Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216303 Renewal 12/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Greater than one year elapsed between Staff Member 1's two most recent fire safety trainings, dated 9/21/21 and 12/8/22.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.Staff 1 did not have current fire safety training. Fire safety training was conducted on 12/08/22 ¿ she is now in compliance. (See attached 2390-1a) A New Hire / Annual Checklist has been developed to track Fire Safety Training and other required documentation. Monthly reviews of the checklist will be conducted by the HR Manager to ensure compliance with Fire Safety and other annual trainings. (See attached 2390-1b). Completed on 12/08/22. 12/19/2022 Implemented
2390.126(b)The client files were unsecured in the program office (ADT) office.The client record is the property of the facility whose responsibility is to secure the information against loss, defacement, tampering or use by unauthorized persons. Client records shall be removed from the facility's jurisdiction and safekeeping only in accordance with a court order, subpoena or statute.Individual records were in an unlocked office on the second floor. The records have been removed and placed in the Records Room on the first floor. (See attached 2390-2a, 2b). The Records Room is locked at all times. The only key to the Records Room is kept locked in the Executive Directors office and only members of the management team can access it. (See attached 2390-2c). Completed on 12/21/22. 12/21/2022 Implemented
2390.151(a)Individual 1 was admitted to program on 1/31/22. There has not been an assessment completed since that time. Individual 2's last assessment was completed on 8/31/21.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.Individual 1 and 2 did not have an updated annual assessment. Individual 1¿s initial assessment was completed on 04/01/22. (See attached 2390-3a, 3b, 3c, 3d, 3e, 3f). Individual 2¿s annual assessment was completed on 04/15/22. (See attachments 2390-3g, 3h, 3i, 3j, 3k). A Participant Checklist has been put in place to track Assessments for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2390-3L). completed on 12/29/22. 12/29/2022 Implemented
SIN-00166037 Renewal 11/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(d)The first aid kit located on the lower level of the 2390 program did not contain antiseptic, tweezers or tape. The first aid kit located on the second level of the 2390 program did not contain antiseptic, tweezers or scissors.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors.Corrective action: Who: Josh Butterline Maintenance Manager. On 11/06/19, immediately following the inspection, the first aid kit was replenished with antiseptic, tweezers and tape. PEP has now included the addition of first aid kit inventory list to each kit. This is to ensure inventory is identified and noted monthly during the regular maintenance inventory review. A list of regulatory items is present in each kit. Each kit will be identified by a kit number and its location in the building and will be included in the monthly inventory inspections. The inspections will be completed by Josh Butterline, the maintenance manager. If Items are not present at the time of inspection, it will be noted on the updated Maintenance inventory form. Josh will notify the Director of any missing items so that they may be replenished or purchased. Date of completion: -Kit was refilled on 11/06/19 -Updated inventory list for each kit was place inside individual kits on 12/10/19. An updated Monthly inspection sheet was created on 12/12/19 to include the kit identification number, location and inventory. The new sheet was utilized and reviewed on 12/13/19. Josh will maintain logs monthly as part of the monthly maintenance inspection and fire drill. This protocol was put in place after the last monthly fire drill but before Decembers therefore it was done separately this month from the Firedrill-Maintenance inspection Documents set to inspector -Photo of replenished kit -Photo of regulatory requirement items for each kit 11/06/2019 Implemented
2390.124(5)The Annual Physical Examination for Individual #1 was completed late, the last physical was completed 10/20/17 the current physical was completed 12/04/18.Each client's record must include the following information: Physical examinations.Who: Beth Ryan will oversee and be responsible for correction. What: Each individual¿s record must have a physical. However, the 2390 program is only required to have a physical upon acceptance/entrance. There is no regulatory requirement for ongoing annual physicals. While there is no requirement PEP has decided to maintain the same protocol and consistency as the 2380.11 regulations in regards to the maintenance of the physicals. The 2390 program will maintain physicals in the same protocol as the 2380 program for the purpose of annual and lifetime medical assessments. How: A plan to prevent future occurrences: Although annual physicals are not required in the 2380 Program, Coordinator will be re-trained on the updated reminder letter and spread sheet by 12/12/19. Staff must document all correspondence in regards to delays or issues and report them to the SC/Supervisor. Beth Ryan will be responsible for the 2390 Program Coordinator training. Date of completion: As of 12/12/19, the 2390 Coordinators have been trained on the update. 12/12/2019 Implemented
