Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234165 Renewal 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment for this site was not completed since last year's renewal inspection had concluded on 12/1/22. [Repeat Violation- 11/29/22 et al]The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. CEO will complete a self-assessment for this site and will in the future be sure to complete a self-assessment within regulatory requirements annually for all homes licensed by provider. 01/31/2024 Implemented
6400.67(a)At 10:32 AM on 11/8/23 in the home's only bedroom, a circular hole measuring five inches by four inches was observed on the lower wall with the bedroom's only light switch. At 10:20 AM on 11/8/23 in the home's activity room, three holes in the wall facing the door of the room were observed. The wall to the left of the wall facing the room's door entrance from the living room had two circular holes, each measuring four inches by four inches. [Repeat Violation- 11/29/22 et al]Floors, walls, ceilings and other surfaces shall be in good repair. CEO will ensure all necessary repairs are completed as soon as possible so that all surfaces in the home are in good repair. 01/31/2024 Implemented
6400.67(b)At 10:45 AM during the physical on-site renewal inspection conducted on 11/8/23, puddling water coming in from the outside wall to the right of the descending stairs was observed laying on the basement floor, spanning an area of ten feet by five feet, and covering primarily the entire middle section of the room. Floors, walls, ceilings and other surfaces shall be free of hazards.CEO contacted plumber who then inspected the situation/area. Ground water was coming into the home and waterproofing company suggested by plumber. Baker's Waterproofing to inspect on 12/7/2023 for repair recommendations. CEO will schedule necessary and recommended repairs as quickly as possible. 01/31/2024 Implemented
6400.112(a)The fire drill written record did not include a drill conducted in January 2023. An unannounced fire drill shall be held at least once a month. Administration to conduct immediate audit of fire drill records to ensure all houses are compliant with regulations. 01/31/2024 Implemented
6400.18(a)(6)EIM Incident#: 9260232 involving exploitation was discovered on 7/7/23 and reported on 10/6/23.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Exploitation .Provider administration responsible for HCSIS/EIM reporting will ensure that all incidents or suspected incidents are reported timely and within regulatory requirements. 01/31/2024 Implemented
6400.18(i)EIM Incident#: 9260232 involving exploitation was discovered on 7/7/23 and finalized on 10/6/23. The due date for finalization was 8/6/23, and no extensions were filed.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.CEO will assess all current EIM reports to verify dates for finalization of incidents for compliance. 01/31/2024 Implemented
SIN-00197905 Renewal 12/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 5/31/2021, had a criminal background check requested on 7/2/2021.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Criminal background was obtained as soon as deficiency was realized. 01/20/2022 Implemented
6400.73(a)There was no handrail for the four outside steps leading from the basement to the backyard. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Handrail will be installed as soon as possible in order to remedy deficiency/violation. 01/28/2022 Implemented
6400.152(c)The Tuberculin skin test completed 5/21/2021 for Direct Service Worker #2 did not include the medical credentials of who read the test, therefore compliance was unable to be measured. The physician's written instructions and precautions shall be followed.Provider will immediately begin monitoring employee files (specifically physicals and TB results) to verify that credentials are included on TB documentation. 01/13/2022 Implemented
6400.20(b)The home did not complete a trend analysis for the period from 1/1/2021 -- 12/22/2021, therefore compliance was unable to be measured.The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.CEO will conduct trend analysis starting 01/2022 then in 04/2022, 07/2022 and then 10/2022 to continue quarterly in the future. CEO will identify incident number, severity of risk associated with those incidents and likelihood of recurrence. Additionally, CEO and administrative staff will monitor incidents and take action necessary to mitigate and manage risk. 01/31/2022 Implemented
6400.165(g)Individual #1 had a review of medications prescribed to treat symptoms of a psychiatric illness on 1/5/2021 and again on 4/14/2021. The psychiatric medication reviews completed 1/5/2021, 4/14/2021, 7/22/2021, and 10/2021 did not include the reason for prescribing the medication and they were not signed by a licensed physician. The psychiatric medication reviews completed 1/5/2021, 7/22/2021, and 10/2021 did not include the name of the medications and necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.CEO will conduct monthly audits of individual files and related medical documentation to remedy violation and prevent recurrence. All applicable regulations will be monitored for compliance and documentation of audits will be kept. 01/14/2022 Implemented
