| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00264273
|
Renewal
|
04/07/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(b) | The most current physical exam for staff person #1 was not dated by the physician. This section was blank on the physical form. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | The 2380 Director is responsible to ensure compliance of staff physical examinations, including monitoring for completeness, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.
The 2380 Director was trained in the requirements of regulation 2380.113(b). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) |
04/16/2025
| Implemented |
| 2380.181(f) | Individual #2's annual assessment completed 9/5/24 was not sent to all team members. Individual #2's legal guardian was not sent the 9/5/24 assessment. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | It is the responsibility of the Program Specialist to ensure that Assessments are sent to ALL team members at least 30 calendar days prior to the ISP Planning meeting as required in 2380.181(f).
The Director and Program Specialist were trained in the requirements of regulation 2380.181, specifically (f). (Attachment # 3 -Training sheet & Attachment # 4 - Memo)
Individual #2's Assessment was completed on 09/05/2024 but was not sent to Individual #2's legal guardian. The Assessment was mailed to the legal guardian on 04/09/2025. (Attachment # 5 -Letter) |
04/16/2025
| Implemented |
|
|
|
SIN-00201276
|
Renewal
|
03/08/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.57 | The back door way of the HUB does not have a light outside the door. | Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. | The Director is responsible to ensure compliance with this regulation. The Director was trained in the requirements of regulation 2380.57. (Attachment # 1 -Training sheet & Attachment # 2 - Memo)
A motion light-detector was purchased and installed to ensure proper lighting outside the kitchen door. Light-detector was installed on 3.17.2022 (Attachment #3 ¿ Photo). |
03/17/2022
| Implemented |
| 2380.58(a) | The HUB third ceiling tile, left of main doorway, has an approximate 6x4 inch brown water stain. The ceiling tile in front of it also has a brown water stain approximately 6 inches long. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Director, Program Specialist and Direct Service Workers are responsible to ensure compliance with this regulation. The Director Program Specialist and Direct Service Workers were trained in the requirements of regulation 2380.58(a). (Attachment # 4 -Training sheet & Attachment # 5 - Memo)
Ceiling tiles were replaced. (Attachment #6 Photo). |
03/18/2022
| Implemented |
|
|
|
SIN-00180972
|
Renewal
|
12/29/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.70(d) | There was no tape in the first aid kit. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | 2380.70d - First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.
Program Specialists are responsible to ensure that all needed items are kept in the first aid kit. Additionally, the Program Specialist needs to check the first aid kit following each monthly fire drill to ensure all required items are in the kit and to check for any expired items.
Program Specialists were trained on regulation 2380.70 and their responsibilities. (Attachment # 1 -Training sheet, Attachment # 2 Memo)
Tape was placed in the first aid kit. (Attachment # 3 Photo) |
01/04/2021
| Implemented |
| 2380.70(e) | The first aid manual was in the backpack with the first aid kit but not in the first aid kit. | A first aid manual shall be kept with each first aid kit. | Program Specialists are responsible to ensure that all needed items are kept in the first aid kit. Additionally, the Program Specialist needs to check the first aid kit following each monthly fire drill to ensure all required items are in the kit and to check for any expired items.
Program Specialists were trained on regulation 2380.70 and their responsibilities. (Attachment # 1 -Training sheet, Attachment # 2 Memo)
First Aid Manual placed with the first aid kit. (Attachment #4 Photo) |
01/04/2021
| Implemented |
|
|
|
SIN-00157433
|
Renewal
|
09/11/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.34 | Upon interviewing staff #5 regarding the support and care she provides individual #1 on a daily basis, staff #5 did not know individual #1 has a seizure protocol. When licensing representative asked staff #5 if she could explain individual #1's seizure protocol, staff #5 stated, "individual #1 does not have a seizure protocol here at program. If Individual #1 did have a seizure, we would call 911". Individual #1's seizure protocol per her updated ISP 6/13/19 states, "seizure protocol: on the onset of a seizure, ease individual #1 to the floor and place her on her side, to promote drainage of oral secretions and to prevent choking. Do not place on back. Be sure patient is clear of any objects that may cause injury during the seizure. Call for help if there is time. Seek medical assistance if the seizure lasts longer than 5 minutes. Seek medical assistance if multiple seizures take place in a row. Seek medical
assistance if the individual does not regain consciousness after the seizure starts." | A direct service worker shall be responsible for the daily care, training and supervision of individuals. | The Direct Service Workers are responsible to provide daily care, training and supervision of individuals. ensure that ¿clean and sanitary conditions are maintained in the facility¿ per regulation 2380.34 ¿ Direct Service Worker.
