Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256650 Renewal 12/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill records do not indicate which exit routes were used during the 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.Correction Plan: ¿ Vocational Director will make appropriate corrections to fire drill documentation forms to include which exit routes were used. ¿ Vocational Director will ensure staff who are responsible for conducting fire drills are trained on updated fire drill documentation, to include exit routes taken. ¿ Staff Assigned to Conduct Fire Drills will conduct and document fire drills accurately, ensuring exit routes are recorded. ¿ Timeline: Fire Drill Documentation forms were updated and implemented on 1/29/2025. All Fire Drill Documentation forms now include the date, time, the amount of time it took for evacuation, the exit route used, if any problems were encountered and whether the fire alarm was operative. Additionally, All Staff Assigned to Conduct Fire Drills were trained on the new documentation form on 1/29/2025. 01/30/2025 Implemented
2380.89(g)The fire drill records do not indicate whether the individuals met at the designated meeting place during each drill or the location of the designated meeting place.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Correction Plan: ¿ Vocational Director will make appropriate corrections to fire drill documentation forms to include whether or not the individuals met at the designated meeting place during each drill and the locations of the designated meeting places. ¿ Vocational Director will ensure staff who are responsible for conducting fire drills are trained on updated fire drill documentation, to include whether or not the individuals met at the designated meeting place during each drill . ¿ Staff Assigned to Conduct Fire Drills will conduct and document fire drills accurately, ensuring if the designated meeting places were utilized or not. ¿ Timeline: Fire Drill Documentation forms were updated and implemented on 1/29/2025. All Fire Drill Documentation forms now include the date, time, the amount of time it took for evacuation, the exit route used, if the designated meeting places were utilized, if any problems were encountered and whether the fire alarm was operative. Additionally, All Staff Assigned to Conduct Fire Drills were trained on the new documentation form on 1/29/2025. 01/29/2025 Implemented
2380.111(c)(11)Special instructions for individual #1's diet was not completed on the annual physical examination.The physical examination shall include: Special instructions for an individual's diet.Correction Plan: ¿ Vocational Director will oversee corrections to ensure all required dietary instructions are documented in annual physical examinations. ¿ Vocational Director will ensure Program Specialists are trained on reviewing physical examination forms for completeness. ¿ Program Specialists will verify that all physical examinations include dietary instructions before submission. ¿ Timeline: o This plan/policy went into immediate effect on 12/5/2024. 12/04/2024 Implemented
SIN-00163953 Renewal 10/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)In the showering room there was an unlocked cabinet containing various poisons.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The materials in question were removed from the cabinet upon discovery. As of 11/12/2019 the showering room was added to quarterly room checklist (see attachement) that are completed by room leaders During these quarterly checks the room leaders will check the showering room to assure that there are no unlocked poisonous materials in it. 11/12/2019 Implemented
2380.53(c)There was a closet in room 2 which contained both chemicals/poisons and food products.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.A storage container for food was purchased by the program director so that the food and poisonous materials will be kept separate. The room leader moved the food items into the containers. As of 11/12/19 it was added to quarterly room checklist (see attachment) that all food items and poisonous materials are stored separately. These checks are conducted by the room leaders in each room quarterly. 11/12/2019 Implemented
2380.58(b)The rugs throughout the facility were loose and gathering in bunches possibly from being loose. The bunches of rugs are a tripping hazard.Floors, walls, ceilings and other surfaces shall be free of hazards.The program director is in the process of getting estimates from flooring companies to replace the carpet. The agency is required to go through a bidding process for the work to be completed. Once all bids are received the carpeting will be fixed so that it no longer bunches. As of 11/12/19 the hallway floor have been added to the quarterly room checklist (see attachment) which is completed by room leaders each quarter. 11/15/2019 Implemented
2380.111(c)(6)Individual #1's annual physical dated 10/17/18 did not indicate whether or not they were free of communicable disease.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.All other physicals were reviewed and none were found to be missing information. The physical in question was returned to the physician so that they could properly complete the form (see attachement). When the form was returned to the day program the individual was marked as free from communicable disease. Going forward all physicals will go through a three step check for thoroughness. As of 11/11/19 once the physical is received the program specialist will review it and note any missing items, it will then be turned over to the program director who will review it and note any missing items. It will then go back to the program specialist who will do a third and final review and note any missing items. If an item is missing it will be returned to the family/provider so that the error can be fixed. 11/11/2019 Implemented
