Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269637 Renewal 08/05/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(b)Individual #3's record does not contain a letter informing Individual #3 of the decision for acceptance.Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. If accepted, the notification shall specify the service for which the client is accepted. If an individual is not accepted, the reasons for that decision shall be included in the notification.The Director of Admissions and Quality Assurance shall complete checklist, Attachment 2390Admissions, for each new intake. 08/15/2025 Accepted
2390.111(c)Individual #3's record does not contain required admission and placement notifications. Individual #6's record does not contain required admission and placement notifications. Individual #9's record does not contain required admission and placement notifications.The facility shall keep dates of interviews and notifications of admission and denial of admission on file for 3 years.The Director of Admissions and Quality Assurance shall complete checklist, Attachment 2390Admissions, for each new intake. 08/15/2025 Accepted
2390.112(a)Individual #1, #3, #6, and #9's records do not include documentation that orientation occurred.Upon admission, a client shall be oriented to the facility and to the services offered. The date of the orientation shall be written in the client's record.The Director of Admissions and Quality Assurance shall complete checklist, Attachment 2390Admissions, for each new intake. 08/15/2025 Accepted
2390.112(b)Individual #1, #3, #6, and #9's records do not include documentation that Individual #1 was given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client.Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client. A written record of the explanation shall be signed by the client and available in the client's record.The Director of Admissions and Quality Assurance shall complete checklist, Attachment 2390Admissions, for each new intake. 08/15/2025 Accepted
2390.127Individual #8 does not have a valid written consent. It is not dated, nor does the release identify who information can be obtained from.Written consent of the client, or guardian, if the client is adjudicated incompetent, is required for the release of information, including photographs, to persons not otherwise authorized by statute to receive it.Written consent was obtained for Individual #8 on August 7, 2025. Attachment 2390.127 08/29/2025 Accepted
2390.151(e)(1)Individual #7's assessment completed 8/1/24 does not clearly identify their strengths or needs.The assessment must include the following information: Functional strengths, needs and preferences of the client.Individual #7's assessment has been updated to include strengths, needs, and preferences. Attachment 2390.151e1 08/18/2025 Accepted
2390.21(l)The provider did not have conversations quarterly with Individuals #1-9 relating to their preferred community participation and activities as required.A client has the right to make choices and accept risks.Program Specialists shall review their caseloads to identify all individuals whose quarterly conversations have not been held. Those for whom no quarterly conversation has been held shall have a conversation and document it. Attachment 2390.21l. The process of completing quarterly conversations has begun. Attachment 2390.21ldoc. 09/08/2025 Accepted
SIN-00249507 Renewal 08/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.104(4)Individual #2's record does not include information pertinent to diagnosis and treatment in 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.Program Specialist shall complete an Emergency Information form which will include information pertinent to diagnosis and treatment in an emergency. The form to document this information has been sent home with Individual #2. It has not been returned as of 9/6/24. 09/10/2024 Implemented
2390.111(c)Individual #2's record does not include a record of a preadmission interview.The facility shall keep dates of interviews and notifications of admission and denial of admission on file for 3 years.Preadmission interview has been modified to clearly indicate its purpose. 09/03/2024 Implemented
2390.127Individual #1 does not have a valid release on file; they did not sign and date the form. Individual #5 does not have a valid release of information on file. The signed release was dated for 2028.Written consent of the client, or guardian, if the client is adjudicated incompetent, is required for the release of information, including photographs, to persons not otherwise authorized by statute to receive it.Program Specialist shall ensure that Individual#1 signs and dates the form. Program Specialist shall ensure that Individual#5 completes a release of information with the correct date. Attachment 2390.127_#5 is the release of information for Individual #1. Attachment 2390.127_#5 is the release of information for Individual #5. 09/03/2024 Implemented
2390.151(a)Individual #2's record does not include a current Annual Assessment. Individual #5's assessment was completed on 12/2/22 and not again until 1/15/24, outside of the annual timeframe. It is not complete, until the PS signs and dates the assessment.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.An annual assessment shall be completed by the end of October 2024 for Individual #2. 09/10/2024 Implemented
2390.151(e)(1)Individual #1's most recent assessment completed on 7/16/24 did not document their strengths, needs, or preferences. Individual #4's most recent assessment completed on 8/25/23 did not document their strengths, needs, or preferences.The assessment must include the following information: Functional strengths, needs and preferences of the client.The Program Specialist will update the annual assessment for Individual #1 and Individual # 4 to document their strengths, needs, or preferences. Attachment 2390.151e1_#1 is an updated assessment for Individual #1. Attachment 2390.151e1_#4 is an updated assessment for Individual #4. 09/17/2024 Implemented
2390.152(a)Individual #2's record does not include an Individual Support Plan (ISP).The program specialist shall coordinate the development of the individual plan, including revisions with the client and the individual plan team.An ISP shall be completed on or before the anniversary admission date of 1/18/2025 for Individual #2. 09/06/2024 Implemented
2390.153(a)(3)Individual #3 did not have a direct care worker attend their most recent ISP team meeting on 3/28/24. Individual #4's most recent ISP team meeting held on 11/16/23 did not include a direct care worker. Individual #5 did not have a direct service worker attend their most recent ISP team meeting held on 1/12/24. Individual #6's 02/13/24 ISP meeting was attended by a Program Specialist from Lighthouse, but not a direct service worker.The individual plan shall be developed by an interdisciplinary team, including the following: The client's direct care staff persons. Direct Service Workers will attend ISP team meetings moving forward. Attachment 2390.153a3_#1 is the signature sheet for Individual #1's ISP meeting held August 29, 2024. 08/29/2024 Implemented