SIN-00142803 Renewal 10/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Program Specialist #1 had training in first aid, Heimlich techniques and cardio-pulmonary resuscitation on 3/15/16 and then again on 6/30/18. Direct Service Worker #2, date of hire 10/17/17 was initially trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation on 8/29/18.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Program Specialist has currently posted calendars for years 2019 through 2020 in order to track all employee physical/TB and CPR/First Aid due dates. CEO and Program Specialist will conduct monthly reviews of calendars to ensure continued compliance. [Immediately, the CEO or designee shall develop and implement a tracking and notification system to ensure staff have first aid/CPR trainings completed, timely. Documentation of audits of the tracking system and trainings shall be kept. (DPOC by AES, HSLS on 10/24/18)] 10/17/2018 Implemented
6400.151(a)Program Specialist #1's most recent physical examination was completed 6/1/16. Direct Service Worker #3 had physical examination completed on 3/28/16 and then again on 8/9/18. 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Program Specialist has currently posted calendars for years 2019 through 2020 to monitor all employee requirements. CEO will perform monthly checks of calendars/employee files including the Program Specialist file to ensure compliance with all applicable requirements. [Program Specialist had TB and physical examination completed on October 16, 2018. Documentation of aforementioned audit by the CEO shall be kept. (DPOC by AES, HSLS on 10/24/18)] 10/17/2018 Implemented
6400.151(c)(2)Program Specialist #1's most recent Tuberculin skin testing was completed 6/4/16. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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, licensed physician's assistant or certified nurse practitioner. Program Specialist had TB and physical examination completed on October 16, 2018. In the future, CEO will conduct a review of all employee records on a monthly basis (including Program Specialist file) to ensure compliance with applicable regulations. [Documentation of aforementioned audit by the CEO shall be kept. (DPOC by AES, HSLS on 10/24/18)] 10/17/2018 Implemented
SIN-00122170 Renewal 10/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The basement door exiting to the backyard had a wooden drop bar preventing egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The wooden drop bar has been removed.[Within 2 weeks of receipt of the plan of correction, all staff persons shall be educated that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the course of their daily duties. Immediately and at least quarterly, the CEO or designee shall completed an onsite check of all community homes to ensure stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed. (AS 10/25/17)] 10/16/2017 Implemented
SIN-00103510 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's Certificate of Compliance expires on 8/19/17. The agency completed the self-assessment on 9/23/16.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Program specialist will make sure that the self assessment is in the time line of 3-6 months before certificate of compliance expires. Program specialist will review monthly to ensure that it is done in the time line and submitted.[Upon receipt of the Certificate of Compliance, the CEO will determine the time period to complete the self-assessment and will develop and implement a tracking system to ensure the agency completes the self-assessment for all community homes 3 to 6 months prior to the expiration date on the Certificate of Compliance. Within 30 days of receipt of the plan of correction all staff persons responsible for completion of self-assessment shall be trained in the aforementioned tracking system. Prior to 3 months of the expiration date of the agency's certificate of compliance the CEO shall review all self-assessment to ensure timely and full completion. (AS 12/9/16)] 12/03/2016 Implemented
6400.46(i)Program Specialist #2's first aid and cardio-pulmonary resuscitation training expired on 12/30/15 and then was retrained on 3/15/16.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Program specialist will make sure that there is not a lapse in time with her certification. Program specialist will review all staff files to make sure there is no lapse in certification. [Immediately, the CEO will develop and implement a tracking system for all staff trainings to ensure required trainings including first aid and CPR are completed within the required timeframes. Immediately and at least quarterly, the CEO will review all staff trainings and enter into the tracking system to ensure all trainings are completed, timely. Documentation of reviews shall be kept. (AS 12/9/16)] 12/03/2016 Implemented
6400.77(b)The first aid kit did not contain a thermometer. The Neosporin Triple Antibiotic ointment expired in 2/2012 and the Benedryl Anti-Itch Cream expired in 2/2016. [Repeated Violation-10/23/15] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer and Antibiotic has been purchased and put in the first aid kit. Afternoon Staff will go over the kit weekly and the program specialist will review it monthly. A meeting has been scheduled for Dec 2, 2016 to go over regulation.77 [Immediately, the CEO shall attach a list of required items to all first aid kits in all community homes and ensure all required items are present. Within 30 days of receipt of the plan of correction, the CEO will train all staff as to the required items and where the extra supplies are kept. Documentation of all weekly and monthly audits including checking expiration dates shall be kept. (AS 12/9/16)] 12/03/2016 Implemented