SIN-00140995 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The men's bathroom door was scrapped up at the bottom edge.Floors, walls, ceilings and other surfaces shall be in good repair.The bathroom door was sanded and stained by the janitorial staff on 8/24/18. Going forward a quarterly (Sept., Dec., March and June) checklist will be completed by room supervisor for the building which asks if all doors are in good repair. The checklist will then be turned into the director. Any issues will be corrected and addressed. 08/24/2018 Implemented
2380.67(a)In room number 3 the sofa was very dirty on the cushions and armrest.Furniture and equipment shall be nonhazardous, clean and sturdy.The sofa in question was steamed cleaned by the janitorial staff on 8/24/18. Going forward all room supervisors will complete a quarterly (Sept., Dec., March and June) room checklist which asks if all the furniture is clean and in good repair. This checklist will be turned into the program director once it is completed and any attention needed to furniture will be addressed. 08/24/2018 Implemented
SIN-00116516 Renewal 06/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)Staff #1 (CEO) did not complete 24 hours of training in the most recent complete training year.The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.The CEO shall turn in his training syllabus to the program director quarterly for review. [Program designee will be responsible to inform staff of training requirements, and monitor and track training completions in order to ensure that all staff complete the required training during the training year. 12/13/17, JG] 08/01/2017 Implemented
2380.53(a)A bottle of isopropyl alcohol was found unlocked in an activity closet and Avant brand hand sanitizer (labeled "call poison control if ingested") were found unlocked in Room 1. A bottle of nail polish remover (labeled "call poison control if ingested") was found unlocked in a file cabinet in Room 2. A bottle of hand sanitizer (labeled "call poison control if ingested") was found unlocked on top of the desk in Room 3. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All poisonous materials will be locked when not in use. Also, the safety inspector shall inspect for unlocked poisonous materials during their monthly safety inspections and report the findings to the program director. [Program designee will provide training to staff regarding safe storage of poisons and 2380 regulations concerning the storage of poisons. Periodic spot checks will be completed by the program designee to ensure ongoing compliance. 10/13/17 JG] 08/01/2017 Implemented
2380.58(a)A cabinet door in the kitchen was missing the handle. The Men's bathroom door was missing two wooden slats.Floors, walls, ceilings and other surfaces shall be in good repair.The cabinet door handle and missing slats will be replaced. Also, going forward the safety inspector will not an missing or broken items on their monthly safety inspection reports and report the findings to the program director. 08/01/2017 Implemented
2380.111(c)(8)The annual physical examination dated 9/08/2016 for Individual #3 did not indicate whether the individual had any physical limitations.The physical examination shall include: Physical limitations of the individual.Once yearly physicals are turned into the program specialist they will review it to assure that all required information is included on the physical. If it is not the program specialist will contact the family/provider and request that the information missing be completed. Once the missing information is completed the physical will be turned into the program director who will review it for accuracy. 08/01/2017 Implemented
2380.111(c)(10)The annual physical examination dated 7/25/2016 for Individual #1 did not include information pertinent to diagnosis and treatment in case of emergency. The annual physical examination dated 11/02/2016 for Individual #2 did not include information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Once yearly physicals are turned into the program specialist they will review it to assure that all required information is included on the physical. If it is not the program specialist will contact the family/provider and request that the information missing be completed. Once the missing information is completed the physical will be turned into the program director who will review it for accuracy. 08/01/2017 Implemented
2380.177Individual #1's record did not contain a signed consent for release of information. Individual #2's record did not contain a signed consent for release of information.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.Consent for release of information shall be signed yearly during the ISP meetings by the individual and or parent and guardian. Once the release is obtained by the program specialist they will turn it into the program director who shall review it. 08/01/2017 Implemented