Direct Service Workers were trained in the requirements of regulation 2380.34. (Attachment # 33 -Training sheet & Attachment # 34 - Memo)
Direct Service Workers were retrained on Individual #1¿s seizure protocol by 09/17/2019. (Attachment #35 -Training Record & Attachment #14- Seizure Protocol per Assessment Addendum) |
10/09/2019
| Implemented |
| 2380.55(a) | Community Room- The refrigerator in the Community Room has red liquid residue on the top shelf of the refrigerator.
The oven in the Community Room has black residue on the floor of the oven approximately 1 foot by two feet in length. The four burners of the stovetop are black with what appears to be burnt on food residue.
Underneath the sink in the Community Room there is a mouse trap that has been there for over a year. Underneath this sink is rusty, pockets of dirt, and stains.
The kitchen cabinets and counter tops in the Community Room are sticky; need to be cleaned with an antibacterial agent.
The men's bathroom by the Aging Room has yellow residue to the right of the toilet seat on the wall facing the toilet seat. The residue appears to be spackling or possibly dried toilet paper which is approximately a half dollar size. | Clean and sanitary conditions shall be maintained in the facility. | The Program Specialist (PS) and Direct Service Workers are responsible to ensure that ¿clean and sanitary conditions are maintained in the facility¿ per regulation 2380.55(a) ¿Sanitation.
Staff was trained in the requirements of regulation 2380.55(a). (Attachment # 25 -Training sheet & Attachment # 26 - Memo)
The Community Unity room refrigerator¿s top shelf was cleaned, removing the red liquid residue. (Attachment # 27 ¿ Photo)
The Community Unity room oven was cleaned, removing the black residue on the floor of the oven. (Attachment #28 ¿ Photo)
The Community Unity room stovetop ¿ 4 burners were cleaned, removing the black, burnt food residue. (Attachment #29 ¿ Photo)
Underneath the Community Unity sink the mouse trap was removed and the cupboard was cleaned to remove the rust, dirt and stains. (Attachment #30 ¿ Photo)
The Community Unity kitchen cabinets and counter tops were cleaned with an antibacterial agent to remove the sticky residue. (Attachment #31 -Photo)
The Adult Training Facility men's bathroom by the Aging Room was cleaned to remove the yellow, half dollar size residue to the right of the toilet seat on the wall facing the toilet seat. (Attachment #32 ¿ Photo). |
10/04/2019
| Implemented |
| 2380.58(a) | The bottom drawer to the right of the sink in the Community Unity room is missing wooden trim handle on top of the drawer face.
The aging room in the ATF area has five walls, each with approximately 2 feet long spackling which needs repainted. Staff indicate that the room was last painted over 10 years ago.
The women's rest room by the Aging Room has gouges in the drywall in front of the toilet seat which are approximately 1 foot by 3 feet in length. Staff report that these gouges are caused by wheelchair use. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Director, Program Specialist (PS) and Direct Service Workers are responsible to ensure the ¿floors, wall, ceilings and other surfaces are free of hazards¿ per regulation 2380.58(a) ¿Surfaces.
Staff were trained in the requirements of regulation 2380.58(a). (Attachment # 22 -Training sheet & Attachment # 23 - Memo) The Direct Service Workers are responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Program Specialist. The Program Specialist is responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Director. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair and free of hazards.
Community Unity Room bottom drawer was missing wooden trim handle on the top of the drawer face. - Repaired on 09/25/2019. (Attachment # 24 ¿ Photo )
Suncom is in the process of acquiring bids for repairing and painting the Adult Training Facility walls in all restrooms and program areas. It is projected that this will occur by 12/31/2019. |
12/31/2019
| Implemented |
| 2380.58(b) | The cabinet facia under the sink and above the cabinet, in the community room, has ridged, sharp edges on the bottom of the facia. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Director, Program Specialist (PS) and Direct Service Workers are responsible to ensure the ¿floors, wall, ceilings and other surfaces are free of hazards¿ per regulation 2380.58(b) ¿Surfaces.