SIN-00230529 Renewal 09/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87For all individuals attending the facility, there isn't documentation by the fire safety trainer (agency staff) conducting the fire safety training to individuals, which individuals are attending fire safety trainings, when the training is conducted, or the content discussed.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.Provider is maintaining a roster of participants who have been trained for the new training cycle. There are a few participants whose training will be scheduled. See attachment 2390.87R and 2390.87C. 11/01/2023 Implemented
2390.111(a)Individual #2 started attending the vocational setting at the facility on 9/11/23. The date that Individual #2 had a preadmission interview for the vocational program was not kept in their record.A client shall have a preadmission interview.Provider shall write and implement a policy stating that any participant who moves from Adult Training to the Vocational setting shall have a preadmission interview in their record. Attachment 2390.111a 11/07/2023 Implemented
2390.112(b)Individual #2's record states the review of the participant handbook was reviewed with them on 7/21/23. Information that is contained in this handbook was not documented or provided to show the individual received information about the facility's working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures.Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client.The Participant Handbook containing the required information is attached. Attachment 2390.112(b)1 11/07/2023 Implemented
2390.151(e)(5)Individual #1's only assessments in their record, completed on 2/8/22 and 10/21/22, state the agency is unsure if the individual would be able to administer the correct dose of medication or know their medications. There is contradictory information throughout the record whether Individual #1 can self-administer their medications or not. The assessment must include the following information: The client's ability to self-administer medications.Individual #1's annual assessment was completed on 10/6/23 and is attached as 2390.151e5. This assessment reflects the current status of the Individual's ability to self-administer medication. 10/06/2023 Implemented
2390.151(e)(9)Individual #1's current, 10/21/22 assessment doesn't include their medical limitations of their allergy to Trileptal or pollen extracts, their seizure diagnosis, their seizure rescue medication prescribed for seizure events, their prescribed seizure protocol, or any of their medical and functional limitations around their seizures. The individual experienced 2, 5-minute seizures at the facility.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.Provider was not aware of these allergies as of 10/21/22. Individual #1's allergy to Lamictal is noted in their initial assessment. An updated seizure protocol was obtained for Individual #1 along with a matching label for their medication. Information regarding the seizures will be updated to the assessment by 11/14/23. 10/06/2023 Implemented
2390.21(j)Individual #1 has a seizure disorder and is prescribed Nayzilam, a seizure rescue medication administered as a nasal spray. Staff are to administer the medication if the individual has a seizure greater than 3 minutes, per the pharmacy issued-medication label. The order also includes instructions to administer a second dose of the Nayzilam in 10 minutes in the alternate nostril if the seizure continues. During the 9/21/23 onsite inspection, only one dose of Nayzilam nasal spray was available to the individual. On 7/21/23 staff documented the individual had two separate, 5-minute seizures at the facility. Nayzilam was never administered. Individual #1's record contains a physician's ordered seizure protocol developed 2/24/22 that states to administer Midazolam 5mg spray into affected nostril(s) 2 (two) times a day as needed (seizure convulsion lasting greater than 5 minutes) 1 spray as a single dose in 1 nostril for seizure-shaking lasting greater than 5 minutes. According to the individual's medication label on their medication available at the facility for the previous year, from September 2022 to September 2023, they were prescribed Nayzilam 5mg spray use 1 spray into affected nostril(s) 2 times a day as needed (seizure convulsions lasting greater than 3 minutes) 1 spray as a single dose in 1 nostril for seizure-shaking lasting greater than 3 minutes. This seizure protocol and the medication label contradict each other on the amount of time of the seizure before the medication is to be administered. Additionally, the MAR goes back and forth between using the directions on the protocol for the administration of the Nayzilam and the directions on the medication label for administering the Nayzilam. On 9/13/23, the medication label instructed the staff to administer the medication if the individual was having trouble breathing but the 2/24/22 seizure protocol, medication list attached to their 9/19/23 physical examination record, and mars from December 2022- September 2023 state do not administer if having trouble breathing or excessively sleepy. At the time of the inspection, the agency does not know which instruction is the correct and current written orders and instructions from the individual's physician. Individual #1's Nayzilam is to be administered for seizures greater than 3 minutes. The medication is stored in a separate, locked room (approx. 20 feet away) from the individual's program room and in a locked medication closet within this locked room. The only staff who hold the keys to the locked medication room and locked medication cabinet are staff that are not working directly with the individual, and not in the same program room of the individual. The agency does not have a system in place to ensure the medication can be swiftly obtained and administered to the individual should they need it 3 minutes. According to the individual's current seizure protocol, staff need to time, observe, and record what happens during the individual's seizure. Staff are to call 911 if: seizure lasts longer than 5 minutes, if there are repeated seizures, difficulty breathing, if a seizure occurs in water, if the patient is injured, or if the person does not return to their usual state within 10 minutes. On 7/21/23 staff documented that Individual #1 had two separate, 5-minute seizures. · The agency did not track when either seizure started to know if the seizures were considered "repeated seizures." Staff entered notes on 2:20pm and 2:31pm about the separate, 5-minute seizures. · Staff also did not track, monitor, or document if or when the individual returned to baseline to know if 911 needed called. · For the seizures, the following was recorded in the "after" column but did not define how long after the seizure these symptoms persisted: for one of the seizures- the individual states they were very tired, shaky and dizzy. They did not want to attempt walking. For the other seizure- they appeared shaky and lethargic. They stated that they were tired. Staff called the individual's mother and their mother noted that the individual will sometimes talk during a seizure and advised staff not to call 911 at that time. · 911 was never contacted for either seizure. · The agency also reported to the department during the inspection that there isn't a plan or protocol in place to ensure that staff can time the individual's seizures when they occur.A client may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Updated seizure protocol has been developed based on updated physician's order. Staff who administer medication along with the DSP's who support Individual #1 shall be trained in the updated protocol. Attachment 2390.21j Protocol Physician's order has been updated as well as labeling of the nasal spray, so they match. Attachments 2390.21jProtocol and 2390.21jLabel. Medication administration trainers shall be trained by a medical professional on the proper procedures to administer nasal spray. Trainers shall subsequently train the DSPs who administer medications. 11/21/2023 Implemented
