Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00162267 Renewal 09/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical exam on 1/20/2016. He didn't have another physical exam until 4/23/2019, which exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Director will continue to stress the importance of the annual examinations to the parent/ caregiver. Program Director will continue to send reminder notices to the parent/caregiver. 09/30/2019 Implemented
2380.111(c)(3)There are no records of Diphtheria & Tetanus immunizations on the physical exams for Individual #1 (4/23/2019), Individual #2 (3/25/2019) and Individual #3 (4/25/2019).The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.A section for Diphtheria & Tetanus immunizations is now included on the new physical form. ((Brass Castle will contact the physicians of Individual #1, Individual #2, and Individual #3 to obtain the missing information by 12/1/2019 -CH 10/22/2019)) 09/30/2019 Implemented
2380.111(c)(7)Health maintenance needs and the need for bloodwork were not on the physical exams for Individual #1 (4/23/2019), Individual #2 (3/25/2019) and Individual #3 (4/25/2019).The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.An assessment of the individual's health maintenance needs, medication regimen and need for blood work at recommended intervals will be requested from the physician. 09/30/2019 Implemented
2380.111(c)(10)This section was not on the physical exams for Individual #1 (4/23/2019), Individual #2 (3/25/2019) and Individual #3 (4/25/2019).The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A section for Medical information pertinent to diagnosis and treatment in case of an emergency has been included on the new physical form. ((Brass Castle will contact the physicians of Individual #1, Individual #2, and Individual #3 to obtain the missing information by 12/1/2019 -CH 10/22/2019)) 09/30/2019 Implemented
2380.111(c)(11)This section was blank on Individual #2's physical exam dated 3/25/2019.The physical examination shall include: Special instructions for an individual's diet.A section for Special instructions for dietary needs has been included on the new physical form. ((Brass Castle will contact the physicians of Individual #2 to obtain the missing information by 12/1/2019 -CH 10/22/2019)) 09/30/2019 Implemented
2380.113(a)Staff #4 was hired on 6/11/2019. She didn't have a physical exam until 7/7/2019. Staff #5 was hired on 8/23/2019. She didn't have a physical exam until 9/23/2019 (Repeat Violation: 9/21/2018).A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All hiring staff have been retrained (10/23/2019) on hiring policies and practices. The hiring staff will only accept physical examinations completed within twelve (12) months of the proposed hire date. PS will review all new hire paperwork on the 30th day of each month to ensure all new hire paperwork is compliant. 10/23/2019 Implemented
2380.113(c)(2)Staff #4 was hired on 6/11/2019. She didn't have a TB test until 7/7/2019. Staff #5 was hired on 8/23/2019. She didn't have a TB test until 9/23/2019 (Repeat Violation: 9/21/2018).The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.All hiring staff have been retrained (10/23/2019) on hiring policies and practices. The hiring staff will only accept tuberculin test results completed within two years of the proposed hire date. PS will review all new hire paperwork on the 30th day of each month to ensure all new hire paperwork is compliant. 10/23/2019 Implemented
2380.173(1)(ii)Identifying marks are not listed in the records for Individual #1, Individual #2 and Individual #3.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Program Director will indicate an identifying mark in each individual's record no matter how miniscule to satisfy the code. 09/30/2019 Implemented
2380.36(b)Annual fire safety training was late for 3 staff. Staff #1 had fire safety training on 5/11/2017 and not again until 10/20/2018. Staff #2 had fire safety training on 5/4/2018 and not again until 6/5/2019. Staff #3 had fire safety training on 1/5/2018 and not again until 5/3/2019.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program Director was under the impression that the fire safety training could take place within the calendar year as all other 24 hr. trainings. The Fire safety training will now be complete within one year of the last fire safety training. 09/30/2019 Implemented
2380.125(f)Individual #2 is prescribed Risperdal for Hyperactivity. He does not have a SEEN Protocol Plan in his record.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Was not aware of this code. Have contacted the prescribing doctor for guidance. Once guidance is obtained a protocol will be included in the individual's file. 09/30/2019 Implemented
2380.181(f)Individual #2's ISP meeting was held on 3/25/2019. His assessment wasn't sent to his team until 7/12/2019.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.We have always maintained annual assessments for our individuals based on their enrollment date. We will now change this date to coincide with the ISP meeting date. 09/30/2019 Implemented
SIN-00142785 Renewal 09/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1's most recent Tuberculin skin test was administered 4/10/15.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.Program Specialist has created a 30 day alert system for all individuals and/or their care givers to be reminded of their Tuberculin test due date. ((A TB test will be obtained for Individual #1 -CH 12/7/2018)) 10/01/2018 Implemented