Staff were trained in the requirements of regulation 2380.58(b). (Attachment # 19 -Training sheet & Attachment # 20 - Memo) The Direct Service Workers are responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Program Specialist. The Program Specialist is responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Director. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair and free of hazards.
Community Unity cabinet facia under the sink and above the cabinet had ridged, sharp edges on the bottom of the facia. This issue was repaired on 09/25/2019. (Attachment #21 ¿ Photo) |
10/17/2019
| Implemented |
| 2380.111(a) | Individual #3 had a physical completed on 4/20/18 and did not have a physical completed in 2019. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Specialist is responsible to ensure that each individual has a physical examination within 12 months prior to admission and annually thereafter, (within one year of when the physical examination was completed) per regulation 2380.111(a). The Program Specialists were trained in the requirements of regulation. (Attachment #15- Training sheet & Attachment #16- Memo)
Physical Protocol/Memo - The Program Specialist are to notify the individual and/or family 2 months prior to the Physical Examination, Tetanus/Diphtheria immunization or Tuberculin/TB expiration date. Additionally, the residential provider will be notified via email 2 months prior to expiration. (Attachment #3 - Memo) Per the memo, the individual, family or residential provider is responsible to contact the Program Specialist when their appointment has been scheduled. A follow-up phone call will be made (and case noted) one (1) month prior to expiration dates to verify an appointment. If an appointment has not been made, the Director or Program Specialist will contact the Supports Coordinator to assist in the process. The Program Specialist will continue to call and/or email and case note weekly until an appointment has been scheduled.
The Program Specialists were trained in the above Physical Protocol/Memo. (Attachment #17- Training sheet)
Individual #3 had his Physical Examination on 09/10/2019. The Program Specialist received Individual #3¿s Physical Examination on 09/17/2019. (Attachment #18 ¿ Physical Examination)
The Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/31/2019. |
10/31/2019
| Implemented |
| 2380.181(c) | The current Assessment 7/17/19 did not include the seizures and feeding tube protocols as documented in the individual #1 current ISP updated 6/13/19. Also, the Assessment does not include the contraindicated medication, Augmentin, as stated in individual #1's face sheet. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that Assessments are signed, per regulation 2380.181 (c).
The Program Specialists were trained in the requirements of regulation 2380.181(c). (Attachment # 12 -Training sheet & Attachment # 13 - Memo)
An Assessment Addendum was completed for Individual #1 on 10/07/2019, revising the 07/17/2019 Assessment to include the seizure protocol, feeding tube protocol and contraindicated medication, Augmentin. (Attachment # 14 ¿ Assessment Addendum)
An e-mail was sent on 10/17/2019 to the Supports Coordinator for Individual # 1 ¿ notifying them of the revisions. (Attachment # 6¿ E-mail)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/31/2019. |
10/31/2019
| Implemented |
| 2380.181(d) | Individual #3's 04/20/19 assessment was not signed by the Program Specialist staff # 1. The assessment was a typed signature. | The program specialist shall sign and date the assessment. | It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that Assessments are signed, per regulation 2380.181 (d).
The Program Specialists were trained in the requirements of regulation 2380.181(d). (Attachment # 9 -Training sheet & Attachment # 10 - Memo)
Individual #3¿s 04/20/2019 was signed by the Program Specialist on 09/12/2019. (Attachment #11)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/31/2019. |
10/31/2019
| Implemented |
| 2380.181(e)(4) | Individual #1's supervision care description for community supervision as stated in her recent Assessment 7/17/19 is unclear and incomplete. It currently states, "individual #1 requires supervision at all times in the community. She is able to progress with community independence by increasing her safety skills."
Individual #3's 4/20/19 assessment does not specify the level of supervision which he requires in the community. The Assessment states, "individual #3 is not able to remain alone in the community." His ISP last updated 7/03/19 states, "he requires supervision within arms length due to lack of traffic safety and stranger awareness skills within the community." | The assessment must include the following information: The individual¿s need for supervision. | It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s Assessment, specifically the individual¿s need for supervision, per regulation 2380.181 (e)(4). ¿ Assessment.
Supervision levels in Assessments should be written in a manner that clearly and concisely identifies an individual¿s supervision level.