SIN-00162637 Unannounced Monitoring 09/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The Program floor for the 2390 Program located outside the elevator was cracked and lifted, causing a tripping hazard. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Heather Kuzowsky was identified to oversee the completion of the repairs. Josh Butterline was assigned to access and repair the floor in the lower level of the 2380 area. It was identified that the floor was uneven due to an underlying floating track below the tiles. On 9/24/19 Josh removed the old tiles and the rack from the floor. On 9/25, Josh purchased concrete and filled the floor where the track was previously. on 10/1/19 Josh laid the new tiles over the concrete to its completion. While construction was being completed, the area was blocked and individuals rerouted. The safety committee will review bi-weekly to discuss and plan needed repairs and possible hazards. hey will be addressed in the admin meetings for specific date and time resolutions. 10/01/2019 Implemented
SIN-00143865 Renewal 10/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)There was no updated annual Assessment completed for Individual #1. The assessment was due to be completed on 09/29/2018.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.Description of how non-compliance occurred: Individual's Assessment was due but had not been completed. Program Coordinator overseeing his case gave notice of his resignation on 9/20/18 with one week notice. His last date of employment was 9/27/18. We had just received notice that PEP's Annual Licensing would begin in 3 weeks; therefore, program coordinator devoted his last week to finalizing and updating reports, and a review of his Master Schedule indicated his caseload was up to date. This former Program Coordinator's caseload was split up among the remaining two Program Coordinators. This assessment was missed in the transition and in the final review of his caseload before his departure. Immediate Correction 1. Program Coordinator completed Annual Assessment (10/26/18) and forwarded to team. 2. Another Program Coordinator for ADT, conducted an audit of Annual Assessments due dates on 12/5/18 & assisted in updating Assessments. All Assessments will be complete by 12/30/18. Plan of Correction to Prevent Future Occurrences: 1. A policy was written by QA & Training Consultant and approved by Executive Director and Program Directors to ensure that supervisors inspect the work of any staff who has given notice of resignation and ensure unfinished work is either completed, immediately assigned to other staff to complete, or is completed by the supervisor. All program coordinators and program directors have been trained on this procedure. This was completed by 12/13/18. 2. A procedure was written by QA & Training Consultant and approved by Executive Director and Program Directors to ensure there is immediate coverage of caseloads for program coordinators who resign or leave unexpectedly or who are out for an extended period. All program coordinators and program directors have been trained on this procedure. This was completed by 12/13/18. 3. A policy & procedure was written was written by QA & Training Consultant and approved by Executive Director and Program Directors stating that all program coordinators are required to request assistance from peers or supervisor if they are at risk of not meeting regulatory deadlines. Directors, supervisors and program coordinators from all programs are required to assist wherever needed in ensuring documentation is complete. All program coordinators and program directors have been trained on this procedure. This was completed by 12/13/18. 10/26/2018 Implemented
SIN-00113977 Renewal 04/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.54The chemical "Gum Remover II" was labelled "extremly flammable" and contained "isobutane/propane" was found in the janitorial closet. This chemical was not stored in an explosion proof container. Combustible supplies and equipment shall be utilized safely, stored in a fire retardant cabinet or closet and stored away from heating sources.The "chemical Gum Remover II" in the janitorial closet was removed immediately from closet and building. 04/04/2017 Implemented
2390.61The basement exit to the ouside has a broken wired glass panel on the door. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The broken wired glass panel on the basement exit door is scheduled to be prepared by sub-contractor by June 30, 2017. 06/30/2017 Implemented