2380.181(e)(14)Individual #4's annual assessment dated 9/30/2016 did not document the individual's ability to swim. The assessment must include the following information: The individual's knowledge of water safety and ability to swim.Assessments shall include the individuals ability to swim. Once the assessment is completed by the program specialist it will be turned into the program director who will review the assessment to assure that this information is included. 08/01/2017 Implemented
SIN-00091981 Renewal 02/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff# 1's annual fire safety training dated 09/17/2015 was not completed by a fire safety expert. Staff # 2's annual safety training dated 09/23/2015 was completed by a fire safety expert. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).All staff will be trained annually be a fire safety expert. The fire safety expert will have the proper documentation proving their credentials to the program director yearly.(The program director or designee will conduct a record review of all staff which will be completed within 30 days of receipt of this plan in order to identify any other staff out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08/03/2016) 04/11/2016 Implemented
2380.111(a)Individual # 2's previous physical examination was dated 05/28/2014 and most recent physical examination was dated 06/17/2015.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The program specialist will send out a 3 month reminder prior to the date a physical is needed for an individual. A 1 month reminder will be sent by the program specialist to both the home provider and supports coordinator.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 05/13/2016 Implemented
2380.111(c)(3)Individual # 1's most recent diphtheria and tetanus was administered on 01/23/2004. The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The program specialist will review the physical and assure that the immunizations are completed when it is turned into the day program. If it is not complete the program specialist will contact the home provider and request the information that is missing from the physical.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.111(c)(4)Individual # 5's physical examination dated 05/12/2015 indicated further evaluation is recommended for a vision screening and there was no documentation this occurred.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The program specialist will review the physical and assure it is complete. If there are any areas that require follow up the program specialist will contact the home provider and request the additional information.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.111(c)(10)Individual # 2's physical examination dated 06/17/2015 did not document information pertinent to diagnosis and treatment in case of an emergency. Individual # 3's physical examination dated 09/09/2015 did not document information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The program specialist will review the physical and assure that the medical information pertinen to diagnosis is completed when it is turned into the day program. If it is not complete the program specialist will contact the home provider and request the information that is missing from the physical.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.113(b)Staff# 1's physical examination completed on 08/04/2015 was not dated by the physician. Staff # 2's physical examination completed on 12/03/2015 was not dated by physician. Staff # 3's physical examination completed on 09/05/2015 was not dated by physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.The program specialist will review the physical and assure that physician has dated it when it is turned into the day program. If it is not complete the program specialist will contact the home provider and request the information that is missing from the physical.(The program director or designee will conduct a record review of all staff which will be completed within 30 days of receipt of this plan in order to identify any other staff out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08/03/2016) 04/11/2016 Implemented
2380.173(1)(ii)Individual #5's record did not document the individual's identifying marks.(Repeat Violation 11.13.14)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.The program specialist will fill out the personal information sheet including race, height, weight, color of hair, color of eyes and identifying marks. If any of the information is not applicable it will be marked with a N/A. They will then turn the sheet into the program director who will review it for compliance with regulations.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.173(1)(iv)Individual # 4's record did not document the individual's religious affiliation.(Repeat Violation 11.13.14)Each individual¿s record must include the following information: Personal information including: Religious affiliation.The program specialist will fill out the personal information sheet which includes religious information. If it is not applicable it will be marked N/A. The sheet will then be turned into the program director who will review the sheet for compliance with regulations.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.177Individual # 1's record did not contain a written consent for release of information. 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 program specialist shall obtain written consent for release of information from individuals yearly. After obtaining the consents they will share them with the program director.