The Program Specialists were trained in the requirements of regulation 2380.181(e) (4). (Attachment # 3 -Training sheet & Attachment # 4 - Memo)
An Assessment Addendum was completed for Individual #1 on 10/07/2019, revising the 07/17/2019 Assessment to include a description of the individual #1¿s supervision care needed while in the community. (Attachment # 5 ¿ Assessment Addendum)
An e-mail was sent on 10/17/2019 to the Supports Coordinator for Individual # 1 ¿ notifying them of the revisions. (Attachment # 6¿ E-mail)
An Assessment Addendum was completed for Individual #3 on 10/01/2019, revising the 04/20/2019 Assessment to include a description and clarification of the individual #3¿s level of supervision care needed while in the community. (Attachment # 7 ¿ Assessment Addendum)
An e-mail was sent on 09/27/2019 & 10/01/2019 to the Supports Coordinator for Individual #3 ¿ notifying them of the revisions and clarification of community supervision to be added to the ISP. (Attachment # 8A¿ E-mail and Attachment #8B ¿ ISP Revised)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/31/2019. |
10/31/2019
| Implemented |
| 2380.188(a) | Licensing representative observed a medication pass for individual #6. The medication was Benztropine Mes 1mg tab at 12pm. Staff #4 prepared the medication in the medication room. She put medication into a paper cup and then proceeded to travel with the medication to the kitchen area and retrieved a glass of water. Staff #4 went over to individual #6 where he was lounging on a recliner near the medication room. Staff #4 asked individual #6 to sit up and take his medication. The individual took his medication.
The was no communication to individual #6 from staff #4 what medication she was offering him and why she was giving it to him. She should have stated the name of the medication and the reason why he was prescribed it. Ultimately, as providers, they are to communicate and educate all individuals they are assisting with medications. The ultimate goal for all individuals is self-administration. The staff person failed in this respect. | The facility shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | Medication Administration staff were trained on the importance of communicating and providing education (name of medication and the reason why it is prescribed) to the individual during a medication pass in order to assist, train and support the individual to acquire, maintain or improve functional skills, personal needs, communication and personal adjustment. The ultimate goal of medication administration would be for the individual to gain skills to advance toward self-medication.
Additionally, Medication Administration staff were informed that medication passes should occur in the medication area, not in the program area. This is important to maintain confidentiality, respect the individual¿s privacy/dignity and to reduce the likelihood of spilling or losing the medication while walking to the individual. (Attachment # 1 -Training sheet & Attachment # 2 - Memo) |
10/07/2019
| Implemented |
|
|
|
SIN-00114776
|
Renewal
|
07/26/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | Individual #3's physcial dated 12/1/16 and individual #4's physical dated 6/7/17 did not inlcude vision and hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The physical examination shall include: Vision and Hearing Screening, as recommended by the physician.
The Program Specialist is responsible to ensure that the physical examination contains all the required items per regulation 2380.111(c), specifically 111(c)(4) Vision and Hearing screening. The Program Specialists were trained in the requirements of regulation 2380.111(c). (Attachment #18- Training sheet & Attachment #19- Memo)
Individual #3 and individual #4 ¿ The citation stated that the physical did not include vision and hearing screening as recommended by the physician.
Individual #3 ¿ The individual has an appointment on 08/23/2017 for a vision and hearing screenings. The results will be attached to the physical examination form when received. Attachment #20- (Appointment slip)
Individual #4 ¿ Per physician¿s note received on 08/23/2017, individual #4 ¿did not require an eye exam or hearing test at her appt on 07/26/2017¿. Attachment #21- Physician note)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/31/2017. |
08/31/2017
| Implemented |
| 2380.173(9) | Individual #3's ISP updated 4/13/17 states no diet restrictions. The physcial dated 12/1/16 states he is on a low salt diet. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Each individual¿s record must include the following information: Content discrepancies in the Individual Support Plan, the annual update or revisions under 2380.186.
The Program Specialist is responsible to ensure that the individual's record includes documentation of any identified discrepancy in the ISP or ISP Revision. If there is content discrepancy identified in the plan, there should be documentation that the discrepancy was communicated to the Plan Lead or SC per 2380.173(9). The Program Specialist was trained in the requirements of regulation 2380.173(9). (Attachment # 15 -Training sheet & Attachment # 16 - Memo)
Individual #3¿s diet restrictions on the 12/01/2016 physical and ISP did not match. On 08/08/2017 the Program Specialist sent an e-mail to the Supports Coordinator addressing the content discrepancy between the ISP and the diet restrictions on the physical for individual #3. It should be noted that the physical¿s information was correct. (Attachment #17 ¿ e-mailed to SC)
The Program Specialist is in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/31/2017. |
08/31/2017
| Implemented |
| 2380.176(a) | Individual records were left unattended in the older adult area. | Individual records shall be kept locked when they are unattended. | Individual records shall be kept locked when they are unattended.