2390.153(a)(4)A program specialist, or representative of the facility did not attend Individual #1's 11/6/22 individual support plan planning meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The program specialist. Provider was not notified of the ISP meeting date. 11/01/2023 Implemented
2390.194(c)According to Individual #1's mars they are ordered acetaminophen 325mg tablets, take two tablets every 6 hours if needed for headache. Staff person #4 administered acetaminophen to Individual #1 on 2/10/23 at 11:45am and recorded the medication and dosage was acetaminophen 325mg; two pills wasn't identified as being administered.A prescription medication shall be administered as prescribed.Staff who administer medications were retrained on the importance of ensuring documentation of the medication given is accurate. 11/01/2023 Implemented
2390.195(a)(2)Individual #1's medication administration records (mars) from September 2022 to 9/13/23 do not include the name of the prescriber for their Dexmethylphe er, Acetaminophen, Nayzilam, or Rizatriptan Benzoate medications.A medication record shall be kept, including the following for each client for whom a prescription medication is administered: Name of the prescriber.Medication Administrator Trainers shall ensure MARs include all required information. Attachment 2390.195a2. 10/31/2023 Implemented
2390.195(a)(11)Individual #1's medication administration records (mars) from September 2022 to 9/13/23 do not include the diagnosis or reason for prescribing and administering Dexmethylphe ER 10mg at 12noon.A medication record shall be kept, including the following for each client for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Medication Administrator Trainers shall ensure MARs include all required information. Attachment 2390.195a2. 10/31/2023 Implemented
2390.195(a)(13)Staff persons did not include their name on Individual #1's medication administration records (mars) on the following occasions when they administered medication to the individual: · In March 2023 Staff person #6 administered dexmethylph er to the individual and didn't include their name. · In July 2023 Staff person #5 administered rizatripton to the individual and didn't include their name.A medication record shall be kept, including the following for each client for whom a prescription medication is administered: Name and initials of the person administering the medication.All staff who administer medications have been retrained to include their name on all MARs. Attachment 2390.194c and 2390.195a2. 11/06/2023 Implemented
2390.198(a)At the time of the 9/19/23 inspection, Staff person #5 is administering medications to individuals at the facility. The facility produced records that the staff had their annual medication administration training completed on 5/28/21 and not again until 5/26/23, outside the annual time frame requirement. Additionally, it's unclear if the required medication administration record reviews or medication observations (2 of each) were completed in 2023 as records of their completion were not produced during the inspection. At the time of the 9/19/23 inspection, Staff person #4 was administering medications to individuals at the facility. The facility produced records that the staff had their annual medication administration training completed on 6/3/21 and not again until 5/26/23, outside the annual time frame requirement. Additionally, it's unclear if the required medication administration record reviews or medication observations (2 of each) were completed in 2023 as records of their completion were not produced during the inspection. At the time of the 9/19/23 inspection, Staff person #6 administered medication to Individual #1 in the facility. The Agency did not complete any medication training (initial or annual) to Staff person #6 prior to them administering medications to individuals. Staff person #6 purportedly received annual medication administration training from another provider.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Staff persons 4 and 5 annual training was missed during staff transition. Attachment 2390.198a is documentation that staff person 6 did receive annual medication training from another provider. However, staff person 6 is not permitted to administer medications until her annual training is completed. 11/06/2023 Implemented
SIN-00211607 Renewal 09/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.104(4)Individual #3's record does not include medical information pertinent to diagnose/treat in the event 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.1. Individual #3's record has been corrected to include pertinent information to diagnose/treat in the event of an emergency. (Attachment 1) 10/19/2022 11/18/2022 Implemented
2390.151(a)(Repeat from Inspection Completed 11/17/21) Individual #2's date of admission was 6/28/22. No assessment was completed within 60 days of admission. Individual #4 had an assessment completed on 12/23/21. No documentation was provided verifying Individual #4 had an assessment completed prior to that date.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.1. Documentation of assessment completed 12/24/2020 for Individual #4 was located. See attachment 3. 2. Documentation of an assessment completed within 60 days of admission for Individual #5 is included as Attachment 4. 3. Documentation of Individual #5's admission date is Attachment 5. The admission date is in the lower right of the page. 10/19/2022 Implemented
2390.151(e)(1)Individual #3's most recent assessment completed 11/23/21 did not identify their needs or preferences.The assessment must include the following information: Functional strengths, needs and preferences of the client.1. Individual #3's most recent assessment has been updated to include needs and preferences. See Attachment 6. 11/18/2022 Implemented
2390.151(e)(10)Individual #3 most recent assessment completed on 11/23/21 does not have a completed lifetime medical history.The assessment must include the following information: A lifetime medical history.1. Individual #3's most recent assessment has been updated to include Lifetime Medical History. See Attachment 6. 11/18/2022 Implemented
2390.151(f)(Repeat from Inspection completed 11/17/21) Individual #4's most recent assessment completed on 12/23/21 was sent to the team on that date. The ISP team meeting was held on 12/30/21.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.1. A recent assessment for Individual #6 was sent to the team on September 9, 2022 in preparation for the October 20, 2022 ISP meeting. Attachments 7 & 8 10/19/2022 Implemented