2380.111(c)(10)The physical examination dated 5/23/18 for Individual #1 did not document information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist has created an 'emergency instructions' related to diagnosis, section on the examination form to be completed by the doctor or medical professional. ((The physician for Individual #1 will be contacted to obtain the missing information. -CH 12/7/18)) 10/01/2018 Implemented
2380.113(a)Staff #1's most recent physical examination occurred on 6/06/16.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Program Specialist has created a 30 day alert system for all staff to be reminded of their annual physical due date. ((Staff #1 will receive an updated physical examination -CH 12/7/18)) 09/25/2018 Implemented
2380.113(c)(2)Staff #1's most recent Tuberculin skin test was administered on 6/06/16.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Program Specialist has created a 30 day alert system for all staff to be reminded of their Tuberculin skin test due date. ((Staff #1 will receive an updated TB test -CH 12/7/18)) 09/25/2018 Implemented
SIN-00124153 Renewal 12/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(d)Staff #2 was hired on 4/27/2016. A copy of her Criminal History Check is not in her file.A copy of the final reports received from the State Police, and the FBI, if applicable, shall be kept.Staff #2 criminal history check is now on file. 01/05/2018 Implemented
2380.36(c)Brass Castle does not have an established training year. Staff #1(date of hire: 8/2010) and Staff #2 (date of hire: 4/27/16) did not have the required 24 hours of training.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.All staff training requirements will now follow a calendar year rather than DOH. ((the calendar year is 1/1-12/31 - CH 3/13/18)) 12/29/2017 Implemented
2380.36(e)There was no record of fire safety training for staff #1. Repeat violation 11/17/2016.Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff #1 will now be required to sign the fire safety training attendance sheet. ((Fire Safety training was completed on 12/29/17 - CH 3/13/18)) 12/29/2017 Implemented
2380.84The annual fire safety inspection was done on 5/12/17. There's no other fire safety inspection on file so it couldn't be determined if it was done annually.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.All previous fire safety inspections will be maintained along side current inspections. 01/05/2018 Implemented
2380.89(c)The monthly fire drill record did not list which exits are utilized during fire drills.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.A checkbox for rear and front exits have been added to the fire drill form. 01/05/2018 Implemented
2380.89(e)Due to exits not being documented in the fire drill record, it was unknown if alternate routes were utilized.Alternate exit routes shall be used during fire drills.A checkbox for alternated exit routes is now listed on the fire drill form and will be completed going forward. 01/05/2018 Implemented
2380.91(a)Individual #2 had fire safety training on 3/5/15. She didn't have fire safety training again until 3/6/2017, which exceeds the annual requirement.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.A tickler system has been implemented to ensure all fire safety trainings are completed annually. ((The Team Leader is responsible for ensuring fire safety training is completed annually by monitoring the tickler system - CH 3/13/18)) 01/05/2018 Implemented
2380.111(a)Individual #1 was admitted on 1/5/2012. There are no physical exams for him in his record. Individual #2 was admitted on 3/7/2011. There is no current physical exam in her record. Individual #3 was admitted on 4/29/2013. There are no physical exams for her in her record.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.All staff are now required to 'sign out an individual's record when reviewing an individual's record for updates and changes to ensure all documents remain secure. ((Brass Castle will maintain an electronic copy as a back-up for hard copies in an individual's file. Physicals will be completed in March/April 2018 - CH 3/13/18)) 01/05/2018 Implemented
2380.113(a)Staff #1 had a physical exam on 6/6/2016. Her 2014 physical exam was not in her file. Repeat violation 11/17/2016.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All physical exams documentation will be maintained in each staff person's file onsite. ((The Program Specialist will be responsible for ensuring physical exams are in the staff files. Staff #1's 2014 physical has been returned to the file - CH 3/13/18)) 01/05/2018 Implemented
2380.113(c)(2)Staff #2 had a TB test on 10/23/2015. As of 12/28/2017, she has not had another TB test, which exceeds the requirement.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Each staff person will receive a reminder notice for all due dates for physical exams and TB tests. ((Staff #2 has been scheduled for a Mantoux test 3/9/18 - CH 3/13/18)) 01/05/2018 Implemented
2380.171(b)(3)Name, address and telephone number of the person able to give consent for emergency medical treatment was not in the records for Individual #1, Individual #2, and Individual #3.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.Name, address and telephone number of the person able to give consent for emergency medical treatment is now part of the record for Individual #1, Individual #2 and Individual #3. 01/05/2018 Implemented
2380.173(1)(ii)Weight, height, race, hair color, eye color, and identifying marks weren't listed in the records for Individual #1 and Individual #3. Race, hair color, eye color and identifying marks weren't listed in the record for Individual #2.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.A standard identification form has been created which includes weight, height, race, hair color, eye color and other identifying marks and will now be included in every individual's file. 01/05/2018 Implemented