It is the responsibility of the all staff to ensure compliance with this regulation and ensure that individual records are kept confidential and locked when unattended.
All staff was trained in the requirements of regulation 2390.176(a). (Attachment # 13 -Training sheet & Attachment # 14 - Memo) |
08/07/2017
| Implemented |
| 2380.181(e)(4) | Individual #3's assessment dated 7/7/17 states remain alone in a room of his choice while staff are on site. Does not specifiy the amount of time or what room he can be alone in the facility. | The assessment must include the following information: The individual¿s need for supervision. | The assessment must include the following information: The individual¿s need for supervision.
It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s Assessment, specifically the individual¿s need for supervision, per regulation 2380.181 (e)(4). ¿ Assessment.
Supervision levels in Assessments should be written in a manner that clearly and concisely identifies an individual¿s supervision level.
The Program Specialists were trained in the requirements of regulation 2380.181(e) (4). (Attachment # 9 -Training sheet & Attachment # 10 - Memo)
An Assessment Addendum was completed for Individual #3 on 08/21/2017, revising the 07/07/2017 Assessment to include individual¿s need for supervision, specifically the length amount of time and what room he can be alone in while at the facility.. (Attachment # 11 ¿ Assessment Addendum)
An e-mail was sent on 08/21/2017 to the Supports Coordinator for Individual # 3 ¿ notifying them of the revisions. (Attachment # 12¿ E-mail)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/31/2017. |
08/31/2017
| Implemented |
| 2380.183(7)(i) | Individual #3 and indivdual #4's ISP does not inlcude the potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | The Individual Support Plan, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include: Assessment of the individual¿s potential to advance in the following: (i) Vocational Programming.
The Program Specialist is responsible to ensure compliance with this regulation and ensure that the required information is documented in each client¿s ISP, specifically an assessment of the individual¿s potential to advance in the following: (i) Vocational Programming.
The Program Specialists were trained in the requirements of regulation 2380.183(7)(i). (Attachment # 4 -Training sheet & Attachment # 5 - Memo)
On 08/09/2017 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #3¿s ISP to include an assessment of the individual¿s potential to advance in Vocational programming. (Attachment #6 ¿ Email)
On 08/10/2017 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #4¿s ISP to include an assessment of the individual¿s potential to advance in Vocational programming. (Attachment #7 ¿ Email)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/31/2017. |
08/31/2017
| Implemented |
| 2380.183(7)(iii) | Individual #2, #3, and #4 ISP's did not include the potential to advance in competitive community integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | The Individual Support Plan, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include: Assessment of the individual¿s potential to advance in the following: (iii) Competitive community integrated employment.
The Program Specialist is responsible to ensure compliance with this regulation and ensure that the required information is documented in each client¿s ISP, specifically an assessment of the individual¿s potential to advance in the following: (iii) Competitive community integrated employment.