SIN-00196381 Renewal 11/17/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59The telephone number to the nearest hospital was not stored on or near the telephone in the program specialists' offices. The number was half cut off the bottom of the attached sticker.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneThe incomplete sticker was replaced with stickers that were complete and legible. 12/14/2021 Implemented
2390.72(c)Individual #3 is blind. The work aisles and passageways throughout the facility were not equipped with tactile guides.Work aisles shall be marked with visible lines that are at least 2 inches wide. If visually handicapped clients are served, work aisles shall be marked with tactile guides.The lines shall be repainted with tactile guides. 12/17/2021 Implemented
2390.82(a)The written emergency evacuation plan did not include an emergency shelter location or the means of transportation to the emergency shelter location in the event of a fire or emergency not allowing for re-entry of the building.Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.The emergency evacuation plan was updated and provided to the reviewer during the inspection. Evacuation diagrams were posted throughout the building at the time of inspection. 12/14/2021 Implemented
2390.83(b)-1Staff person #4 documented as testing the alarms monthly. However, there aren't records maintained that Staff person #4 is trained in the operation of the fire equipment at the facility or that the alarms were operable during their monthly testing. Staff person #5 also provided documentation that they tested the fire alarms monthly at the facility. There aren't records maintained that they are trained in the operation of the fire equipment at the facility. Additionally, the name of the staff who completed the monthly testing in October, July, June, May, and April 2021 wasn't recorded and testing for March 2021 was missing. The forms provided by Staff person #5 didn't indicate if the alarms were operable during their testing and on 6/23/21 the forms indicated there were issues with the system but didn't indicate what the issues were or if they were fixed.An employe trained in the operation of the equipment shall check the fire alarm monthly. Staff #5 was trained on operation of the fire alarm in 2018. Documentation is attached. 12/14/2021 Implemented
2390.86-4Individual #3 is blind. The facility did not have tactile exit markings on all the exit doors/signs in the facility.There shall be tactile exit markings if one or more visually impaired clients are served.Tactile exit markings have been placed on all the exit doors/signs in the facility. A photo documenting placement is attached. 12/10/2021 Implemented
2390.87At the time of the 11/15/2021 inspection Staff persons #1 and #3 received fire safety training on 9/18/2020 and not again since then.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.Documentation of fire safety training completed on April 16, 2021 was located and is attached. 12/22/2021 Implemented
2390.103The written emergency medical plan does not include the specific hospital or source of health care that the individuals will be transported to in the event of an emergency. The current plan states, "transported to the nearest hospital."A facility shall have a written emergency medical plan listing the following:(1)The hospital or source of health care that will be used in an emergency. (2) The method of transportation to be used.(3) Written consent from the client, parent or guardian for emergency medical treatment.(4) The staffing plan during the emergency.The emergency medical plan has been updated to specify Ephrata Community Hospital as the place where participants will be transported to in case of emergency. The plan is attached. 12/14/2021 Implemented
2390.151(a)Individual #2's date of admission to the facility was 8/31/2020 and their initial assessment wasn't completed, signed and dated by the program specialist, until 12/23/2020.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.Program Specialists shall be trained to ensure initial assessments are completed, signed and dated within one year prior or 60 calendar days after admission. 01/28/2022 Implemented
2390.151(e)(13)(i)Individual #1's 7/16/21 assessment didn't include their current level and progress over the previous 365 days in health. The progress recorded in the assessment was verbatim to their 2020 assessment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually. 01/28/2022 Implemented
2390.151(e)(13(ii)Individual #1's 7/16/21 assessment didn't include their current level and progress over the previous 365 days in motor and communication skills. Their 2020 and 2021 assessments state the same information, therefore not assessing the individual in 2021 of their skills.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.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually. 01/28/2022 Implemented
2390.151(e)(13)(iii)Individual #1's 7/16/21 assessment didn't include their current level and progress over the previous 365 days in personal adjustment skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually. 01/28/2022 Implemented
2390.151(e)(13(iv)Individual #1's 7/16/21 assessment didn't include their current level and progress over the previous 365 days in socialization. The individual's 2020 and 2021 assessments were verbatim, thus not assessing current skill levels and progress over the previous year. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually. 01/28/2022 Implemented
2390.151(e)(13)(v)Individual #1's 7/16/21 assessment didn't include their current level and progress over the previous 365 days in vocational skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually. 01/28/2022 Implemented
2390.40(a)Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, were not kept for all staff. For example, the training source, content, and hours of training Staff person #1 received on 5/21/21 was not kept. Their training record stated they attended a morning session and evening session on 5/21/21, both for 8 hours of training a piece, for a total of 16 hours of training in one day. The content and training source was not documented or provided. The evening session of training on 5/21/21 did not include the name of the employee received credit for completed the training. The agency confirmed during the inspection, that the total number of hours of the training should have been 8. The content of all training provided to Staff person #2 from 3/29/21 to 5/10/21 was not provided. The content and training source for trainings completed on 4/16/21 and 5/21/21 were not provided. Additionally, the training completed on 5/21/21 states it was for a total for 16 hours. However according to the agency, this training was only 8 hours long.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.New employee orientation records for two staff hired after licensing are attached. There has not been an all staff training since licensing. 01/21/2022 Implemented