2390.67The men's room on the lower level had significant staining on the inside of the front door. This same door has a loose door handle.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.The men's room on the lower level with stains on the inside of the front door was removed and cleaned by maintenance department. The screws on the loose door handle were tightened by maintenance. 04/05/2017 Implemented
2390.101The physical dated 1/13/16 for indiividual #2 was found without communicable disease authorization.Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician.The Physician completing the consumer¿s physical did not check off the section of the Annual Physical noting whether or not the consumer has a communicable disease. Effective 4/5/17, reminder letters will be sent at least four weeks in advance to remind caregivers of the due date and required sections to be completed for the physical. An Annual Physical form with the communicable disease section highlighted with be included in the letter. If a Physical with the communicable disease section not checked is received, it will be sent back to the caregiver with a reminder that the section is required to be completed. In addition, when Program Specialists complete book reviews, they will check the Physicals to ensure this section is completed. 04/05/2017 Implemented
2390.151(d)Individual #6's assessment dated 9/23/16 was not dated when signed by the program specialist.The program specialist shall sign and date the assessment.The Annual Assessment was completed on time, but was not signed by the Program Specialist. When completing book reviews, Program Specialists will check all documents requiring a signature and date to ensure all documents are signed and dated. 04/05/2017 Implemented
2390.151(e)(5)The assessment dated 6/13/16 for individual #2 , the assessment dated 9/1/16 for individual #4 and the assessment for individual #6 dated 9/23/16 did not assess their ability to self-administer medications. The assessment must include the following information: The client's ability to self-administer medications.Whether a consumer self-medicates or does not self-medicate is stated in the Annual Assessment; if a consumer does not take medications it was simply noted that the consumer does not take medications. At the licensing review, the word ¿ability¿ was interpreted as meaning that the Annual Assessment needs to state particularly why a person cannot self-medicate (such as limited cognitive ability, etc.) and that stating a consumer does not take medications is not sufficient. Though the interpretation of the code¿s meaning of ¿ability¿ is not clear, effective 4/5/17, the Program Specialists will make an effort to discover why a person cannot self-medicate, even if the individual has no prescribed medications, and document this reasoning in the Annual Assessment. 04/05/2017 Implemented
2390.151(e)(12)The assessment dated 6/13/16 for individual # 2 did not have recommendations for training, programming, and services.The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.The Annual Assessment noted that PEP was still assessing possible recommendations for the consumer, rather than stating recommendations for training or vocational placement. The information was not completed as the consumer was a new admission and the team felt more time was needed for assessment. As of 4/5/17, recommendations for training or vocational placement will be noted in the Assessment. Reminders in the form of a multiple checklists have been developed to ensure that Program Specialists note recommendations for training or vocational placement in the Annual Assessment. In addition, when Program Specialists complete book reviews, they will review this section of the Annual Assessment 04/05/2017 Implemented
2390.156(a)The quarterly for individual # 1 ending on 3/9/17 was missing. The quarterlies for individual # 2 ending in 2/22/17, 11/22/16 and 8/22/16 were not dated by the program specialist. The quarterlies for individual # 3 period ending 10/4/16, 7/4/16 and 4/2/16 were not dated by the PS. The quarterlies for individual #4 with the period ending 2/27/17, 11/27/16, 8/27/16 and 5/21/16 were not dated. The quarterlies for individual #6 period ending 3/30/17, 12/30/16, 9/30/16 and 6/30/16 were not dated by the program specialist at date of completion. 