Implemented
2390.151(a)Individual #1's assessment were not completed.Each client 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.The rehabilitation manager, Mary Krumrine, met with all program specialists on 11/30/16, 12/5/16, 12/7/16, 12/12/16 and will continue to meet weekly with all program specialists. All assessments will be completed, checked, updated and monitored weekly in meetings. All other documents were reviewed and the violations were fixed. Please see attachment #2 as it relates to this licensing #151a. 12/19/2016 Implemented
2390.156(a)Individual #1's ISP reviews were not completed. 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.Rehabilitation manager, Mary Krumrine, held meetings with the program specialists on 11/30/16, 12/5/16,12/7/16, 12/12/16 and will continue to hold weekly meetings and monitor files/paper work. All other files have been reviewed concerning this violation. Staff will be given training and reminders in weekly meetings. The program specialists will make copies of e-mails and keep a log of necessary changes as needed to be shared with support coordinators. All copies and corrections have been observed, copied, logged and fixed. Please see attachment # 3 as it relates to this licensing number 156a. 12/19/2016 Implemented
2390.156(c)(1)Individual #2's ISP reviews the outcome of trust and respect but the ISP outcome is work. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.Rehabilitation manager, Mary Krumrine, held meetings with program specialists on 11/30/16, 12/5/16, 12/7/16, 12/12/16 and will continue to have weekly meetings to check files and paper work. All other files have been reviewed and the violations have been fixed. As seen in attachments #6 the reviews match with the ISP. The plan to prevent future occurrences will be weekly meetings to discuss process and check/monitor paper work. 12/19/2016 Implemented
2390.156(d)Individual #2 and #3's ISP reviews were not sent team. 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.All program specialists met with rehabilitation manager, Mary Krumrine, on 11/30/16, 12/5/16, 12/7/16,12/12/16 to discuss the correction of this violation. All other files were reviewed and the violation was corrected. The rehabilitation manager will continue to meet weekly with program specialists and to monitor and check files. A document was developed to provide the necessary information to team members within 30 calendar days. Attachment # 4 displays the document and necessary dates and information sent to the team. 12/19/2016 Implemented
SIN-00080038 Renewal 05/28/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #7's assessment was completed on 2/12/2015 but was not completed previously in 2014.Each client 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.Each individual will have a initial assessment completed with 1 year prior to or 60 calendar days after admission and an updated assessment annually. The rehabilitation manager met with program specialists on June 1,2,9&10 to train and further explain this policy. A policy was written, reviewed, signed and dated by program specialist to assure continued compliance. Attachment #7. The rehabilitation manager will review the assessments to insure compliance in the future. 06/12/2015 Implemented
2390.151(e)(10)Individual #7's assessment did not include a lifetime medical history. The assessment states see physical in the lifetime medical history section. The assessment must include the following information: A lifetime medical history.Each individual will have a lifetime medical history in the assessment. The rehabilitation manager met with program specialist on June 1,2,9&10 for training of this regulation. The responsibilities of this regulation were also explained and addressed to assure continued compliance. The rehabilitation manager will review the assessments to insure compliance in the future. Attachment #10,#11 06/12/2015 Implemented
2390.151(e)(13(ii)Individual #3, #7, #11, and #13 did not show progress and growth over the last 365 calendar days and current level in the following areas: Motor and communications 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.Each individual will have an assessment that will include progress over the last 365 calendar days in section of motor and communication skills. The rehabilitation manager met with program specialists on June 1,2,9&10 to train and further explain the regulation and responsibilities. Weekly training and monitoring of this regulation will occur. A random assessment will reviewed to assure continued compliance. The rehabilitation manager will review the assessments to insure compliance in the future. Attachment #10,#11 06/12/2015 Implemented
2390.151(e)(13)(iii)Individual #3, #7, #11, and #13 did not show progress and growth over the last 365 calendar days and current level in the following areas: 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.Each assessment will include progress over the last 365 calendar days and current level in personal adjustment. The rehabilitation manager met with program specialists on June 1,2,9&10 for training of this regulation. The purpose of these meeting were to also to explain the responsibilities of this regulation. Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns or questions. Assessments will be randomly inspected during weekly meeting to assure compliance. The rehabilitation manager will review the assessments to insure compliance in the future. Attachment #10,#11 06/12/2015 Implemented
2390.151(e)(13(iv)Individual #3, #7, #11, and #13 did not show progress and growth over the last 365 calendar days and current level in the following areas: 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.Each individual assessment will include progress over the last 365 calendar days in the current level of socialization. The Rehabilitation Manager met with the program specialist on June 1,2,9&10 to train and further explain this part of the assessment. Weekly training/meetings and monitoring of this regulation will occur to assure continued compliance. Program Specialist feel comfortable asking questions on a daily basis to their supervisor if they have questions or concerns. A random assessment will be inspected during meetings weekly. The rehabilitation manager will review the assessments to insure compliance in the future. Attachment #10,#11 06/12/2015 Implemented
2390.151(e)(13)(v)Individual #3, #7, #11, and #13 did not show progress and growth over the last 365 calendar days and current level in the following areas: Vocational 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: (v) Vocational skills.Each individual will include progress in the assessment over the last 365 calendar days in the current level of vocational skills. The Rehabilitation Manager met with program specialists on June 1,2,9&10 for training and further explanation of this regulation. Weekly training and monitoring will occur to assure continued compliance. A random assessment will be inspected during meetings weekly. Program Specialists feel comfortable asking questions on a daily basis to their supervisor if they have any concerns. The rehabilitation manager will review the assessments to insure compliance in the future. Attachment#10,#11 06/12/2015 Implemented