2390.48(b)(3)Orientation training for Staff person #2 did not include a full review of individuals rights defined in Pa Code 55 chapter 2390.21.The orientation must encompass the following areas: Client rights.The statement of participant rights has been changed to comply with 2390.21. This updated statement has been reviewed with staff #2 and is attached. The updated statement was included in the new employee orientation on December 1, 2021. See attachment for 2390.40a. 12/01/2021 Implemented
2390.49(a)(2)The facility CEO, Staff person #1, only received 16 hours of training for the training year. The agency provided training records stating training occurred on 5/21/21 and 9/17/21, with 16 hours being received in May and 8 hours received in September. However, the agency reported that the 16 hours reportedly received on 5/21/21, was only 8 hours and was documented incorrectly. Therefore, Staff person #1 only received 16 hours of training in the training year. There are no records provided that Staff person #3 received any training over the training year.The following shall complete 24 hours of training related to job skills and knowledge each year: Positions required by this chapter.Additional training documentation was located for staff person #1 totaling 38 hours of training for the agency's training year, October 1 - September 30. Errors on the 5/21/21 documentation form have been corrected. Training documentation was located for staff person #3. Staff person #3 had 30 hours of training in the agency's training year. Documentation is attached for each staff person. 12/14/2021 Implemented
2390.124(1)Individuals #1's and #2's records didn't include their date of admission to the facility.Each client's record must include the following information: The name, sex, admission date, birthdate and place, Social Security number and dates of entry, transfer and discharge.The admission dates are not immediately visible on the demographics page for each participant in Setworks. Program Specialists shall be trained to enter the date of admission so that it is clearly visible. 01/28/2022 Implemented
2390.151(f)Individual #1's 7/16/21 assessment was not sent to the individual and all plan team members, nor sent 30 days prior to the individual's 8/5/2021 annual individual support plan meeting. Their record states the assessment was only sent to their supports coordinator on 8/17/21. Individual #2's 10/1/21 assessment was not sent to the individual and all plan team members prior to the individual's 11/12/21 annual individual supports plan meeting. The assessment wasn't sent to the individual or their LLESS staff and wasn't sent to Individual #2's mother until 11/16/21.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Program Specialists shall be trained to ensure assessments are completed and sent to plan team members at least 30 days prior to the individual meeting. 01/28/2022 Implemented
2390.153(a)(4)The development of Individual #1's current individual support plan did not include the program specialist from the facility. Individual #1's annual individual support plan meeting was held on 8/5/21. The facility program specialist was not present for the meeting either virtually, by phone, or in person, nor did the program specialist provide the team members with Individual #1's assessment prior to the 8/5/2021 team meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The program specialist. The Lighthouse Program Specialist did not attend due to a technical glitch with the online meeting platform. The Program Specialist has been advised to call into meetings via telephone if the situation recurs. 01/28/2022 Implemented
2390.193(d)Multiple, individually packaged containers of Aspirin were unlocked and accessible in the first aid kit in the first aid area. There are individual's attending the facility that are assessed to be unable to self-administer medications and unsafe around poisonous materials.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.All Aspirin was removed from the first aid kit immediately during licensing. All bottles of alcohol based hand sanitizer were removed. 11/19/2021 Implemented
SIN-00150838 Renewal 02/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(b)Individual #7's pre-admission interview was conducted on 2/8/18. Written notification of acceptance was dated 3/22/18. (42 calendar days). Individual #2's pre-admission interview was conducted on 12/11/18. Written notification of acceptance was dated 1/15/19 (35 calendar days).Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. A new position is being created to provide additional support for the intake process and other processes. The Program Director shall ensure systems are established to monitor intakes to ensure they are completed in a timely manner. 06/03/2019 Implemented
2390.151(a)Individual #4's annual assessment was completed 01/12/18 and not again until 02/05/19. Individual #5's assessment was completed 02/02/18, and not been completed since (due 02/02/19).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.Program Coordinator shall develop and implement systems to monitor completion of assessments within required time frame. 05/13/2019 Implemented
2390.153(4)Individual #3's current ISP does not include information on day supervision, or supervision levels while at the pre-vocational program (or when in the community with pre-vocational staff).The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence.Each Program Specialist shall review the ISP when it is updated in HCSIS to ensure information concerning supervision levels while participating in pre-vocational training is current. 03/01/2019 Implemented
2390.156(a)Individual #5's ISP review, due in November of 2018, was not completed. 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.Individual #5's ISP date is September, 2018. His quarterly review was completed 12/3/18. 12/03/2018 Implemented
SIN-00127501 Renewal 01/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(1)Individual # 3 had an assessment 11/08/16 and not in 2017.The program specialist shall be responsible for the following: Coordinating and completing assessments. The Program Coordinator shall ensure Program Specialists fulfill the responsibility for coordinating and completing assessments. 02/21/2018 Implemented
2390.33(b)(6)Individual # 2 takes psychiatric medications for a psychiatric diagnosis and this was not identified until date of inspection. His/her ISP annual review updated is 03/25/17. Individual # 2 is also a fall and choking risk as his/her food must be cut up into small pieces. This content was also not accurate until date of inspection.The program specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions for content accuracy.The Program Coordinator shall ensure Program Specialists fulfill the responsibility for reviewing the ISP, annual updates and revisions for content accuracy. 02/21/2018 Implemented
2390.33(b)(18)Direct service workers are not being trained on resident SEEN plans or respective protocols.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each client.The Program Coordinator shall ensure Program Specialists coordinate training of direct service workers in the content of health and safety needs relevant to each participant. 02/21/2018 Implemented
