Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235473 Renewal 12/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)Staff #4's TB test was placed on 8/8/23. It was read on 8/11/23 by a certified medical assistant.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.Staff #2 reached out to Staff #4's doctor on 12-18-2023 as Staff #4 stated the doctor was there for the TB test results. Staff #2 faxed the physical to check that there was a 2380 regulation approved medical professional there to help oversee the TB test and if so, to sign the physical since they were present as well. The doctor's office faxed back Staff #4's updated physical on 12-19-2023 with the 2380 approved medical professional that oversaw Staff #4's TB test results (Attachment 04). 12/19/2023 Implemented
2380.181(e)(7)Individual #1's assessment dated 9/5/23 does not address their knowledge of the danger of heat sources or ability to sense heat and move quickly away.The assessment must include the following information: The individual¿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.Individual #1's recognizing heat sources section of the assessment was updated 12-19-2023 (Attachment 01), and it was reviewed, signed, and sent to the team on 12-19-2023 (Attachment 02). Track changes were also sent to the Supports Coordinator on 12-19-2023 to update their knowledge of heat sources in the safety section of the ISP. 12/19/2023 Implemented
SIN-00219700 Renewal 02/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff #2 's date of hire was 8/20/21, the physical exam was not completed until 8/21/21.This was completed after the date of hire.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 current Mount Union employees have been checked and confirmed that their physical and TB read dates are in compliance with these regulations. A new staff was hired and did orientation on 02/22/2023. Their physical was completed on 02/20/2023 and their TB test was read on 02/22/2023 before orientation. (Attachment #1) 02/22/2023 Implemented
2380.113(c)(2)Staff person #2's date of hire was 8/20/21. The TB was not read until 8/21/21. This was completed after the date of hire.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 current Mount Union employees have been checked and confirmed that their physical and TB read dates are in compliance with these regulations. A new staff was hired and did orientation on 02/22/2023. Their physical was completed on 02/20/2023 and their TB test was read on 02/22/2023 before orientation. (Attachment #1) 02/22/2023 Implemented
SIN-00200798 Renewal 03/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.61At the time of the 3/2/22 inspection, there was no telephone easily accessible to staff persons or individuals.The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.A noncoin-operated telephone has been added to the main space of the facility, so individuals and staff persons have access to it. Emergency numbers have been posted on the telephone as well. Please see attachments 1-4. 03/21/2022 Implemented
2380.62At the time of the 3/2/22 inspection, there were no emergency numbers posted.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.A noncoin-operated telephone has been added to the main space of the facility, so individuals and staff persons have access to it. Emergency numbers have been posted on the telephone as well. Please see attachment 2 and 4 for the phone numbers listed on the back of the phone. 03/21/2022 Implemented
2380.70(a)At the time of the 3/2/22 inspection, there was no partition or privacy screen separating the first aid area from program areas.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.Partitions were purchased on 3/9/22 and will be installed as soon as it arrives. Please see attachment 5 for receipt for partition items. 03/21/2022 Implemented
2380.111(c)(4)Individual #1 did not have a vision or hearing exam at their 9/21/21 annual physical examination. The physical examination form stated, "could not check" and "could not be tested."The physical examination shall include: Vision and hearing screening, as recommended by the physician.The program specialist reached out to individual #1's PCP a few times to get a note stating what happened during the visit whether the Individual refused and was educated on it or if the doctor had to defer the vision and hearing tests and why. They are waiting to get a note from the doctor as the doctor has been out of office, but in the meantime sent a note on 3/21/22 that they have document the need for a note and that the program specialist has reached out to the PCP. Please see attachment 6. 03/21/2022 Implemented
2380.177Individual #2's release of information is not signed by their legal guardian.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.The release of information form was signed by individual #2's legal guardian and individual #2 on 3/9/22. Please see attachment 7 and 8 for individual rights and release of information signed by the individual and their legal guardian. 03/21/2022 Implemented
2380.129(a)Staff person #1's medication administration training recertification that was due 9/23/21 was not completed correctly. Staff person #1 has been administering medications without properly completing course renewal requirements.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Staff person #1 stopped giving medications and will be retrained by completing the Medication Administration Train the Trainer course. Please see attachment 9 displaying the my ODP screen where staff person #1 signed up for the Med Admin Train the Trainer course and it is awaiting payment. 03/21/2022 Implemented
SIN-00184379 Renewal 03/09/2021 Compliant - Finalized
SIN-00169456 Initial review 02/05/2020 Compliant - Finalized