2390.152(d)(1)Individual #3's ISP was not completed annually. The ISP was completed on 7/22/2014. The facility did not have a copy of the 2013 ISP in the individuals record. The plan lead shall develop, update and revise the ISP according to the following: The ISP shall be initially developed, updated annually and revised based upon the client's current assessment as required under § §  2380.181, 2390.151, 6400.181 and 6500.151 (relating to assessment).Each individual will have a completed ISP annually. The Rehabilitation Manger met with program specialists on June 1,2,9&10 for training and mandating responsibilities of this compliance area. A policy was also written, reviewed, signed and dated by program specialists to assure compliance. The rehabilitation manager will review the ISP to insure compliance in the future. Attachment#7 06/12/2015 Implemented
2390.152(d)(2)Individual #1's initial ISP to be completed in 90 days of admission. Completed on 3/25/2015. Should have been completed on 11/14/2014.The plan lead shall develop, update and revise the ISP according to the following: The initial ISP shall be developed within 90 calendar days after the client's admission date to the facility.Each individual will have an initial ISP completed in 90 days of admission. The Rehabilitation Manager met with program specialists on June 1,2,9&10 to train and review the regulation. The Rehabilitation Manager will meet weekly with program specialists to assure, monitor and provide training of this regulation. Responsibilities of this regulation will be explained to program specialists and monitored by the Rehabilitation Manager. A policy was written, reviewed, signed and dated by program specialists to assure continued compliance. The rehabilitation manager will review the ISP to insure compliance in the future. Attachment#7 06/12/2015 Implemented
2390.152(d)(3)Individual #3's ISP was not on Department of Human Services form. The plan lead shall develop, update and revise the ISP according to the following: The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) And also on the Department's web site.Each individual will have an ISP formulated on the DPW form. The Rehabilitation Manager met with the program specialists on June 1,2,9&10 to provide training on this regulation. The Rehabilitation Manager will continue hold weekly training and monitoring of this regulation to assure compliance. The rehabilitation manager will review the ISP to insure compliance in the future. Attachment #8,#9 06/12/2015 Implemented
2390.153(5)Individual #1, #3, and #12's ISP did not include a SEEN Plan. A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Each individual will include a SEEN plan attached to the ISP. Rehabilitation Manager met with program specialists on June 1,2,9 & 10 for training and review of this regulation. Responsibilities of this regulation concerning continued compliance were also discussed. Weekly training and monitoring of this regulation will occur. The Rehabilitation Manager will inspect files to assure that this regulation is in compliance. The rehabilitation manager will review the ISP to insure compliance in the future. Attachment #1,#2 06/12/2015 Implemented
2390.153(7)(i)Individual #1 and #3's ISP did not include the potential to advance in the vocational programming. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.Each individual ISP review and revision will include documentation to advance in vocational programming. The Rehabilitation Manager met with program specialists on June 1,2,9&10 to train and review this regulation. Responsibilities of this regulation concerning continued compliance were addressed. Weekly training and monitoring of this regulation will occur.The rehabilitation manager will review the ISP to insure compliance in the future. Attachment #3,#4 06/12/2015 Implemented
2390.153(7)(ii)Individual #1 and #3's ISP did not inlcude the potential to advance in the community-integrated employment. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.Each individual ISP review and revision will include potential to advance in community-integrated employment. The Rehabilitation Manager met with program specialists on June 1,2,9&10 for training and review of this regulation. Responsibilities of this regulation concerning continued compliance were discussed. Weekly training and monitoring of this regulation will occur. The rehabilitation manager will review the ISP to insure compliance in the future. Attachment #5,#6 06/12/2015 Implemented
2390.156(c)(2)Individual #12's ISP review did not review the SEEN Plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Each individual will have a SEEN Plan reviewed. Rehabilitation Manager met with program specialists on June 1,2,9&10 for training and review of this regulation. Responsibilities of this regulation concerning compliance were addressed as well. Weekly training and monitoring of this regulation will occur. The Rehabilitation Manager or program specialist/Evaluator will randomly inspect and initial the SEEN plan beside the program specialists signature on the document to assure continued compliance. The rehabilitation manager will review the ISP to insure compliance in the future. Attachment #1,#2 06/12/2015 Implemented
SIN-00066080 Renewal 05/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(13(ii)The annual assessment for Individual #4 on 3/10/14 did not contain any progress and growth in the following sections: Personal adjustment, socialization and vocational skillThe 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.Meeting was held with Program Specialists on June 2, 2014. This meeting discussed and reviewed the assessment on the individual's progress over the last 365 calendar days. The importance of fully complying with licensing to document progress was noted. Assessments were discussed and weekly meetings with program specialists were held to continue this progress and licensing requirement. 06/02/2014 Implemented
2390.158(b)The ISP reviewes for Individuals #1, 2, 3, 4, 5 & 6 did not contain documentation that they were given opportunities for participation in community life. The facility shall provide opportunities and support to the client for participation in community life, including competitive community-integrated employment.Meeting was held on June 2, 2014 to discuss the importance of complying with this meaningful regulation. A specific section on the ISP comment sheet was added to provide documentation for participation in community life, including competitive community-integrated employment. The added section to the ISP comments sheet was labeled Community Involvement. A bulletin board was added to provide additional information. Follow up weekly meetings were held to with program specialists to ensure continued compliance with this regulation. 06/02/2014 Implemented
SIN-00197883 Renewal 01/25/2022 Compliant - Finalized
SIN-00175234 Renewal 11/04/2020 Compliant - Finalized