Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230723 Renewal 09/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)Individual #1's physical examination, completed 3/11/2023, does not address physical limitations.The physical examination shall include: Physical limitations of the individual.We have obtained additional documentation from the physician to address the physical limitations of the individual. We have also reviewed all physicals for any blanks and missing information for the other individuals at the day program. 10/13/2023 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 3/11/2023, does not address medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.We have obtained documentation from the physician for the individual to include any information that might be pertinent to diagnosis and treatment in the event of an emergency. 10/13/2023 Implemented
2380.126(a)(13)Program Manager #1 administered Individual #2's prescribed medication at 12:00PM on 9/1/2023. Individual #2's September 2023 medication record did not include Program Manager #1's name.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The Program Manager is in the process of being re-trained in the full medication administration course. The Program Manager completed the on-line portion thus far and will be doing the remaining in person portion of the trainings next week. She will also review medication records for each individual monthly for regulatory compliance. 10/31/2023 Implemented
SIN-00212045 Renewal 09/30/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1's assessment was completed on 2/18/21 then again 4/11/22.Each individual 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.Program Specialist to develop spreadsheet for each individual's functional assessment that indicates the due date of two months prior to annual ISP meeting. 10/14/2022 Implemented
2380.181(f)The program specialist provided Individual #1's assessment, completed 4/11/22, to Individual #1's plan team members on 4/11/22 for the annual individual plan meeting on 6/16/22. The program specialist provided Individual #2's assessment, completed 5/18/22, to Individual #2's plan team members on 5/18/22 for the annual individual plan meeting on 6/13/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program Specialist to develop spreadsheet for each individual's functional assessment that indicates the due date of two months prior to annual ISP meeting. 10/14/2022 Implemented
SIN-00179094 Renewal 10/30/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1, date of admission 6/1/1993, had a tuberculin evaluation via Mantoux method read on 2/14/2019; however, this reading was completed by a Medical Assistant.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.The individual physical evaluation form has been modified to include TB test must be administered and read by an LPN, RN, PA or Physician only. [Upon submission, the CEO or designee educated in the requirements of individual physical examinations shall audit individuals' physical examination documentation to ensure completion with required information including that qualified medical professionals have completed the Tuberculin skin testing. (DPOC by AES,HSLS on 12/3/20)] 11/03/2020 Implemented
2380.113(c)(2)Program Specialist #1, date of hire 8/11/2003, had a tuberculin evaluation via Mantoux method read on 3/20/2019; however, this reading was completed by a 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.The Staff Physical form will be revised to include that the TB test must be administered and read by either a LPN, RN, Physician's assistant or Physician.[Upon submission, the CEO or designee educated in the requirements of the staff persons physical examinations shall audit staff persons' physical examination documentation to ensure completion with require information including that qualified medical professionals have completed the Tuberculin skin testing. (DPOC by AES,HSLS on 12/3/20)] 11/30/2020 Implemented
SIN-00156953 Renewal 06/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #2 had Tuberculin skin testing with negative results completed 5/11/16 then again 11/15/18.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.Director of Quality Improvement will create shared calendar for ATF supervisor, program director, and program specialist on Outlook. The shared calendar will list all scheduled annual physical appointments and TB appointments as well as reminders to schedule appointments at 90 and 30 days prior to the due date. Director of Quality Improvement will provide staff training on the use of the calendar. The process will be reviewed in 3 and 6 months with staff to see if any changes are necessary. [On 7/3/19, the Compliance Officer & Director of Quality Improvement contacted the Department and upon review of the aforementioned tracking process to ensure timely completion of tuberculin skin testing and other required information has developed and implemented a tracking system using an excel spreadsheet in place of the outlook calendar as stated above. The excel spreadsheet will be shared among the director, supervisor, and program specialist and quarterly reviews will be completed by the director or designee to ensure compliance.(AES,HSLS on 7/11/19)] 07/01/2019 Implemented