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.Quarterlies for consumers did not have dates next to the signatures of the consumer and Program Specialist, as the date noted on the Quarterly (the end date of the Quarter) was previously thought to be sufficient. In addition, the licensing reviewers suggested adding a date range, rather than the end date of the quarter, to make the Quarterlies easier to read and to understand. In response, the Program Specialists developed a new Quarterly template, effective 4/13/17, that notes ¿Signature and Date¿ for both the consumer and Program Specialist and notes a time range for the Quarterly. ¿ The Quarterly for W. Lanciano for the date range of 12/9/2016 to 3/09/17 was not completed by the day of the licensing review, 4/4/17. The Quarterly was completed that day. The licensing reviewers noted that 15 days from the end of the quarter is considered to be a timely completion. The Quarterly was not completed as the information needed for the review (case notes, labor history) was not complete within 15 days. Though the 15 day period is not specified in PA code, effective 4/5/17, the Program Specialists will attempt to complete Quarterlies within 15 days of the end of the Quarter if the information needed for the quarterly review is available. As the dates of the Quarterlies are specific to the consumer¿s specific ISP date, the time needed for case notes, production notes, and labor history to be completed is not necessarily available within a 15 day period form the end of that specific consumer¿s Quarter. In addition, the consumer may not be available to review and sign the Quarterly if the consumer is sick or out on vacation. 04/13/2017 Implemented
2390.156(c)(1)Individual #5's monthlies were not completed when due. Monthlies for 12/16, 01/17 and 02/17 were not completed until 3/23/17. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.The information for the consumer¿s monthly was completed on time and stored electronically on the VERTEX system. However, the information was not printed out and placed in the consumers book by the previous Program Specialist (the new Program Specialist printed out the information and dated and signed for the date printed out). As of 4/5/17, the Program Specialists will ensure that the monthly documentation is placed in the consumer¿s book by the following month and will insure that documentation is not missing at the Program Specialist¿s book reviews. 04/05/2017 Implemented
SIN-00084509 Renewal 10/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The lower level men's restroom had a stall bent and corroded on the corner edge. The lower level women's restroom had 2 rusted receptacle covers. The lower level program had 3 ceiling panels detached from the ceiling. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.2390.61 At the direction of the maintenance dept. manager, Gus Nyekan, each of these repairs were made and completed by PEP's maintenance dept. staff by 10/30/15. The maintenance staff will conduct monthly physical site inspections to ensure that all surfaces and equipment are in good repair and free of hazards, starting within 30 days of receipt of this plan of correction. [SW 12.11.15] 10/30/2015 Implemented
2390.67The first floor janitor's closet had a jar of Skippy peanut butter stored with cleaning supplies.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.2390.67 Food in the janitor's closet was immediately removed and staff received disciplinary counseling for keeping food in closet by his manager, Gus Nyekan. Staff was advised to ensure that no food is ever kept in that closet, and that the closet will be monitored daily to ensure compliance. 10/15/2015 Implemented
2390.85(a)-2The fire drill log, dated 8/24/2015, did not include a hypothetical fire location.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.2390.85(a)-2 The fire drill log excluded a hypothetical location of the fire. This was an oversight by the fire marshal and will be more closely monitored in the future by the fire marshal, Beth Ryan, by reviewing the sheet for each fire drill at the monthly safety committee meetings. 10/21/2015 Implemented
2390.151(a)Individual #3's assessment was last completed on 9/21/2014.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.2390.151(a) The citation description above is incorrect for Individual #5. It should read that the assessment should have been completed and sent by 9/21/15 to the Supports Coordinator. An assessment was completed by 10/14/15 which was beyond the 60 day period after admission. This was simply an oversight by program specialist, Laura Shaeffer. Going forward, each program specialist will routinely track their respective caseloads monthly for start date, 60 day assessment date, and annual review date with regular oversight by program director, Robert Scott. 10/14/2015 Implemented
2390.151(c)Individual #4's assessment, dated 2/3/2015, Individual #5's assessment, dated 3/7/15, and Individual #6's assessment, dated 3/20/15, did not include a basis for the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations.2390.15.(c) The assessments for Individual #4 (2/13/15) and for Individual #5 (3/1/15) and Individual #6 (3/20/15) omitted a statement indicating the entire source of the data utilized and compiled by staff for the assessment instrument. A statement has now been included by PEP's program specialist, Lisa Hannum, for Individual # 4 and 5, and by program specialist, Laura Shaeffer, for Individual #6 in the assessment at the beginning of the narrative section for each, with Individual #4 assessment dated 11/16/15, and Individual #5 dated 10/28/15, and Individual #6 dated 11/16/15. Both the initial assessments and the updated assessments for each of these individuals are included as attachments. 11/16/2015 Implemented