6400.112(e)The home held eleven fire drills between 8/29/15 through 9/14/16. The only drill held during sleeping hours was 9/14/16 at 5:30 AM. A fire drill shall be held during sleeping hours at least every 6 months. We have informed staff that sleeping hours are between 12am to 6am, not 11pm to 7am. Program specialist will monitor the fire drills monthly to ensure that a sleeping drill is being done between the set hours. A meeting has been scheduled for Dec 2, 2016 to go over regulation 181. [Immediately, the CEO shall train all staff persons in the requirements of conducting and documenting fire drills as per 6400.112.(a)-(I) to ensure at least every 6 months a fire drill is held when individuals' living in the home are sleeping. Within 7 days after completion and documentation of fire drills, the program specialist shall review the fire drill documentation to ensure fire drills are being conducted and documented as required. At least quarterly for 6 months the CEO shall review all fire drill records to ensure fire drills are being conducted and documented as required. Documentation of all reviews shall be kept. (AS 12/9/16)] 12/03/2016 Implemented
6400.163(c)Individual #1 is prescribed Prozac for depression and Tenex for impulse control. The two most recent psychiatric medication reviews with documentation by a licensed physician were 5/9/16 and 8/23/16. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Program specialist will accompy the individual to all psychiatric medication reviews to ensure that all required paperwork has been filled out properly before we leave the appointment. [DOES NOT ADDRESS THE VIOLATION (AS 12/9/16) Immediately, the CEO shall develop and implement a tracking system to ensure timely completion of required medication reviews. Within 30 days of receipt of the plan of correction, the CEO shall train the program specialist on the tracking system and procedures to schedule reviews to ensure timely completion. At least quarterly for 1 year, the CEO shall review all psychiatric medication review documentation and tracking system to ensure timely completion. Documentation of reviews shall be kept. (AS 12/9/16)] 12/02/2016 Implemented
6400.181(e)(10)The assessment for Individual #1, completed on 8/18/16, did not include a lifetime medical history. [Repeated Violation-10/23/15]The assessment must include the following information: A lifetime medical history. There was a lifetime medical history but it was not acceptable. A new lifetime medical history form has devolped with includes all required information that is needed. All medical history forms will updated on the new form by Dec 12, 2016. Program specialist will review monthly to ensure all required information has been added. [Individual #1 had a lifetime medical history completed. Within 30 days of receipt of the plan of correction and at least annually thereafter, the CEO shall train the program specialist on the required information to be included in individuals' assessments as per 6400.181(e)(1)-(14). Documentation of the trainings shall be kept. Immediately, the program specialist shall review all individuals' current assessments to ensure all required information is present including life time medical history. At least quarterly for 1 year the CEO shall review all individuals' assessment to ensure all required information is included and accurate. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.181(f)The program specialist did not provide the assessment dated 11/3/15 for Individual #1 to plan team members. [Repeated Violation-10/23/15](f) The program specialist shall provide the assessment to the SC, 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). Program specialist will provide the assessment to all planned team members. Program specialist will review monthly to ensure all assessments has been submitted to all planned team members. [On 12/15/16, the program specialist provided Individual #1's assessment to the plan team members that were missed. Immediately and at least annually thereafter, the CEO shall review the job responsibilities of the program specialist position with the program specialist(s) as per 6400.44b(1)-(19). Documentation of the training shall be kept. The CEO shall develop and implement a tracking system to ensure all individuals' assessments are provided to all plan team members, timely. Prior to providing the assessments to all plan team members, the program specialist shall review each individual's record including the invitation letter, the current ISP and other documentation to ensure all plan team members are provided the assessment as required and documentation of correspondence shall be kept. At least quarterly for 1 year, the CEO shall review the tracking system and the correspondence documentation for all assessments provided to plan team members to ensure all plan team members were provided the assessments, timely. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.186(d)The program specialist did not provide the ISP review documentation for Individual #1, completed on 12/15/15, 6/15/16 and 9/15/16 to plan team members. [Repeated Violation-10/23/15]The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Program specialist will provide documentation of the isp review to all planned team members. Program specialist will review Individuals files monthly to ensure that the isp review has been submitted to all team members.