2380.181(f)The program specialist provided Individual #1's assessment completed 3/19/19 to the plan team members on 3/27/19 for an annual ISP meeting on 4/3/19.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 Assessment Policy was reviewed by management and is in compliance as per regulations. The Assessment Policy will be reviewed with the Program Specialist and Supervisor and staff will sign acknowledgement forms stating they understand the timeframe for distributing the assessment to the other team members. [At least quarterly for 1 year, the CEO or designee shall audit the correspondence documentation to ensure the program specialist provided all individuals' current assessments to all plan team members, timely. (DPOC of AES,HSLS on 6/27/19)] 07/01/2019 Implemented
SIN-00118279 Renewal 07/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Direct Service Worker #1 had fire safety training 11/17/15 and then again 3/22/17.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).[Immediately, a designated management staff person shall develop and implement a tracking system to ensure all staff persons are trained annually in fire safety as required. At least quarterly for 1 year, a designated management staff person shall review the tracking system to ensure timely completion of fire safety training for all staff persons. Documentation of reviews shall be kept.(AS 8/8/17)] 08/06/2017 Implemented
2380.89(c)The fire drill record for the fire drill held on 4/27/17 did not indicate the exit route used. 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.[Upon completions of all fire drills, a designated management staff person shall review the fire drill records to ensure a written record of the fire drill has all required information including the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. Documentation of the reviews of fire drills shall be kept. (AS 8/8/17)] 08/06/2017 Implemented
2380.186(a)The program specialist completed the ISP review for the period of 8/15/16 to 11/14/16 on 1/9/17 for Individual #1. The program specialist completed the ISP review for the period of 6/30/16 to 9/29/16 on 11/13/16 and the ISP review for the period of 9/30/16 to 12/29/16 on 1/26/17 for Individual #2. The program specialist completed the ISP review for the period of 6/24/16 to 9/23/16 on 10/26/16 for Individual #3.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.An ISP three month review policy was created and is posted below. The policy creates a new system of accountability for ISP reviews and all staff will be trained on the new policy on 8/9/2017. ¿Individual Documentation Timelines¿ will be completed by Program Specialists by August 31, 2017 for all currently consumers. The program manager will monitor 10% of all 3 month reviews monthly. It is the policy of TCV Community Services to provide all services as defined by the ISP in compliance with state, county, and federal regulations. Therefore, 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. PROCEDURE Each program specialist is to document the ISP review date for all assigned individuals. The program specialist will notify the program manager via email of all ISP meetings. Based on the ISP review date the program specialist will determine monthly and three month review dates and document all due dates on the ¿individual documentation due¿ form. (PHI/IDD/IDDPolicy & Procedures / forms) This form is to be completed and submitted to the program manager by August 31, 2017. The form is to be updated at each annual ISP meeting and submitted to the program manager within 5 days of the meeting. The three month review is to include the following information: (1) A review of the monthly documentation (2) A review of each section of the ISP specific to the residential home. (3) The program specialist shall document a change in the individual¿s needs, if applicable. (4) The program specialist shall make a recommendation regarding the following, if applicable: (i) The deletion of an outcome or service¿ (ii) The addition of an outcome or service... (iii) The modification of an outcome or service¿ (5) If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment . (d) 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. (e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. (f) If a recommendation for a revision to a service or outcome in the ISP is made, the plan lead as applicable shall send an invitation for an ISP revision meeting to the plan team members within 30 calendar days of receipt of the recommendation. (g) A revised service or outcome in the ISP shall be implemented by the start date in the ISP as written. At the end of each month the program specialist will review all documentation to ensure it has been completed, signed, dated, sent to all appropriate team members, and filed appropriately. The program specialist will complete a monthly checklist and submit it to the program manager by the fifth of each month confirming completion of the all applicable quarterly ISP reviews. The program manager will review all monthly checklists and review 10% of all three month reviews to ensure they are completed in the ECR and also signed, dated, distributed and filed appropriately. The program specialists will complete a quarterly peer review process as outlined in the peer review policy. Any late or incomplete documentation will be corrected by the assigned program specialist at the time the error is identified. Failure to comply with this policy will result in personnel corrective action. [Documentation of the reviews of checklists and ISP reviews by program manager shall be kept. (AS 8/8/17)] 08/06/2017 Implemented