2390.151(c)Individual #1's assessment, dated 3/14/15, and Individual #2's assessment, dated 9/22/2015, did not include the basis of the instrument.The assessment shall be based on assessment instruments, interviews, progress notes and observations.2390.15.(c) The assessments for Individual #1 (3/14/15) and for Individual #2 (9/22/15) omitted a statement indicating the entire source of the data utilized and compiled by staff for the assessment instrument. A statement has now been included by PEP's program specialist, Laura Shaeffer, in the assessment at the beginning of the narrative section for each, with Individual #1 assessment dated 11/16/15, and for individual #2 dated 11/16/15. Both the initial assessment and the updated assessment for each of these individuals are included as attachments. The Program Specialist will review all participants assessments to ensure it includes the basis for the assessment, starting within 30 days of receipt of this plan of correction. [SW 12.11.15] 11/16/2015 Implemented
2390.151(e)(7)Individual #5's assessment, dated 3/7/15, did not include knowledge of heat sources.The assessment must include the following information: The client'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.2390.15.(e)(7) The assessment dated 3/1/15 for Individual #5 omitted a statement pertaining to his awareness of heat sources. PEP's program specialist, Lisa Hannum, updated that assessment with a statement of his awareness of heat sources. That updated assessment and the prior assessment are both included in the attachments.The Program Specialist will review all participants assessments to ensure that all the required elements are included, starting within 30 days of receipt of this plan of correction. [SW 12.11.15] 10/28/2015 Implemented
2390.151(f)Individual #7's assessment was not sent to plan team members 30 days prior to the ISP meeting on 12/2/2014.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).2390.151(f) The assessment for Individual #7 was not sent 30 days prior to ISP. The individual¿s assessment actually was sent on 10/15/14 prior to his ISP meeting on 12/2/14. The auditor took issue with the fact that the assessment sent was done on 11/17/13 (or, annually after the initial admissions assessment), while the ISP meeting was held on 12/2/14. Therefore, the assessment that was sent to the Supports Coordinator on 10/15/14 meeting was dated 11/17/13 and was 11 months old. It was current at the time it was sent. The Supports Coordinator was given the more recent assessment (11/17/14) at the aforementioned ISP meeting. Per the suggestion of the auditor, the individual's assessment date will be moved up by one month. The assessment referenced of 11/17/13 by the auditor as well as the newest assessment of 11/17/14 are being forwarded as attachments. 10/28/2015 Implemented
2390.155(b)Individual #2's behavior support plan states a behavior tracking sheet is to be maintained at the day program and the home. This behavior tracking form is not being utilized.The ISP shall be implemented as written.2390.155(b) The ISP for Individual #2 presently indicates that a behavior tracking sheet is to be maintained at the day program and the home. However, this statement was no longer pertinent at the day program and so the program specialist, Laura Shaeffer, spoke with the Behavioral Specialist who confirmed on 10/22/15 that the data tracking form was no longer necessary and should be removed from both the behavioral plan and ISP. The SC was informed of this change on 10/22/15 as well. Upon receipt of the critical revision to the ISP and the behavior plan, we will submit a copy as an attachment. The Program Specialist will review all participants ISP's to ensure that all outcomes documented in the ISP are implimented, starting within 30 days of receipt of this plan of correction. [SW 12.11.15] 10/22/2015 Implemented
2390.156(a)Individual #4 and #7 did not have an Individual Support Plan review for August of 2015. 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.2390.156(a) The program specialist, Lisa Hannum, for Individual #4 and for Individual #7 missed the target date for each of their quarterly reviews: for #4 it should have been done on 8/13/15. For #7, it should have been completed on 8/28/15. She has since completed the reviews for both #4 and for #7 on 10/28/15. Program director, Robert Scott, will assist staff to more closely scrutinize the target dates at the weekly Book Reviews each Wednesday. Both of the updated quarterlies are being forwarded as attachments. 10/28/2015 Implemented