2390.61The men's bathroom had paint chipping behind the middle and right sink. The far right Urinal was out of order. The center toilet had a wood board and chipping paint behind the toilet. Floor tile was cracking under the left toilet. Floor molding/baseboard under middle sink pulling away from wall at the seam. Paper towel dispenser has packing tape keeping cover on. Cover fell open upon use during inspection. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Plan of Correction ¿ The physical site checklist provided by the Licensing Representative during the review has been adapted for use. The Safety and Transportation Coordinator has been assigned the responsibility to complete a monthly site inspection, document results on the Monthly Site Inspection Checklist, submit the Checklist to the Director of Programs. The Director of Programs shall ensure any issues identified are corrected promptly. Flooring and baseboard molding was replaced February 16, 2018. Remaining repairs will be completed by March 5, 2018. 03/05/2018 Implemented
2390.83(b)-1Monthly fire alarm checks not completed from May 2017-December 2017An employe trained in the operation of the equipment shall check the fire alarm monthly. Plan of Correction ¿ Responsibility to complete monthly checks of the fire alarm was shifted to the Safety and Transportation Coordinator and the General Manager. Both staff were trained on operation of the system by Select Security on January 31, 2018. An initial test of the fire alarm system shall be completed on or before February 28, 2018 and monthly thereafter. 02/28/2018 Implemented
2390.85(b)Fire drills held 04/18/17, 07/27,17, 10/31/17 and 01/25/17 did not include time of day which drills were held.Fire drills shall be held at different times of the day. Fire drill report has been revised to include the time of day at which drills were held. 02/20/2018 Implemented
2390.87Individual # 5 was admitted to program 09/19/17. No documentation that an initial fire safety training occurred. Staff #1 was hired on 07/17/17 and received initial fire safety training on 07/27/17. Individual # 4 began program on 10/05/17. There is no documentation that initial Fire Safety training occurred.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.Plan of Correction ¿ Participant GS was admitted on January 18, 2018 and participant AA was admitted on February 12, 2018. Initial fire safety training was provided to both participants. The Intake Checklist was updated to include Fire Safety Training. See Attachment 02/12/2018 Implemented
2390.112(a)Individual # 4 began program on 10/05/17. There is no documentation that an orientation occurred. Individual # 5 began program on 09/19/17 and there is no documentation that an orientation occurred.Upon admission, a client shall be oriented to the facility and to the services offered. The Director of Programs ensured documentation of orientation for participants admitted on 1/18/18 and on 2/12/18 was completed. 02/12/2018 Implemented
2390.124(5)A physical exam for individual # 5 is not contained in the record.Each client's record must include the following information: Physical examinations.The Program Coordinator has requested a copy of the physical exam for Individual #5 for his record. 02/21/2018 Implemented
2390.124(9)(i)ISP signature sheets not contained in record for Individual # 4Each client's record must include the following information: A copy of the signature sheet for: The initial ISP meeting.ISP signature sheets have been placed in the record for Individual #4. 02/21/2018 Implemented
2390.124(9)(ii)ISP signature sheets are not contained in Individual # 5's record.Each client's record must include the following information: A copy of the signature sheet for: The annual update meeting.ISP signature sheets have been placed in the record for Individual #5. 02/21/2018 Implemented
2390.124(11)(iv)An option to decline ISP reviews was not offered to team members.Each client's record must include the following information: Documentation of ISP reviews and ISP revisions under §  2390.156 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation.Program Coordinator shall ensure plan team members are offered the option to decline ISP reviews. 02/21/2018 Implemented
2390.124(12)Individual # 7's assessment date 10/17/17 states that Individual #7 is capable to remain at his/her work station with visual supervision for 30 minutes. ISP dated 12/12/17 states he/she is able to be at his/her work station with visual supervision for up to 15 minutes. Individual # 1's current physical states to limit sugary sweets and drinks. Current ISP states Individual # 1 has a regular diet.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Individual #7¿s assessment has been updated to match the ISP regarding supervision needs. The Program Coordinator has contacted Individual #1¿s Supports Coordinator requesting the ISP be updated to match his physical. 02/21/2018 Implemented
2390.151(e)(4)Individual # 1's 9/14/17 assessment states Individual # 1 always has some kind of supervision when he/she is at lighthouse, both on the work floor and in the break room. He/she can be at his/her workstation for up to 45 minutes at a time with visual supervision. Specific details of supervision needs unclear. Individual # 3's assessment states 30 minutes visual supervision at a time. Specific details of supervision unclear. The assessment must include the following information: The client's need for supervision.Assessments for Individuals 1 and 3 have been updated to provide specific details of supervision needed by each one. 02/21/2018 Implemented
2390.151(e)(7)Individual # 1's 09/04/17 assessment does not state his/her ability to sense and move away quickly from heat sources. Individual # 3's assessment does not state his/her ability to sense and move away quickly from heat sources. Individual # 4's 10/30/17 assessment does not indicate his/her ability to move away from heat sources. Individual # 6's 03/15/17 assessment does not indicate his/her ability to sense and move away from heat sources. Individual #5's 11/07/17 assessment does not indicate his/her ability to move away from heat sourcesThe 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.Assessments for Individuals 1, 3, 4, 5 and 6 have been updated to provide information about the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. 02/21/2018 Implemented
2390.153(7)(i)Individual # 6's 04/27/17 ISP does not assess his/her potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.The Program Coordinator has contacted Individual #6¿s Supports Coordinator requesting to update the ISP to include an assessment of Individual #6¿s potential to advance in vocational programming. Awaiting response. 02/21/2018 Implemented
2390.156(a)Individual # 1's October 2017 ISP review was not contained in the record. Individual # 3's October 2017 ISP review was not contained in the record. 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.Records have been updated to include missing reviews. The Program Coordinator shall monitor records to ensure all reviews are completed and filed timely. 02/20/2018 Implemented