2380.186(d)The program specialist provided the ISP review dated 10/26/16 for Individual #3 to the plan team members on 1/5/17. The program specialist provided the ISP review dated 1/3/17 for Individual #3 to the plan team members on 2/6/17. 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.An ISP three month review policy was created and is posted below. The policy creates a new system of accountability for ISP reviews and all staff will be trained on the new policy on 8/9/2017. ¿Individual Documentation Timelines¿ will be completed by Program Specialists by August 31, 2017 for all currently consumers. The program manager will monitor 10% of all 3 month reviews monthly. It is the policy of TCV Community Services to provide all services as defined by the ISP in compliance with state, county, and federal regulations. Therefore, 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. PROCEDURE Each program specialist is to document the ISP review date for all assigned individuals. The program specialist will notify the program manager via email of all ISP meetings. Based on the ISP review date the program specialist will determine monthly and three month review dates and document all due dates on the ¿individual documentation due¿ form. (PHI/IDD/IDDPolicy & Procedures / forms) This form is to be completed and submitted to the program manager by August 31, 2017. The form is to be updated at each annual ISP meeting and submitted to the program manager within 5 days of the meeting. The three month review is to include the following information: (1) A review of the monthly documentation (2) A review of each section of the ISP specific to the residential home. (3) The program specialist shall document a change in the individual¿s needs, if applicable. (4) The program specialist shall make a recommendation regarding the following, if applicable: (i) The deletion of an outcome or service¿ (ii) The addition of an outcome or service... (iii) The modification of an outcome or service¿ (5) If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment . (d) 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. (e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. (f) If a recommendation for a revision to a service or outcome in the ISP is made, the plan lead as applicable shall send an invitation for an ISP revision meeting to the plan team members within 30 calendar days of receipt of the recommendation. (g) A revised service or outcome in the ISP shall be implemented by the start date in the ISP as written. At the end of each month the program specialist will review all documentation to ensure it has been completed, signed, dated, sent to all appropriate team members, and filed appropriately. The program specialist will complete a monthly checklist and submit it to the program manager by the fifth of each month confirming completion of the all applicable quarterly ISP reviews. The program manager will review all monthly checklists and review 10% of all three month reviews to ensure they are completed in the ECR and also signed, dated, distributed and filed appropriately. The program specialists will complete a quarterly peer review process as outlined in the peer review policy. Any late or incomplete documentation will be corrected by the assigned program specialist at the time the error is identified. Failure to comply with this policy will result in personnel corrective action. [Documentation of the audits of checklists, ISP reviews and correspondence documentation by program manager shall be kept. (AS 8/8/17)] 08/06/2017 Implemented
SIN-00098818 Renewal 07/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #3's most recent vision screening was completed on 11/10/14 and there was no record of a hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.A policy was developed to ensure thorough review of annual physicals as they are obtained. Site supervisors and program specialists were trained on the new policy on 8/12/2016. The policy includes a list of all regulatory requirements for the annual physical and identifies the program specialist as the person who is responsible to ensure all information is included on the document. If there is missing information or if the information is not consistent with the ISP the program specialist is to contact the team members (including the physician) to ensure accurate information is on the physical and in the ISP and TCV Service plan. We are still in the process of reviewing all physicals to ensure proper information is included and we will request additional information and documentation as necessary. [Individual #1 had a hearing and vision screenings are scheduled for 9/8/16. At least quarterly, the Director of IDD Services shall review a 25% sample of individual physical examinations to ensure aforementioned policy is being followed and all required information including vision and hearing screenings are completed within the required timeframes. Documentation of all reviews shall be kept.(AS 9/7/16)] 08/22/2016 Implemented