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.181(d)Individual # 2's annual assessment dated 10/30/2015 was not dated when the program specialist signed and completed the assessment. Individual # 5's annual assessment dated 01/12/2015 was not dated when the program specialist signed and completed the assessment. The program specialist shall sign and date the assessment.The annual assessment will be signed and dated by the program specialist. After completion the program specialist will turn the assessment into the program director who will review the document to assure that it complies with all regulations. Also, the assessment format was updated to reflect a completed by and date section at the end of the assessment.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.181(e)(13)(iv)Individual # 2's annual assessment dated 10/30/2015 did not document progress and growth in the area of socialization. Individual # 5's annual assessment dated 01/12/2015 did not document progress and growth in the area of socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The program specialist will document in the annual assessment progress and growth over the last 365 days in the area of socialization. After the annual assessment is completed it will be turned into the program director who will review the document to assure that it complies with all regulations.(All program specialists will be retrained in their job duties and the program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.181(e)(13)(v)Individual # 2's annual assessment dated 10/30/2015 did not document progress and growth in the area of recreation. Individual # 5's annual assessment dated 01/12/2015 did not document progress and growth in the area of recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The program specialist will document progress and growth over the last 365 days in the annual assessment in the area of recreation. After the annual assessment is completed it will be turned into the program director who will assure that the document complies with all regulations.(All program specialists will be retrained in their job duties and the program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.181(e)(13)(vi)Individual # 2's annual assessment dated 10/30/2015 did not document progress and growth in the area of community integration. Individual # 5's annual assessment dated 01/12/2015 did not document progress and growth in the area of community integration. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The program specialist will document in the annual assessment progress and growth over the last 365 days in the area of community intergration. After the annual assessment is completed it will be turned into the program director who will review the document to assure that it complies with all regulations.(All program specialists will be retrained in their job duties and the program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.185(a)Individual # 1's 3 month ISP review documentation dated 10/17/2015-01/31/2015 was not implemented by the ISP start date of 01/23/2015. Individual # 5's 3 month ISP review documentation covering the period of 02/05/2015-5/20/2015 was not implemented by the ISP start date of 05/15/2015. The ISP shall be implemented by the ISP's start date.The program specialist will adjust 3 month ISP review documentation to coincide with the ISP start date.(The program specialists will be retrained in their job duties and a record review of all individuals served will be completed within 30 days of receipt of this plan. Any individual three month ISP reviews documentation found out of compliance with be correct within 15 days. A tracking system will be developed to ensure the three month ISP reviews follow the individual's ISP annual review update date. DS 08/03/2016) 04/11/2016 Implemented
2380.185(b)Individual # 2's 3 month ISP review documentation covering the period of 04/17/2015, 07/14/2015, 10/08/2015 and 01/07/2016 implemented a "range of motion" outcome and a "prevocational job" outcome and did not report on the outcome identified in the ISP dated 04/07/2015 of "engagement in a sensory activity daily".The ISP shall be implemented as written.The room leader will review the outcome section of the ISP upon receipt of the document to assure that the outcome matches what is to be reported on. If it does not the room leader will inform the program specialist who will contact the supports coordinator via letter and request that the ISP be updated to reflect the proper ISP outcomes. (All program specialists will be retrained in their job duties and the program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.186(a)Individual # 2's 3 month ISP review documentation reviewing the period of 04/07/2015-07/14/2015 is greater than 3 months. Individual # 5's 3 month ISP review documentation reviewing the period of 02/05/2015-05/20/2015 is greater than 3 months. 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.The program specialist will complete the 3 month ISP review documentation and then turn it into the program director. The program director will review the documentation to assure that it falls within the 3 month period. Also, the 3 month ISP review documentation format was changed to reflect reporting periods.(The program specialists will be retrained in their job duties and a record review of all individuals served will be completed within 30 days of receipt of this plan. A tracking system will be developed to ensure the three month ISP reviews are completed according to the timeframe outlined in the regulations. DS 08/03/2016) 04/11/2016 Implemented