SIN-00065306 Renewal 08/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(13(ii)Individual #2's assessment,dated 10-21-13, did not address progress and growth in the area of motor and communications.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.Individual #2: Staff did include motor and communication skills in the original narrative. However, he did not provide a header for "Motor and Communication Skills." Unfortunately, the staff responsible for that oversight did not point out the omission at the time of the review. (The original document and the revised document are being submitted for your review.) The Program Specialist will review all individuals assessments to ensure that all areas of the assessment is completed within 30 days of receipt of this plan of correction. The Dir4ector will conduct periodic audits of individual assessments to ensure they are complete on a quarterly basis beginning within 30 days of receipt of this plan of correction. [SW 1.6.15] 08/28/2014 Implemented
2390.155(a)Individual #1's plan was not implemented on the start date, 6/6/14, of the ISP.The ISP shall be implemented by the ISP's start date.Individual #1: The initial quarterly report was written on 3/24/14, within 90 days of program start date of 12/31/13. However, staff had incorrectly transcribed the ISP Plan Date from the ISP onto the quarterly report as 1/15/14, rather than the correct date of 3/6/14. Consequently, the successive quarterly reports continued to incorrectly reflect the ISP plan date as 1/15/14, causing the next 2 quarterly reports to be incorrectly planned and dated. Immediately after the licensing review of 8/27/14 those dates were corrected onto the previous quarterly reports and then resulted in the most recent quarterly report of 9/5/14 being correctly planned and dated. Although our team has performed routine reviews of individual files with weekly book reviews, the staff and management now more closely scrutinize this particular element of the process and will continue to do so going forward. (Each of these reports is being submitted for your review.) 08/28/2014 Implemented
SIN-00051821 Renewal 08/22/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(2) Individual #2's assessment dated 8/19/13 did not address area of likes and dislikes.(e) The assessment must include the following information: (2) The likes, dislikes and interest of client, including vocational and employment interests of the client.Newly assigned staff in this past year simply overlooked the "likes and dislikes" section in this person¿s assessment. It was immediately corrected the following work day after the audit exit session. Program director, R. Scott, will ensure staff are fully trained to complete the assessment form in its entirety going forward, and will regularly review the assessment tool to ensure its accuracy. 08/26/2013 Implemented
2390.151(e)(12)Individual #1's assessment dated 2/8/13 did not include recommendations toward specific areas of training.(e) The assessment must include the following information: (12) Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.This individual has clearly expressed that she has no interest in competitive employment, and so the staff overlooked a reference to it. Going forward, an addendum to the assessment will include specific recommendations for areas of vocaational training or placement and competitive employment. Program director will regularly review the assessment tool to ensure this section is included. 10/18/2013 Implemented
2390.151(e)(13)(i)Individual #1's assessment dated 2/8/13 did not include recommendations toward specific areas of training.(e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health.(e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (ii) Motor and communication skills.Program director, Robert Scott, will ensure that all relevant information will be included in the assessment. Also, in the future, we will be sure to address all citations at the exit conference. 10/23/2013 Implemented
2390.151(e)(13)(iii)Individual #1's assessment dated 2/8/13 did not include recommendations toward specific areas of training.(e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (iii) Personal adjustment.(e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas:(iv) Socialization.Program director, Robert Scott, will ensure that all relevant information will be included in the assessment. Also, in the future, we will be sure to address all citations at the exit conference. 10/23/2013 Implemented
2390.151(e)(13)(v)Individual #1's assessment dated 2/8/13 did not include recommendations toward specific areas of training.(e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Program director, Robert Scott, will ensure that all relevant information will be included in the assessment. Also, in the future, we will be sure to address all citations at the exit conference. 10/23/2013 Implemented
SIN-00256867 Renewal 12/09/2024 Compliant - Finalized