2380.111(c)(5)Individual #3's most recent Tuberculin skin tests were completed on 11/15/12 and 12/12/14.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 policy was developed to ensure thorough review of annual physicals as they are obtained. Site supervisors and program specialists were trained on the new policy on 8/12/2016. The policy includes a list of all regulatory requirements for the annual physical and identifies the program specialist as the person who is responsible to ensure all information is included on the document. If there is missing information or if the information is not consistent with the ISP the program specialist is to contact the team members (including the physician) to ensure accurate information is on the physical and in the ISP and TCV Service plan. We are in the process of reviewing all physicals to ensure proper information is included and we will request additional information and documentation as necessary. Also, the TB due date is included in the workflow spreadsheet which all TCV program specialists, supervisors, and the IDD administrative assistant have been trained to use. A standard operating procedure on the workflow spreadsheet has been developed and will be emailed to Jared Roser. The spreadsheet includes a reminder for program specialists to make sure all individuals get their TB testing every two years. [At least quarterly, the Director of IDD Services shall review the aforementioned spread sheet and a 25% sample of individuals' physical examination to ensure all required information is completed and completed within the required timeframes. (AS 9/6/16)] 08/22/2016 Implemented
2380.113(a)Direct Service Worker #1, date of hire 6/15/15, had a physical completed on 6/26/15.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.A policy has been developed for hiring in the IDD department. The policy states : ¿ If the candidate accepts the offer of employment the supervisor must direct them to have their physical and TB form completed and to apply for their child abuse and FBI clearances. ¿ The supervisor will schedule the candidate for orientation only after the physical and TB are turned in and the candidate shows proof of applying for the child abuse and FBI clearances. In addition, an area to document date of hire and physical / TB date has been added to the orientation checklist which is reviewed the first day a candidate is onsite. If it is discovered that the individual has not obtained their physical or TB they will not be able to work at the sites until the documentation is obtained.[The Director of IDD Services will review the next 5 newly hired staff persons to ensure aforementioned policies and procedures are being followed and that all staff person have physical examinations within the required time frames. Documentation of reviews shall be kept. (AS 9/6/16)] 08/22/2016 Implemented
2380.113(c)(2)Direct Service Worker #1, date of hire 6/15/15, had Tuberculin skin testing results dated 7/11/15.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. 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.A policy has been developed for hiring in the IDD department. The policy states : ¿ If the candidate accepts the offer of employment the supervisor must direct them to have their physical and TB form completed and to apply for their child abuse and FBI clearances. ¿ The supervisor will schedule the candidate for orientation only after the physical and TB are turned in and the candidate shows proof of applying for the child abuse and FBI clearances. In addition, an area to document date of hire and physical / TB date has been added to the orientation checklist which is reviewed the first day a candidate is onsite. If it is discovered that the individual has not obtained their physical or TB they will not be able to work at the sites until the documentation is obtained.[The Director of IDD Services will review the next 5 newly hired staff persons to ensure aforementioned policies and procedures are being followed and that all staff person have physical examinations to include all required information including TB testing within the required time frames. Documentation of reviews shall be kept. (AS 9/6/16)] 08/22/2016 Implemented