2380.186(b)Individual # 5's 3 month ISP review documentation reviewing the period of 05/20/2015, 08/26/2015 and 11/28/2015 was not dated when the program specialist signed and completed the review.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The program specialist will sign and date the 3 month ISP review documentation. They will then turn the document into the program director who will review it to assure that it complies with all regulations. Also, the 3 month ISP review documentation format was changed to reflect a date completed space.(All program specialists will be retrained in their job duties and the program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
2380.186(c)(3)Individual # 2's 3 month ISP review documentation dated 04/17/2015, 07/14/2015, 10/08/2015 and 01/07/2016 reported on a "range of motion" outcome and a "prevocational job" outcome and did not report on the outcome identified in the ISP dated 04/07/2015 of "engagement in a sensory activity daily". The program specialist did not request a change to the ISP. The ISP review must include the following: The program specialist shall document a change in the individual¿s needs, if applicable.The room leader will review the outcome section of the ISP upon receipt of the document to assure that the outcome matches what is to be reported on. If it does not the room leader will inform the program specialist who will contact the supports coordinator via letter and request that the ISP be updated to reflect the proper ISP outcomes.(All program specialists will be retrained in their job duties and the program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 04/11/2016 Implemented
SIN-00069723 Renewal 11/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1's physical examination, dated 7/16/14, did not include documentation of tuberculin testing; the last physical examination was completed on 8/21/10.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.Once an individuals physical is turned into the agency the room leader will go over the physical to assure all necessary information is present. After the room leader completes this step it will then be turned into the program specialist who will also review it assuring all necessary information is filled in and then it will be turned over to the day program director who will also review the physical assuring all necessary information is on the form. Individual #1's physical examination was updated to include the TB testing date. The Program director will conduct an audit of all Individuals' physical examinations to ensure that a TB test has been completed every two years. 12/29/2014 Implemented
2380.111(c)(9)Individual #2's physical examination, dated 11/11/13, did not include documentation of allergies.The physical examination shall include: Allergies or contraindicated medication.Once an individuals physical is turned into the agency the room leader will go over the physical to assure all necessary information is present. After the room leader completes this step it will then be turned into the program specialist who will also review it assuring all necessary information is filled in and then it will be turned over to the day program director who will also review the physical assuring all necessary information is on the form. Individual #2's physical examination form was corrected by the physician to include allergies. The Program Director will audit all Individuals' physical examination records to ensure all required information is included. 12/29/2014 Implemented
2380.173(1)(ii)Individual #3's record content did not include eye color and identifying marks.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.The program specialist corrected the file on 12/29/14. A quarterly review of all individuals files will be completed by the program specialist during which time the content of the file will be reviewed for compliance. As new participants are admitted, the record will be reviewed by the Program Specialist to ensure all required elements of regulation 2380.173 are included in the record. 12/29/2014 Implemented
2380.173(1)(v)Individual #2's record content did not include religious affiliation. Individual #3's record content did not include religious affiliation. Each individual's record must include the following information: Personal information including: A current, dated photograph.A quarterly review of all individuals files will be completed by the program specialist during which time the content of the file will be reviewed for compliance. 12/29/0201 Implemented
SIN-00057285 Renewal 11/15/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisons were found unlocked in rm. 4: Power Pack SOS, Hydrogen Peroxide, Isopropel Alcohol, Bell furniture polish and Germ X.(a)  Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All poisonous material will remain in the closets with the locks on. The room leader's will assure that the locks are on in their rooms and the program director will double check that the locks are locked when he is in the rooms. 12/01/2013 Implemented
