Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263990 Renewal 04/25/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(d)At the time of the inspection, the first aid kits located on the second floor and on the first floor in the first aid area did not contain tweezers. **Corrected at the time of inspection.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors.Tweezers were replaced in the First Aid Kit on the day of inspection. 04/25/2025 Implemented
2390.73The elevator did not have a valid certificate of operation from the Department of Labor and Industry at the time of the inspection. The certificate on display in the elevator expired 10/31/2024.If an elevator is present in the facility, there shall be a valid certificate of operation from the Department of Labor and Industry.Updated elevator certificate was displayed in the elevator as required. 05/16/2025 Implemented
2390.21(l)ODP Announcement 24-061 outlines the Federal requirements for individuals to be involved in decision-making about desired community activities, the regulatory requirements in Chapters 2380, 2390 and 6100, and what is required to comply with the regulatory requirements. Providers who deliver Community Participation Support and/or Day Habilitation in Chapter 2380 or Chapter 2390 programs must document conversations with individuals, beginning July 1, 2024, relating to their preferred community participation and activities at least quarterly. There was no documentation in the individual records of Individuals #1, #2 and #3 that a conversation occurred with each of the individuals between July 1, 2024 and September 30, 2024, as required by the ODP Announcement, or that quarterly conversation(s) have occurred since then.A client has the right to make choices and accept risks.The Individual Written Program Plan (IWPP) document, which is completed for every individual each quarter and reviewed at a team meeting, has been updated. A box has been added to address community inclusion at each meeting, for each individual. The program specialists will discuss community inclusion choices and opportunities at each meeting, and document the choices made. 05/16/2025 Implemented
2390.33(c)Staff #1 does not meet the minimum qualifications for the position of Program Specialist. Staff #1 holds a bachelor's degree in education, but there was no documentation in the employee's record of having at least one year of experience working directly with disabled persons.(c) A program specialist shall meet one of the following groups of qualifications: (1) Possess a master's degree or above from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field. (2) Possess a bachelor's degree from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field; and 1 year experience working directly with disabled persons. (3) Possess an associate's degree or completion of a 2-year program from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field; and 3 years experience working directly with disabled persons. (4) Possess a license or certification by the State Board of Nurse Examiners, the State Board of Physical Therapists Examiners, or the Committee on Rehabilitation Counselor Certification or be a licensed psychologist or registered occupational therapist; and 1 year experience working directly with disabled persons.Lead Program Specialist Lisa Sanphy has signed off on all meetings conducted by program specialist JW since her start date of 7/1/2024. Lisa has been a program specialist with our agency since 2004. 07/01/2024 Implemented
SIN-00223145 Renewal 04/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not posted near the telephone located on the work floor of the workshop. NOTE: This violation was corrected at the time of inspection; emergency telephone numbers were posted above the telephone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone.A list of emergency phone numbers was immediately posted at the located of the phone. 05/02/2023 Implemented
SIN-00201583 Renewal 04/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 was admitted into program on 8/11/2021. There was no fire safety documentation that reflected the individual had fire safety upon initial admission or at anytime during the year 2021.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The initial fire safety training documentation will be sent to program specialist supervisor along with initial paperwork that is completed when a new participant starts in program. 05/02/2022 Implemented
SIN-00195116 Renewal 10/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(b)There was no documentation that a monthly fire alarm check was completed in March 2021 and July 2021. An employee trained in the operation of the equipment shall check the fire alarm monthly.A written record shall be kept showing the date checked, the name of the person checking the alarm and whether or not the alarm was operative.Fire alarms are typically checked when fire drills are conducted, and these two checks were missed due to to fire drills not being completed those months. In order to rectify this issue, programs will schedule fire drills for the month at the beginning of that month, and the dates will be sent to the agency Safety Committee for tracking. 11/08/2021 Implemented
SIN-00189513 Renewal 06/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.104(4)Individual #1 and Individual #2's emergency medical information did not have documentation of medical information pertinent to diagnosis and treatment in case of an emergency.Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency.The Annual Update/Special Considerations form, which contains the emergency medical information, was updated and missing information was added. In regards to individual #2, his ISP and file were reviewed, and it was determined that he did not have a history of seizures, as was previously indicated. The Annual Update/Special Considerations for was updated to this accurate information. 07/12/2021 Implemented
SIN-00158469 Renewal 07/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61Multiple loose hallway floor tiles were held in place with packing tape, causing a potential tripping hazard. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Floor tiles were replaced by Avenues Maintenance. Documentation will be submitted via email. Additional tiles were purchased in the event that new tiles need to be replaced for safety. 08/01/2019 Implemented
2390.75(a)(3)The mechanical dishwasher was not operational (for several months, by staff report) and staff were washing pots, pans, food preparation and serving utensils are being washed by hand in a two sink system (one sink for wash, one for rinse) with Dawn dishwashing liquid. This process does not adhere to the Department of Environmental Resources sanitation standards, as specified in the Chapter 2390 Regulatory Guide.If the facility provides meals for clients or a food service training facility program in the facility, the following conditions shall be met: (3) Utensils used for eating, drinking, preparation and serving of food or drink shall be washed after each use by a mechanical dishwasher.Currently requesting bids for replacement of dishwasher. Until the new dishwasher is installed, only cold food will be served. Only plastic ware and paper plates will be utilized. Completion date reflects when the new dishwasher is expected to be installed and functional. documentation will be submitted upon completion. 11/01/2019 Implemented
2390.151(a)The initial assessment for Individual #1 was completed late. Individual #1's date of admission was 1/02/19 and the initial assessment was completed on 4/09/19.Each client 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.The initial assessment was added to the Avenues Admission checklist. Submitted to the Lead Program Specialist for approval. 09/12/2019 Implemented
SIN-00095646 Renewal 07/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)Individual #1 had ISP reviews on 12/8/2015, 4/8/2016, and 6/3/2016. The timeframe between December and April exceeded the 3 month requirement. 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.Regardless of any individual's issue that may prohibit having a regular scheduled team meeting on time every 3 months, shall be followed through accordingly as per our facility regulations under Chapter 2390. Moving forward, if at anytime an individual is not able to attend a meeting under any medical or legal circumstances, Avenues Program Specialist will assess the current needs of the individual, complete the paperwork and document the facts. As soon as the individual and the team are able to meet, Avenues will then prepare a follow-up meeting to review the original meeting that was assessed on the original date assigned. 09/12/2016 Implemented
SIN-00240663 Renewal 04/17/2024 Compliant - Finalized
SIN-00134415 Renewal 07/17/2018 Compliant - Finalized
SIN-00116048 Renewal 08/30/2017 Compliant - Finalized
SIN-00058397 Renewal 12/10/2013 Compliant - Finalized
SIN-00045462 Renewal 12/12/2012 Compliant - Finalized