[On 12/15/16, the program specialist provided Individual #1's ISP reviews to the plan team members that were missed. Immediately and at least annually thereafter, the CEO shall review the job responsibilities of the program specialist position with the program specialist(s) as per 6400.44b(1)-(19). Documentation of the training shall be kept. The CEO shall develop and implement a tracking system to ensure all individuals' ISP reviews are completed and are provided to all plan team members, timely. Prior to providing the ISP reviews to all plan team members as required, the program specialist shall review each individual's record including the invitation letter, the current ISP, signed declinations and other documentation to ensure all plan team members are provided the assessment as required and documentation of correspondence shall be kept. At least quarterly for 1 year, the CEO shall review the tracking system and the correspondence documentation for all ISP review provided to plan team members to ensure all plan team members were provided the ISP documentation, timely. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.186(e)The program specialist did not notify the plan team members for Individual #1 of 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. Program Specialist will notify all planned team members they have the option to decline the isp review and a signature page will be put in their file. Program will review monthly to ensure that the option to decline has been submitted to all planned team members. [On 12/15/16, the program specialist notified Individual #1's plan team members that were missed of the option to decline. Immediately and at least annually thereafter, the CEO shall review the job responsibilities of the program specialist position with the program specialist(s) as per 6400.44b(1)-(19). Documentation of the training shall be kept. Immediately, the program specialist shall review all individuals' records to ensure all plan team members have been notified of the option to decline as required and documentation is kept. At least quarterly for 1 year, the CEO shall review the tracking system and the correspondence documentation for all assessments provided to plan team members to ensure all plan team members were provided the ISP documentation, timely. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
SIN-00086310 Renewal 10/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Telephone numbers for the fire department was not on or by any of the telephones in the home. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The program specialist has added the fire departments number to the emergency list which are posted by each phone in the home. Lead staff will check daily to make sure the numbers are still posted. The program specialist will check monthly o make sure the numbers are still listed by the phones.[At least monthly physical site checks will be done by the Program Specialist to include required telephone numbers. Physical site checks will be documented and reviewed by the CEO. (AS 1/19/16)] 01/10/2016 Implemented
6400.77(b)The first aid kit did not contain scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Lead staff will check the first aid kit weekly to make sure that everything is in there that is required. The program specialist will check the kit monthly to make sure everything is in there that is required. The program specialist has also attached a list of items that are required to be in the kit to the lid of the kit.[At least monthly physical site checks will be done by the Program Specialist to include first aid kits. Physical site checks will be documented and reviewed by the CEO. (AS 1/19/16)] 01/10/2016 Implemented
6400.112(a)A fire drill was not held in September 2015. An unannounced fire drill shall be held at least once a month. The program specialist will make sure that all fire drills are being done. The program specialist will check the fire log book Bi-weekly to make sure workers are doing the drills correctly. Monthly the program specialist and CEO will review the drills and make sure everything has been done on time and correctly.[CEO will maintain documentation of the aforementioned fire drill reviews. (AS 1/19/16)] 01/10/2016 Implemented
6400.141(c)(3)Physical examination, dated 11/14/2014, for Individual #1, date of admission 12/15/2014, did not include an immunization record for tetanus or diphtheria.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. It is believed that during inspection that the MA-51 form was being looked at, the individuals physical form which has been faxed includes the immunization record. The program specialist will review physical forms upon getting them to make sure that everything has been filled out correctly. Quarterly the program specialist and CEO will review all forms to make sure everything has been done correctly.[CEO will maintain a record of the aforementioned reviews. (AS 1/19/16)] 01/10/2016 Implemented
6400.141(c)(4)Physical examination, dated 11/14/2014, for Individual #1, date of admission 12/15/2014, did not include a vision or hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. It is believed that during inspection that the MA-51 form was being seen, the individuals physical form has been faxed which includes vision and hearing. The program specialist will review physical forms upon getting them to review and make sure that everything is done correctly. [At least quarterly and prior to an new admissions, CEO will review all current and new physical examination documentation to ensure all required information is present and address as needed. (AS 1/19/16)] 01/10/2016 Implemented