2380.173(1)(iv)Religious affiliation was not listed in the records for Individual #1, Individual #2, and Individual #3.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Religious affiliation is now included and part of every individual's record. 01/05/2018 Implemented
2380.173(5(ii)Invitations for Annual ISP meetings were not in the records for Individual #1, Individual #2 and Individual #3.Each individual¿s record must include the following information: A copy of the invitation to: The annual update meeting.Invitations for the annual ISP meetings will be placed in each individual's file upon receipt from the SC/plan lead. 01/05/2018 Implemented
2380.173(6)(ii)The Annual ISP meeting signature sheet was not in the record for Individual #2.Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting.The signature sheet for Individual #2 is now included in the file. 01/05/2018 Implemented
2380.181(e)(13)(ii)The area of motor skills was not evaluated in Individual #1, Individual #2, and Individual #3's annual assessments.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.The area of motor skills has been added to the annual assessment form to be used for all assessments going forward. 12/29/2017 Implemented
2380.181(f)There is no documentation of assessments being sent to the plan team 30 days prior to the ISP meetings for Individual #1, Individual #2, and Individual #3.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).A checklist has been created to ensure all assessments are forward to the SC at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under 2380.12, 6500, 6400.182 (relating to development annual update and revision of the ISP). 12/29/2017 Implemented
2380.186(a)Individual #2 had ISP reviews on 12/9/16, 6/9/17, 9/12/17 and 12/8/17. The timeframe between 12/9/16-6/9/17 exceeds the 3 month requirement.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.A tickler system has been implemented to ensure all ISP reviews of the services and expected outcomes are completed every 3 months. ((Program Specialist is responsible for monitoring the tickler system - CH 3/13/18)) 01/26/2018 Implemented
2380.186(b)Individual #3 did not sign her ISP review dated 3/28/17. Repeat violation 11/17/2016.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #3 has signed her ISP review dated 3/28/17. ((Program Specialist will be responsible for ensuring individuals sign their ISP Reviews. -CH 3/13/18)) 12/29/2017 Implemented
SIN-00104686 Renewal 11/17/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1's last fire safety training was completed on 06/29/15Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Director has implemented a tickler calendar file to ensure that all staff receive their annual fire safety trainings as required by Code Chapter 2380.36(f). Staff #1 fire safety training has been completed. 12/01/2016 Implemented
2380.111(c)(3)There were no immunizations on file for Individual #1. On the physical dated 04/13/16, "yes" is checked for "immunizations are current" however there is no date listed as to when it was administered nor is their information regarding which immunizations are current. There were no records of immunizations for Individual #2.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Director has forward a letter to all caregivers to have the individual's medical provider attach a separate record/list of the individual's immunization history. 11/21/2016 Implemented
2380.111(c)(4)Individual #1's physical examination did not include a hearing or vision screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Director has contacted individual #1's caregiver for an updated form. Updated physical is now on file. Director will review all physical forms upon receipt to ensure all information is completed as required by Code Chapter 2380.11(c)(4). 12/08/2016 Implemented
2380.111(c)(10)"Info pertinent to diagnosis in case of emergency" was left blank on Individual #2's physical dated 03/02/16.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Director has implemented a '2 person staff check system' to ensure all required information has been completed on the physical form upon receipt. 11/21/2016 Implemented
2380.111(c)(11)Special diet instructions was left blank on Individual #2's physical.The physical examination shall include: Special instructions for an individual's diet.Director will ensure individual's physical form includes current dietary needs as recommended by their medical provider. The 'Physical Form Checklist" will ensure individuals' physical have been completed and is correct upon receipt. Individual #2's physical has been updated. 02/17/2017 Implemented
2380.113(a)Staff #1 had no physical on file.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Staff #1's physical was misfiled. Director has filed staff #1's physical correctly and will ensure all physicals are filed in the confidential health files upon receipt. 11/17/2016 Implemented
2380.173(9)There was content discrepancy between Individual #2's ISP and annual assessment in regard to dietary instructions.In the assessment dated 07/11/16 under "eating" it states Individual #2 is not on a speical diet and makes no mention of special needs. However, in the ISP dated 06/24/16, it states Individual #2 needs his food cut into bite sized pieces and should be within 10 feet of supervision and prompted to slow down because it couold cause an asthma attack.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Director has implemented a checklist and policy to have all ISP's updates and annual assessments reviewed for accuracy and consistency. This will occur at individual ISP review dates and when the annual assessments are completed. Individual #2's dietary instructions are noted in the ISP and annual assessment. 11/21/2016 Implemented