The Program Specialists were trained in the requirements of regulation 2380.183(7)(iii). (Attachment # 4 -Training sheet & Attachment # 5 - Memo)
On 08/09/2017 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #3¿s ISP to include an assessment of the individual¿s potential to advance in Competitive community integrated employment. (Attachment #6 ¿ Email)
On 08/10/2017 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #4¿s ISP to include an assessment of the individual¿s potential to advance in Competitive community integrated employment. (Attachment #7 ¿ Email)
On 08/10/2017 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #2¿s ISP to include an assessment of the individual¿s potential to advance in Competitive community integrated employment. (Attachment #8 ¿ Email)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/31/2017. |
08/31/2017
| Implemented |
| 2380.186(e) | Individual #3's option to decline was not sent to the entire team. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist is responsible to notify the plan team members of the option to decline the Individual Support Plan (ISP) Review documentation. The Program Specialists were trained in the requirements of regulation 2380.186(e). (Attachment # 1-Training sheet & Attachment # 2- Memo)
Individual # 3 The Option to Decline form was updated on (08/04/2017) to include all team members. (Attachment # 3 ¿ Option to Decline form)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/31/2017. |
08/31/2017
| Implemented |
|
|
|
SIN-00095113
|
Renewal
|
06/24/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.173(9) | Individual #1's physical form completed on 3/25/16 indicated that the following were contraindicated medications; Ritalin, Ritodrine, Trazodone, and Zyrtec. Individual #1's Individual Support Plan (ISP) indicated that they only had allergies to Ritalin, Zyrtec and seasonal allergies. The same individual's medication administration record indicated that they did not have any allergies or contraindicated medications. Individual #1's assessment completed on 10/12/15 indicated that they could be unsupervised in the restroom and on the ramp of the building with 15 minute checks. The current ISP for the same individual indicated that they are independent with supervision in all the program areas including the ramp. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Program Specialist is responsible to ensure that the individual's record includes documentation of any identified discrepancy in the ISP or ISP Revision. If there is content discrepancy identified in the plan, there should be documentation that the discrepancy was communicated to the Plan Lead or SC per 2380.173(9). The Program Specialists were trained in the requirements of regulation 2380.173(9). (Attachment #3-Training sheet & Attachment #4- Memo)
Individual #1. The citation stated that the supervision information in the ISP and Assessment did not match. The ISP indicated that the individual was independent in the program areas including the ramp. The Assessment indicated that the individual could be unsupervised while in the restroom and on the ramp with 15 minute check. ¿The content discrepancy between the ISP and the Assessment was resolved by 07/22/2016. (Attachment #5- Email to SC and Attachment #6 ¿ Assessment)
The Program Specialist is responsible to ensure that the physical examination checklist is completed upon receipt of a physical examination form to ensure all documents (Assessment, Physical, Emergency Care form and ISP) match. The Program Specialists were trained on how to complete the Physical Examination Checklist form. (Attachment #7- Training sheet & Attachment #8- Memo)
The Medication Administration Trainers, Medication Administration staff and the Program Specialists are responsible to ensure that the MARs contain accurate information. The Medication Administration Trainers, Medication Administration staff, and Program Specialists were trained on the importance of accurately completing the Medication Administration Record (MAR), specifically Allergies as well as ensuring that the Physical Examination, Individual Support Plan and MARs match. (Attachment #9-Training Sheet & Attachment #10 ¿ Memo)
Individual #1. The content discrepancy between the physical, ISP and Medication Administration Record (MAR) was resolved by clarif |
07/22/2016
| Implemented |
| 2380.181(a) | Individual #1 had an assessment completed on 7/15/14 and not again until 10/12/15. | 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. | The Program Specialist is responsible to ensure the assessment is completed in a timely manner. Per regulation 2380.181(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.
The Program Specialists were trained in the requirements of regulation 2380.181(a). (Attachment #1- Training sheet & Attachment #2- Memo)
Individual #1 (MB) - The assessment was completed on (10/12/2015). The next assessment will be completed by 10/11/2016.
The Program Specialist is in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 07/22/2016. |
07/22/2016
| Implemented |
|
|
|
SIN-00080467
|
Renewal
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06/05/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.90(a) | There was no exit sign located in the facility. | Signs bearing the word ``EXIT¿¿ in plain, legible letters shall be placed at exits. | The CEO/Director/Program Specialist is responsible to ensure that signs bearing the word EXIT in plain, legible letters are placed at exits .The CEO/Director/Program Specialists was trained in the requirements of regulation 2380.90a (Attachment #10-Training sheet & Attachment #11 -Memo)
During the inspection an EXIT sign was not located in the Community Unity program exiting into the vocational program lunchroom. Current photo of EXIT sign indicating this citation has been corrected. (Attachment #12)
|
10/22/2015
| Implemented |
| 2380.181(e)(4) | Individual #1's assessment does not address 1:1 while at program. Addessment does not address whether or not individual #1 needs direct supervision while tempering the water to wash her hands while in the bathroom. Individual #1's ISP states she cannot distingush between hot and cold water. | The assessment must include the following information: The individual¿s need for supervision. | The Program Specialist is responsible to ensure each assessment includes the individual¿s need for supervision. The Program Specialists were trained in the requirements of regulation 2380.181(e)(4). (Attachment #7- Training sheet & Attachment #8- Memo)
Individual #1 ¿ The 12/22/2014 assessment was updated on (10/20/2015) to include and address 1:1 supervision while at the program and whether or not the individual needs direct supervision while tempering the water to wash her hands while in the bathroom. (Attachment #9- Assessment)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/30/2015.