2380.186(d)The program specialist did not provide Individual #1's ISP review documentation, dated 1/28/16 and 7/27/15 to the entire plan team including the Supports Coordinator. The program specialist did not provide Individual #2's ISP review documentation, dated 11/6/15, to the entire plan team including the Supports Coordinator.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.A workflow / due date spreadsheet has been developed and all TCV program specialists, supervisors, and the IDD administrative assistant have been trained to use the workflow spreadsheet to ensure documentation is completed and disseminated in a timely manner and that due dates are not missed. A standard operating procedure on the workflow spreadsheet has been developed and will be emailed to Jared Roser. The spreadsheet includes a reminder for program specialists to provide copies of ISP review documentation to all team members not declining the documentation. [Individual #1's ISP review documentation was provided to the plan team members including the SC on 9/7/16. Within 30 days of receipt of the plan of correction, the Director of IDD Services shall train Program Specialist(s) on job responsibilities as per 2380.33(b)(1)-19)and 2380.186.d. Documentation of the training shall be kept. Prior to providing ISP review documentation the program specialist shall review individuals' ISP, invitation letter and other documentation to ensure all individual plan team members are included when providing individuals' assessment to all plan team members as required. At least quarterly, the Director of IDD Services will review aforementioned spreadsheet and a 25% sample of correspondence showing that the program specialist(s) provided ISP review documentation to the entire team as required within the required timeframes. Documentation of all reviews shall be kept. (9/7/16)] 08/22/2016 Implemented
SIN-00083263 Renewal 07/14/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Direct Service Worker #1, date of hire 9/2/11 and Direct Service Worker #2, date of hire 11/9/09 did not have annual fire safety training in 2013; the most recent annual fire safety training was completed on 12/11/14. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Staff fire safety training has been added to the monthly individual and staff chart audit checklist for program specialists. Program specialists will now audit 10% of their individual and staff charts each month to ensure all requirements are being met. This information will be reviewed quarterly by the program director to ensure compliance. [Documentation of audits and reviews shall be kept and reviewed by the CEO at least twice a year to ensure completion and required trainings including fire safety are completed within the required time frames. (AS 3/4/16)] 09/21/2015 Implemented
2380.89(e)The fire drills held between 7/17/14 and 5/29/15 used the "Maple Street" and "18th Ave" exit routes during each monthly fire drill.Alternate exit routes shall be used during fire drills.This program has used two exits for all fire drills due to having only one accessible egress for the individual who utilizes a wheelchair. We have just received verification of the fire rating for the doorway into the stairwell to create a safe area to park a wheelchair in case the accessible exit is blocked by fire and we will move forward with utilizing one exit or the other for future fire drills. Copies of evacuations will be forwarded if requested. This program will be requesting a waiver to the requirement to have 2 accessible exits to the exterior.[A letter dated 2/8/16 from local Building Code Official/Zoning officer designated the doors enclosing the stairwell as having a 45 minute fire rating. The Department determined on 3/15/16 that a waiver is not needed due the facility providing an accessible exit and a fire safe area for individuals who are unable to access the exit, then one of the two accessible exits may be to a fire safe area. Executive Director or Director of IDD Services will review the fire drill documentation to ensure alternate exits are used during monthly fire drills (AS 3/16/16)] 09/21/2015 Implemented
2380.181(f)The assessements for Individual #1, dated 12/9/14, Individual #2, dated 3/16/15, and Individual #3, dated 3/2/15, were not sent to the entire team.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).On August 3, 2015 all program specialists were provided with a consistent day program chart order and trained to provide the assessment to all team members. As a reminder to the program specialists, this information is included on the cover page for Section 2 that is to be in every chart. [Program specialist will immmediately review all individual records and send assessments to each individuals' entire team as required. (AS 11/5/15)] 09/21/2015 Implemented
2380.186(e)The record for Individual # 1, admission date 10/1/14, did not have notices that the team members may decline the ISP review documentation.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The individual¿s annual ISP meeting was held before her admission and TCV was not included in the meeting. This has been added to the newly developed ¿REFERRAL INFORMATION FORM¿ with reminders to get the declinations either before service or within 90 days of starting the service. [Program Specialists will immediately review all individuals' records and send notices to decline and maintain documentation if not previously done as required. (AS 11/5/15)] 09/21/2015 Implemented