6400.141(c)(6)Physical examination, dated 11/14/2014, for Individual #1, date of admission 12/15/2014, did not include a Tuberculin skin test.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. It is believed tat the MA-51 was being seen during inspection, the individuals physical for which has been faxed includes TB testing. The program specialist will review physical form upon receiving them to make sure that TB testing is included every 2 years for the individuals. Physical forms will quarterly be reviewed by the program specialist and CEO.[Documentation of the aforementioned reviews will be maintained. (AS 1/19/16)] 01/10/2016 Implemented
6400.141(c)(10)Physical examination, dated 11/14/2014, for Individual #1, date of admission 12/15/2014, did not include information pertaining to Individual #1 being free from communicable diseases.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. It is believed that during inspection that the MA-51 was being seen. The individuals physical form which includes communicable disease has been faxed. The program specialist will review physical forms upon receiving them to make sure all areas are correctly filled out. Quarterly the program specialist and CEO will review all forms to make sure everything has been filled out correctly[Documentation of the aforementioned reviews will be kept by the CEO. (AS 1/19/16)] 01/10/2016 Implemented
6400.164(b)Guanfacine 1mg prescribed to Individual #1 was not logged as administered on the medication administration record at 8:00PM on 10/1/2015 and 10/2/2015. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The staff worker did not see the MAR with the medication on it so she made a new MAR adding that medication to it. Lead staff will check the MAR daily to make sure all medications are given and documented. The program specialist will review the MAR and medications Bi-weekly to make sure everything is being signed.[If during reviews of the MARs by the PS documentation errors are noted, additional training will be provided to staff who administer medications. At least quarterly, CEO will review documentation of reviews by the PS to ensure reviews are being completed and are accurate. (AS 1/19/16)] 01/10/2016 Implemented
6400.181(e)(10)Individual #1's assessment, dated 1/1/2015, did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The program specialist has attached a lifetime medical history addendum to the assessment. The program specialist will update the addendum as needed annually. The program specialist and CEO will review the assessment quarterly to make sure the addendum is attached and updated. 01/10/2016 Implemented
6400.181(f)Individual #1's assessment, dated 1/1/2015, was not sent to the plan team members.(f) The program specialist shall provide the assessment to the SC, 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 specialist will send the send the individual's assessment 30 prior to the ISP meeting. The program specialist will send along a form to the team to sign off on that they did receive the assessment 30 prior. The program specialist and CEO will review all files quarterly to make sure that the assessment was send and received.[PS and CEO will develop a tracking system to keep track of when assessment need to be sent and will review ISP invitation letters, ISPs and other documentation to ensure each individual's entire team receive assessments as required. (AS 1/19/16) 01/10/2016 Implemented
6400.186(b)Individual #1's 3 month ISP reviews, dated 6/15/15 and 9/15/15, were not signed by Individual #1.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. (addition to POC)The program specialist has added the individual's signature to the 3-month isp form for the individual to sign. The program specialist and individual will review the 3-month isp review and both will sign off on it. The program specialist and CEO will review quarterly to make sure that both signatures are signed. (original POC)The Program specialist has added the Individual's signature to the 3 month ISP review. In the future I will have the Individual and the Program Specialist sign off on the 3 month review. A copy of the form will be faxed to you. 11/27/2015 Implemented
6400.186(d)Individual #1's 3 month ISP reviews, dated 6/15/15 and 9/15/15, were not sent to plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. (addition to POC) The program specialist made a form for the team members to sign off on if they would like a copy of the individual' 3 month review. The form after being signed will be placed in the individual's file. The program specialist and EO will review quarterly to ma sure that all 3 month reviews that were requested were sent to the team members. (original POC) In the future The Program specialist will send the 3 month ISP review to the plan team members and have them sign off that they received it or they are wishing to decline it. 11/27/2015 Implemented
6400.186(e)The program specialist did not notify the plan team members of the option to decline ISP review documentation for Individual #1. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. (additions to POC)The program specialist has made a form with the option to decline to send to the team members , if the team members chooses to decline, the form with their signatures will be placed in the individual's file. The program specialist and CEO will review quarterly to make sure all documents have been sent and signed. (original POC) The Program Specialist has drawn up a form for the plan team members to sign whether they would like to decline the SP review. I will also fax you the form. 11/27/2015 Implemented
SIN-00182298 Renewal 01/26/2021 Compliant - Finalized
SIN-00163233 Renewal 09/25/2019 Compliant - Finalized