2380.53(b)Poison not kept in original container. "Neutral Cleaner" kept in Folger's coffee can in room # 4.(b)  Poisonous materials shall be stored in their original, labeled containers.All poisonous material will be kept in their original containers. The room leaders will check the closets that hold the materials once a month to assure that they are kept in this condition. The program director will double check the closets once a month to assure compliance. 12/01/2013 Implemented
2380.55(a)The carpet in room # 4 has stains and needs cleaning.(a)  Clean and sanitary conditions shall be maintained in the facility.The carpets shall be professionally cleaned once year at a minimum and more if circumstance arise. This will be arranged by the program director. 12/01/2013 Implemented
2380.58(b)The baseboard panels in rm. # 4 were bent and not attached to the baseboard heater. The folding metal storage cabinet in room # 4 has rust at its' base.(b)  Floors, walls, ceilings and other surfaces shall be free of hazards.The panels for the baseboard heater will be attached to the unit. The metal cabinet will be thrown out and replaced with a plastic cabinet. The room leader will be responsible for these actions and the program director will assure that they are completed. 12/01/2013 Implemented
2380.67(a)The sofa in room # 3 is torn and in need of repair.(a)  Furniture and equipment shall be nonhazardous, clean and sturdy.The small tear in the sofa will be sown and repaired. The room leader will assure this is completed. 12/01/2013 Implemented
2380.111(a)Individual # 2, date of admission 11/13/12, was admitted with a physical dated 4/23/12. The most recent physical is dated 6/11/13.(a)  Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The program specialist will not admit any individual without a physical prior to their admission date. The agency secretary will inform the program director when they have received a physical and the admission date will then be set. 12/01/2013 Implemented
2380.181(a)Individual # 1 was admitted 2/28/13, the assessment was not completed until 9/20/13(a)  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.Any individual transferring from one program to another program within the agency shall be treated as a new admission by the program specialist and will have a 60 day assessment completed. 12/01/2013 Implemented
2380.181(d)Individual # 2's assessment was completed on 1/8/13, but the document was not signed by the program specialist until 2/8/13.(d)  The program specialist shall sign and date the assessment.The vocational assessment agreement sheet for this individual is dated 1/8/13 and signed by both the program specialist and the individual. The date of the ISP meeting on the sheet is listed as 2/8/13. However, the program specialist will sign and date the assessment. 12/01/2013 Implemented
2380.182(a)The ISP for individual #1 was not updated and a meeting was not held 90 days after admission date of 2/28/13. The next meeting was held on 10/30/13.(a)  An individual shall have one ISP.Any individual transferring from one program to another program within the agency shall be treated as a new admission by the program specialist and will have a 90 day meeting and updated ISP. 12/01/2013 Implemented
2380.185(a)Individual # 2 ISP's start date is 2/8/13. The outcomes were not implemented until 3/28/13(a)  The ISP shall be implemented by the ISP'S start date.Upon received new IPS the program specialist will assure that the start dates of outcomes match each other. If there is a discrepancy the program specialist will contact the supports coordinator to resolve the discrepancy. 12/01/2013 Implemented
2380.185(b)Individual # 3's ISP dated 3/3/13 identifies an outcome in which this individual will become oriented to the program by participating in various activities and projects. This outcome has not been implemented.(b)  The ISP shall be implemented as written.Upon receiving the update ISP the program specialist will read the outcomes to assure they are being implement properly. If there is a discrepancy the program specialist will contact the supports coordinator and resolve the discrepancy. 12/01/2013 Implemented
2380.186(a)The only quarterly available for review for individual # 1 was dated 11/14/13. No prior quarterlies for the periods ending 5/13/13 and 8/13/13 were available for review.(a)  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.The program specialist will complete quarterly reviews for all individuals. The program director will receive the dates of quarterlies from the program specialist to assure compliance. 12/01/2013 Implemented
SIN-00040439 Renewal 10/09/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)One person is both deaf and blind and is in need of a body device to alert them to the alarm system in the event of a fire.(b)  If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.The vocational director shall purchase a personal body device and assure that the individual has the device on them while they are at the day program. 11/30/2012 Implemented
2380.113(c)(2)One indviduals physical examination did not include the date on which the Tuberculin skin test was read.(c)  The physical examination shall include:(2)  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 program specialist shall review all incoming physicals to assure that the date that the TB test was read is marked, if it is not marked the physical shall be returned to the doctor to have the necessary information on the physical form. 10/24/2012 Implemented
SIN-00215773 Renewal 12/05/2022 Compliant - Finalized