|
10/30/2015
| Implemented |
| 2380.181(e)(7) | Individual #1's assessment did not include the knowledge of heat sources. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The Program Specialist is responsible to ensure each assessment includes the individual¿s understanding of the danger of heat sources and ability to sense and move away from heat sources quickly. This regulation applies even if all heat sources exceeding 120 degree F within the facility are insulated. The Program Specialists were trained in the requirements of regulation 2380.181(e)(7). (Attachment #7- Training sheet & Attachment #8- Memo)
Individual #1 - The 12/22/2014 assessment was updated on (10/20/2015) to include the individual¿s understanding of the danger of heat sources and her ability to sense and move away from heat sources quickly. (Attachment #9- Assessment)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/30/2015.
|
10/30/2015
| Implemented |
| 2380.181(e)(8) | Indiv #1 Assessment does not include her ability to evacuate in event of a fire at day program; it only states her abilities at the residential home. | The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire. | The Program Specialist is responsible to ensure each assessment includes the individual¿s ability to evacuate in the event of a fire. The Program Specialists were trained in the requirements of regulation 2380.181(e)(8). (Attachment #7- Training sheet & Attachment #8- Memo)
Individual #1 - The 12/22/2014 assessment was updated on (10/20/2015) to include the individual¿s ability to evacuate in the event of a fire. (Attachment #9- Assessment)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/30/2015.
|
10/30/2015
| Implemented |
| 2380.186(c)(1) | Individual #1's ISP review does not address the individual participation and progress toward ISP outcomes. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | The Program Specialist is responsible to ensure each review includes monthly documentation of the individual¿s participation and progress during the prior 3 months toward the ISP outcomes that are supported by the services provided by the provider. The Program Specialists were trained in the requirements of regulation 2380.186(c)(1). (Attachment #1- Training sheet & Attachment #2- Memo)
Individual #1 ¿ The ISP Review was completed on (07/27/2015) to include the individual¿s participation and progress during the prior 3 months toward the ISP outcomes that are supported by the services provided. (Attachment #3- ISP Review)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/30/2015.
|
10/30/2015
| Implemented |
| 2380.186(e) | Individual #1'sISP reviews did not include the option to delicne ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist is responsible to notify the plan team members of the option to decline the ISP review documentation. The Program Specialists were trained in the requirements of regulation 2380.186(e). (Attachment #4- Training sheet & Attachment # 5 - Memo)
Individual #1 ¿The Option to Decline form was updated on (10/20/2015) to include all team members. (Attachment #6 ¿ Option to Decline form)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/30/2015.
|
10/30/2015
| Implemented |
|
|
|
SIN-00065083
|
Renewal
|
05/01/2014
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(b) | Both bathrooms in the ATF had radios and fans sitting on top of the paper towel holdres. They were plugged into the oulets next to the sink which could cause an accident/injury. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Program Specialists are responsible to ensure that the floors, walls, ceilings and other surfaces are free of hazards. The Program Specialist and Direct Service Workers were trained in their responsibilities. (Attachment A -Training sheet & B-Memo)
During the inspection both items (fan and radio) were immediately removed from the two restrooms. Current photo of both restrooms indicating elimination of the safety hazards. (Attachment C & D)
|
06/24/2014
| Implemented |
|
|
|
SIN-00070078
|
Renewal
|
05/01/2014
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(b) | Both bathrooms in the facility had radios and fans sitting on top of the paper towel holders and were plugged into the outlet next to the sink. This created an electrical hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Radio and fans removed from bathrooms. Training provided to all staff regarding potetial hazards on June 6, 2014. |
06/06/2014
| Implemented |
|
|
|
SIN-00242735
|
Renewal
|
04/17/2024
|
Compliant - Finalized
|
|
|
SIN-00221375
|
Renewal
|
03/28/2023
|
Compliant - Finalized
|
|
|
SIN-00137772
|
Renewal
|
08/29/2018
|
Compliant - Finalized
|
|
|
SIN-00091799
|
Technical Assistance
|
03/28/2016
|
Compliant - Finalized
|
|
|
SIN-00063019
|
Change in Location Capacity
|
04/28/2014
|
Compliant - Finalized
|
|
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SIN-00060305
|
Closure Verification
|
02/26/2014
|
Compliant - Finalized
|
|
|
SIN-00047793
|
Renewal
|
04/30/2013
|
Compliant - Finalized
|
|