SIN-00060097 Renewal 07/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)An unannounced fire drill was not held in January, 2014. An unannounced fire drill shall be held at least once a month.The IDD Day Program Manager has implemented a new process effective 7/25/14 to ensure that monthly fire drills are completed as required. A monthly fire drill verification form (attachment #1) will be utilized by the Program Supervisor and the IDD Day Program Manager. The Program Supervisor will preschedule all monthly fire drills for the entire calendar year. Both the Program Supervisor and IDD Manager will validate the completion of the scheduled monthly fire drills by initially the form. A staff training form (Attachment #2) validates that the Program Supervisor and IDD Manager reviewed this process. 07/25/2014 Implemented
2380.111(c)(4)Individual #1's most recent vision screening was completed on 3/5/2013. The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #1 -most recent vision screening was completed (Attachment #3). [The CEO/Program Specialists will audit all currentl individual physical examinations to ensure that all required components were completed and documented by 8/25/14. (CHG 7/25/14.)] 07/25/2014 Implemented
2380.111(c)(5)The results of Individual #1's Tuberculin skin test from 1/16/2013 are not documented.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.Individual #1 -TB skin testing is completed (Attachment #4) [The CEO/Program Slist will audit all individual records to ensure the results of the Tuberculin skills testing are noted and occured within the past two years by 8/25/14. (CHG 7/25/14)] 07/25/2014 Implemented
2380.113(a)Staff Person #1's most recent physical examination was completed on 7/8/2014; the prior physical examination was on 4/27/2012. Staff Person #2, date of hire, 7/15/2013 had his/her physical examination completed on 8/15/2013. 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.* A staff medical Examination Form (Attachment #5) was developed by the IDD Manager that details all of the program staff's medical examination and TB skin tests due dates. * A new process has been developed by the IDD Manager and implemented on 7/25/14. This process ensures that all staff are notified of their bi-annual medical and TB skin test dates. * The IDD Administrative Assistant will notify staff staff when their exams are due by sending them a Staff Medical Examination Notification (Attachment #6) two months in advance of the due dates. * A staff training was conducted with Program Supervisor, the Administrative Assistant and the IDD Day Program Manager (Attachment #7). 07/25/2014 Implemented
2380.113(c)(2)Staff Person #1's most recent Tuberculin skin tests were 7/10/2014 and 4/30/12. The results of Staff Person #2's Tuberculin skin test completed on 10/2/2013 are not documented. 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 Administrative Assistant will ensure that all staff is given a two month notice to when their TB tests/results are due. * That same notification process will be utilized as found in Reg. 113 (a) (Attachments #5 and #6)* Staff person #2's TB skin test results are attached (Attachment #8) 07/25/2014 Implemented
2380.113(c)(3)Staff Person #3's physical examination completed 11/8/13 does not include a signed statement that the staff is free of communicable diseases or that the staff has a serious communicable disease but is able to work in the faciity if specific precautions are taken that will prevent spread of disease to individuals. The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.* The Administrative Assistant will forward a Staff Physical Form (Attachment #9) to all applicable staff when bi-annual physical exams and TB tests are due. * This form specifically details if the staff is free of communicable diseases * Staff #3 physical is completed (Attachment #10) which states she is free from serious communicable diseases. 07/25/2014 Implemented
2380.186(b)Individual #2's three month reviews completed on 11/2/2013, 2/2/2014 and 5/2/2014 are not signed by the individual and the program specialist. Individual #3's three-month reviews completed on 8/18/2013 and 11/18/2013 are not signed by the individual and the program specialist. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #2 -3 month reviews have been signed by the Program Specialist and the individual for period 11/2/2013 - 2/2/2014 (Attachment #11, #12, #13) * Individual #3 - 3 month reviews have been signed by the Program Specialist and Individual for period 8/18/13 and 11/18/2013 (Attachment #14, #15) * The applicable staff has been retrained in their responsibilities and duties as a Program Specialist (Attachment #16) 07/25/2014 Implemented
SIN-00195533 Renewal 11/04/2021 Compliant - Finalized
SIN-00137120 Renewal 06/25/2018 Compliant - Finalized
SIN-00047640 Renewal 03/22/2013 Compliant - Finalized