Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215774 Renewal 12/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual rights were signed and reviewed on 3/23/2021 and most recently on 11/29/22 with individual#1. More than one year lapsed between reviews.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.A system will be developed to track the annual paperwork for all individuals that attend the Day Program, to include the Individual Rights form. This will ensure that all required paperwork is signed and filed on an annual basis. 01/04/2023 Implemented
SIN-00163954 Renewal 10/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.66The first aid kit located in room #3 was missing tweezers.Landings shall be provided beyond each interior and exterior door that opens onto a stairway.Tweezers were purchased and put in the first aid kit by the floor supervisor (see receipt). As of 11/14/19 the first aid kits were added to the quarterly room checklist (see attachment). The kit will be checked to the regulations to assure they are properly stocked by the floor supervisor. 11/14/2019 Implemented
SIN-00140994 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61Five individual chair seats were torn and needing to be replaced. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.New chairs were ordered by the room supervisor on 8/6/18. Once the new chairs arrived the room supervisor threw away the old chairs. Going forward room supervisors will complete a quarterly (Sept, Dec, March and June) building checklist that reviews chairs and there conditions. Once completed the checklist will be turned into the director. Any issues will be corrected and addressed. 08/06/2018 Implemented
2390.63The ceiling fluorescent lights were found inoperable. The entry door into the multi-purpose room was missing a door knob.Rooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents.The light bulb in the light fixture was replaced by the janitorial staff on 8/24/18. A door knob was added to the door by janitorial staff on 9/7/18. Going forward room supervisors will complete a quarterly (Sept., Dec, March and June) checklist for the building which asks if all lights and doors are in good repair. The checklist will be turned into the director. Any issues will be corrected and addressed. 09/07/2018 Implemented
SIN-00116663 Renewal 06/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.40(b)Staff #1 did not complete 24 hours of training in the most recent complete training year. Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually.The staff will submit their training syllabus quarterly to the program director 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
2390.112(a)-2The date of orientation was not recorded in Individual #1's record. The date of orientation was not recorded in Individual #2's record.The date of the orientation shall be written in the client's record.The program specialist will note the date of orientation in the individuals files. After the orientation is completed the program specialist will inform the program director who shall review the file to assure it has been documented in order to ensure compliance. 08/01/2017 Implemented
2390.112(b)-2A written record of the explanation provided in the orientation was not signed by Individual #1 and available in the record. A written record of the explanation provided in the orientation was not signed by Individual #2 and available in the record.A written record of the explanation shall be signed by the client and available in the client's record.The program specialist will have the individual and or parent/guardian sign off on the written explanation of the orientation provided. Once this is completed the program specialist will turn it into the program director who will review it for accuracy and ensure compliance. 08/01/2017 Implemented
2390.124(4)Individual #1's record did not contain the written consent from the individual, parent or guardian for emergency medical treatment. Individual #2's record did not contain the written consent from the individual, parent or guardian for emergency medical treatment.Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment.Consent for emergency medical treatment shall be obtained yearly at ISP meetings by the program specialist. Once the consent is obtained the program specialist will turn the form into the program director for review and to ensure compliance. 08/01/2017 Implemented
SIN-00091980 Renewal 02/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(d)Individual # 1's annual assessment dated 12/11/2015 was not dated by the program specialist when it was completed.The program specialist shall sign and date the assessment.The program specialist will sign and date the assessments after they are completed. They will then turn them into the program director who will assure that the comply 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
2390.154(a)Individual # 1's 3 month ISP review documentation reviewing the period of 04/15/2015-07/21/2015 reviews a period greater than 3 months.The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2390.156 (relating to ISP review and revision).The program specialist will turn in the 3 month ISP review documentation to the program director two days prior to the scheduled meeting. The program director will review the documentation to assure that it falls within the 3 month time frame and all regulations.(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 within the timeframes outlined in the regulations. DS 08/03/2016) 04/11/2016 Implemented
2390.154(b)Individual # 1's 3 month ISP review documentation reviewing the periods of 04/15/2015-7/21/2015, 07/21/2015-10/16/2015 and 10/16/2015-01/12/2016 was not dated by the program specialist when it was signed and completed. At least three plan team members, in addition to the client, if the client chooses to attend, shall be present for the ISP, annual update and ISP revision meetings.The program specialist will sign and date 3 month ISP review documentation when completed. The program specialist will then turn the review documentation into the program director who will review it and assure it's compliance with all regulations. Also, a date completed section was added to the 3 month ISP review forms. (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-00069721 Renewal 11/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(b)Individual #1's record did not include notification of acceptance into the 2390 program.Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. The program specialist will send out acceptance letters to all individuals who are accepted into the program. A copy of the acceptance letter will be give to the day program director upon completion. Individual #1's record was updated to include the notification. 12/29/2014 Implemented
2390.151(f)Individual #2's assessment, dated 11/4/13, there is no indication that the assessment was sent to the Supports Coordinator and the plan team members 30 days in advance of the ISP meeting. Individual #3's assessment, dated 12/4/13, there is no indication that the assessment was sent to the Supports Coordinator and the plan team members 30 days in advance of the ISP meeting. 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 program specialist will include a cover letter with all assessments. This cover letter will include the date that the assessment is being sent and also who it is being sent to. Documentation that the assessment was sent will be maintained by the provider. The Program Specialist will develop a tracking form that documents the date of the assessment and the date it was sent for all individuals of the program to ensure that the assessment is sent timely. 12/29/2014 Implemented
SIN-00053472 Renewal 11/15/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62The vocational training room has a fish tank. The top of the tank was not clean and sanitary.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.The production manager and floor supervisor will follow the daily and monthly cleaning schedule implemented by the program director. The program director will check to assure the cleaning was completed. 12/01/2013 Implemented
2390.156(a)Two quarterlies for individual # 1 did not follow the annual review update date of 1/20/13 and exceeded the 90 day evaluation period.(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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.The quarterlies in question were finished in the allotted time frame, the quarterly dates for the individual is as follows, 4/19/13, 7/10/13 and 10/23/13. All which is within the 90 day time frame and the 14 days previous or after the date. However, the program specialist will schedule the quarterlies and then confer the scheduled date with the program director. The program director will assure that the date of the quarterly follows the annual review update. 12/01/2013 Implemented
SIN-00281407 Renewal 12/02/2025 Compliant - Finalized
SIN-00256651 Renewal 12/04/2024 Compliant - Finalized
SIN-00040438 Renewal 10/09/2012 Compliant - Finalized