2380.177Individual #1 had no conesnt for release of information on file.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.All individuals, their parent or guardian will receive a written consent form to sign as required for the release of information upon admission to day program. Individual #1's written consent is now on file. 12/08/2016 Implemented
2380.186(b)Individual #1's ISP review from 06/04/16 was not signed by the program specialist. Individual #2's last ISP was also not signed.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The Director has implemented a '2 person staff check' system to ensure all ISP signature sheet and reviews are signed by the Program Specialist and the individual as required by Code Chapter 2380.186(b). All ISP reviews have been signed. 12/09/2016 Implemented
2380.186(c)(1)No monthly reviews of Individual #1's or Individual #2's ISPs are being completed.The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Director has created a 'tickler system' to ensure all monthly reviews are completed as required. All monthly reviews are on file. 12/12/2016 Implemented
2380.186(c)(2)The only areas of Individual #1's and Individual #2's ISPs reviewed in the quarterly reviews are the areas of behaviors and outcomes; not safety, communication, or medical needs/issues.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Director has included a section for safety, communication, and medical needs/issues to be standard part of all quarterly reviews. The quarterly reviews have been updated. 12/08/2016 Implemented
SIN-00084291 Renewal 09/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)Alternate exit routes were not used during the past twelve months.Alternate exit routes shall be used during fire drills.The fire drill policy has been modified to include alternate exit routes be used during all fire drills. 10/20/2015 Implemented
2380.111(a)Individual #1 was admitted to Brass Castle ATF on 05/28/2015 and as of 09/08/2015 there was no physical examination. Also Individual #2 had a physical examination completed on 03/04/2014 and then not until 04/07/2015.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.All required Physicals are now on file. Program Specialists will send out 'physical due notices' to individuals/designated family members 30 days prior to renewal date. Individuals will not be admitted to day program without the required physical documentation as per policy. 10/20/2015 Implemented
2380.111(c)(5)Individual #2 had a tuberculin skin test on 03/29/2013 and then not until 05/04/2015 exceeding the two year limit.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.A 30- day tickler file monitoring system policy has been implemented to ensure that all TB test and physicals are up to date for all individuals. Program Specialist will review the file system monthly to ensure compliance. 10/20/2015 Implemented
2380.113(a)Staff #1 had a physical examination completed on 02/07/2012 and then not until 05/13/2014 which exceeds the two year limit.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All staff have been trained and given their physical anniversary dates as a reminder. Program Specialist has requested all staff to have their physicals completed 15 days prior to their anniversary dates respectively. 10/20/2015 Implemented
2380.113(c)(2)Staff #2 was hired on 02/02/2015 had a physical examination completed on 01/28/2015 but did not have tuberculin skin test done as of 09/08/2015.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.The staff tuberculin skin test is on file. Program Specialist will ensure documents are ready for inspector. 09/10/2015 Implemented
2380.173(6)(ii)There wasn't a signature sheet for Individual # 2's annual ISP update meeting.Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting.Signature sheet is on file. 09/10/2015 Implemented
2380.186(b)Individual #2 and the Program Specialist did not sign and date his ISP reviews.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Program Specialists will ensure that the ISP signature sheet is completed with all required signatures and dates during the ISP meeting. An ISP 'checklist' has been implemented to ensure all documentation is completed. 10/20/2015 Implemented
SIN-00065916 Renewal 06/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(h)Records of staff training did not include the source of the training.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.All Training records now include the source of the training provided. 06/25/2014 Implemented
2380.113(a)Staff #1 had a physical examination on 10/10/11 and the next physical was not until 05/12/2014 which exceeds the two year limit.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Director will ensure that all employees physicals are completed within the two year period. 06/25/2014 Implemented
2380.182(a)Individual #1 was admitted on 04/29/2013. The Provider did not contact the Supports Coordinator to do a critical revision to include the services at Brass Castle.An individual shall have one ISP.Director will request the SC to do a critical Revision to include services at Brass Castle upon enrollment. 06/30/2014 Implemented
2380.186(c)(1)There were no monthly progress notes on the outcomes for Individual #1.The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Outcomes section will be provided on the monthly progress notes as it is on the weekly progress notes. 06/29/2014 Implemented