2390.156(c)(2)Repeat 11/09/16. Individual #6 is diagnosed with a seizure disorder. ISP reviews did not indicate seizure protocol utilization or indicate the presence/absence of seizures. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Coordinator contacted Individual #6¿s residential provider and a seizure protocol is developed and in place. 02/22/2018 Implemented
2390.156(d)Repeat 11/09/16- There is no documentation that 11/08/17 ISP review for Individual #4 was sent to team members. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Documentation that 11/08/17 ISP review for Individual #4 was sent to team members was completed and is in the file. 02/22/2018 Implemented
SIN-00104035 Renewal 11/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The Cedar plank work station contained a 5 foot section of uncovered electrical cords right behind the individual¿s seats, causing a tripping hazard. Tape was not over the cords like The rest of the 10 foot section of electrical cord. There was an 18¿X5¿X1/2¿ piece of dryer lint in the dryer in unisex bathroom. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The Physical Resource Manager removed all electrical cords from the area cited. The Director of Programs shall develop a safety checklist to be completed at least monthly to ensure all floors, walls, ceilings and other surfaces are in good repair and free of visible hazards. A checklist has been put in place to remind staff to remove lint from the dryer after each use. The Personal Care Assistant shall complete the checklist, indicating the lint has been removed after each use. The STP Team Lead is responsible to monitor the checklist weekly to ensure it is being completed and lint is removed after each use. 01/31/2017 Implemented
2390.67Sanitary conditions- Individual #2 was packaging seasoning without a plastic apron clothing guard and without plastic gloves. She was using her bare hands.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.The Food Line Supervisors shall ensure all workers wear appropriate equipment when packaging food products. The Director of Programs retrained food line staff of the importance of ensuring workers wear appropriate equipment when packaging food. The Director of Programs shall regularly monitor the food line and immediately remind anyone who is not wearing appropriate equipment. Continued noncompliance shall result in teaching/training and may result in the worker¿s removal from the food line if noncompliance persists. 01/31/2017 Implemented
2390.72(c)-2Individuals #8 and #9 are blind/visual impaired. The work aisles were not equipped with tactile guidelines. If visually handicapped clients are served, work aisles shall be marked with tactile guides.The Physical Resource Manager shall ensure tactile lines are painted by January 31, 2017. The Director of Programs shall develop a safety checklist to be completed at least monthly to ensure all work areas are safe and in compliance with applicable regulations. 01/31/2017 Implemented
2390.124(12)Individual #6's isp lists diagnosis of anxiety/depression for which she takes Prozac for. Then isp indicated she didn¿t have a mental health diagnosis. Individual #4's 10/18/16 med list indicated allergies to penicillin, sulfa drugs, bees, latex, Keflex, mold, soy, dust, Zocor, pravachol, and grass. 2/5/16 assessment and isp only indicated Allergies to wheat, dust mites, soy, cats, sulfa drugs, penicillin, and seasonal. Assessment indicated she didn¿t have mh diagnosis. But assessment also said diagnosis of anxiety, ocd, pdd. Isp indicated diagnosis of ocd, pdd, anxiety. Individual Dwayne leonard¿s assessment indicated he didn¿t take psychotropic meds for adhd. Isp indicated he took Ritalin for adhd. Medication list indicated he took methylphenidate for adhd. Individual orie Hershey¿s assessment indicated diagnosis of pdd and obsessive paraphilia. Isp indicated dx: ied, ocd, Paraphilia, narcissistic, and antisocial behaviors. Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Program Specialists I & II shall ensure current assessments for Individual #6 is updated by January 31, 2017 to include progress and growth in the area of personal adjustment. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(a)Assessments for #7 and #6 were not completed. 2015 and 2016 assessments were essentially the same document, word for word. 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.Program Specialists I & II shall ensure current assessments for Individuals 6 and 7 are updated by January 31, 2017 to include progress and growth in the area of personal adjustment. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(3)(i)Progress and growth in assessment missing in area of health for individal #4, individual #5, and individual #1.The assessment must include the following information: The client's current level of performance and progress in the following areas: Acquisition of vocational functioning skills.Program Specialists I & II shall ensure current assessments for Individuals 1, 4 & 5 are updated by January 31, 2017 to include progress and growth in the acquisition of vocational functioning skills. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(3)(iii)Prog and growth in personal adjustment in assessment missing from individual #4, individual #3, individual #7, and individual #1.The assessment must include the following information: The client's current level of performance and progress in the following areas: Personal adjustment.Program Specialists I & II shall ensure current assessments for Individuals 1, 4 & 5 are updated by January 31, 2017 to include progress and growth in the area of personal adjustment. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(3)(iv)Prog and growth in socialization in assessment missing from individual #4. The assessment must include the following information: The client's current level of performance and progress in the following areas: Personal needs with or without assistance from others.Program Specialists I & II shall ensure current assessments for Individuals 1, 4 & 5 are updated by January 31, 2017 to include progress and growth in the area of socialization. Program Specialists I & II II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(5)The assessment for individual #5 didn¿t indicated¿he would need staff to assist to take meds. He is able to administer meds himself. He would be able to use bell system as reminder to take his Meds.¿ The assessment must include the following information: The client's ability to self-administer medications.Program Specialists I & II shall ensure current assessments for Individuals 1, 4 & 5 will be updated by January 31, 2017 to include progress and growth in the area of medication administration. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(10)The assessment for individual #3 didn't have lifetime med history. The assessment must include the following information: A lifetime medical history.Program Specialists I & II shall ensure current assessments for Individuals 1, 4 & 5 will be updated by January 31, 2017 to include a lifetime medical history. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(13(iv)The assessment for individual #4 didn¿t include current level of needs with or without assistance. Assessment indicated independent with familiar tasks but needs staff assistance with unfamiliar tasks. Didn¿t clarify what the tasks were. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialists I & II shall ensure durrent assessments for Individuals 1, 4 & 5 are updated by January 31, 2017 to include progress and growth in the area of level of need for assistance. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(e)(13)(v)Prog and growth in vocational skills in assessment missing from individual #7's assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Program Specialists I & II shall ensure current assessments for Individuals 1, 4 & 5 will be updated by January 31, 2017 to include progress and growth in the area of vocational skills. Program Specialists I & II will retrain all Program Specialists by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.151(f)Individual #5's assessment sent to team members on 7/11/16 but isp meeting was on 8/9/16. Individual #4 assessment wasn¿t sent to day program excentia. Individual #3's assessment sent 12/9/15 and isp meeting 1/7/16. 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 Director of Programs retrained the Program Specialist II that changes in the dates of ISP and Quarterly Review meetings must be clearly documented as to the reasons why. The Director of Programs retrained the Program Specialist II that all team plan members must be provided with the assessment at least 30 calendars prior to the ISP meeting. 12/20/2016 Implemented
2390.153(5)No seen plan in isp for individual #6, individual #1, individal #4, and individual #5. A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.A SEEN plan will be written for Individuals 1, 4, 5 & 6 by January 31, 2017. SEEN plans for Individuals 1, 4 and 6 will be updated to be included in the ISP. A general update will be requested to the respective Supports Coordinators. The plan will ensure all medications match current psychiatric illness diagnoses. Program Specialists I & II shall ensure plans are written by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.156(c)(1)Isp reviews for Individual #4, individual #5, individual #6, individual 7, individual #8, individual #2, individual #3, and individual #1 did not review outcome. Did not specify which part of outcome were working on, and participation and progress towards it. 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.Program Specialists I & II will ensure proper progress and monthly documentation for the prior 3 months toward ISP outcomes. Files for Individuals 1 ¿ 8 will be updated by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 All Program Specialists will be retrained by Program Specialists I & II to write quarterly reviews and proper documentation by January 31, 2017. 01/31/2017 Implemented
2390.156(c)(2)1:1 supervision not reviewed on individual #5 isp reviews. Supervision in bathroom not reviewed on individual #6 isp reviews. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialists I & II will ensure supervision needs for Individuals 5 & 6 will be added to the ISP quarterly reviews and records will be updated by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.156(c)(4)(iii)Isp review for individual #6 12/10/15 indidicated she didn¿t meet goal of working for 15 minutes in her work station. Next isp review covered a goal of working until end of day. No Recommendation made to add that outcome. The ISP review must include the following: The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made.Program Specialists I & II will ensure that the updated goal section for individual #6 includes progress performance as well as projected goal for the next quarter by January 31, 2017. The Director of Programs will ensure files for all individuals are reviewed to ensure compliance by April 1, 2017 01/31/2017 Implemented
2390.156(d)Individual #6 6/16/16 isp review did not indicate that it was sent to all team members. No signature page for this one like the other reviews. Individual #4's isp reviews not sent to excentia. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Effective January 1, 2017, Program Specialist will use standard LVS signature page for all ISP/Quarterly reviews, ensuring all team members received a copy of the review. 01/01/2017 Implemented
SIN-00086744 Renewal 11/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.124(10)Individual #7 did not have a copy of current ISP in the record. Each client's record must include the following information: A copy of the current ISP.ISP was received via fax for Individual #7 on November 19, 2015 by SC. Program Specialists will review individual records on a monthly basis to assure a current ISP or ISP Revision is in each individual's file. A form will be developed to ensure monthly tracking for 30 day follow up. All records will be reviewed by December 31, 2015. 12/31/2015 Implemented
2390.153(5)Individual #6 and #7 did not have a SEEN plan in the ISP. A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Program Specialists will request an ISP General Update via fax for Individuals #6 and #7 to include a statement regarding their SEEN plans. All records will be reviewed, to ensure compliance with all current records. Program Specialists I & II will highlight SEEN plans at Annual ISP meeting to ensure SC enters information into the ISP document. A form will be developed to ensure monthly tracking for 30 day follow up. 12/31/2015 Implemented
2390.156(a)Individual #1's ISP reviews on 11/9/14, 2/4/15, 6/17/15, and 9/11/15 did not take place every 3 months. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.Program Specialists will be retrained by Program Specialists I & II to ensure the time frames for all ISP reviews are scheduled every three months when the monthly meeting schedule is published. Program Specialist II will review the master calendar on a monthly basis to ensure compliance is met. All records will be reviewed by the Program Specialists to ensure compliance. 12/31/2015 Implemented
2390.157Individual #1 had ISP meeting on 11/19/14 and approval letter on 1/15/15. Individual #6 had ISP meeting on 3/11/15 and approval letter on 6/3/15. Individual #7 has ISP meeting on 8/19/15 and had no approval letter in the record. A copy of the ISP, ISP annual update and ISP revision, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, ISP annual update and ISP revision meetings.Program Specialists I & II will develop a request form for Individuals #1,#6,#7, and all individuals going forward, to be faxed to the SC requesting that a copy of the individual's ISP, ISP Annual Update, and ISP revision are provided to plan team members within 30 calendar days. Program Specialists will review all ISP records by December 31, requesting a copy from the SC if not in compliance. Program Specialists will be retrained in correct procedure for ensuring date compliance for the individual's ISP, ISP Annual Update, and ISP revision. The request form will be kept in case note file for each individual. A request will be made every 30 calendar days until ISP, ISP Annual Update, and ISP Revision is received. 12/31/2015 Implemented
2390.158(b)Individual #1, #2, #3, #5, #6, #7 ISP reviews did not include participation in community life. The facility shall provide opportunities and support to the client for participation in community life, including competitive community-integrated employment.Program Specialists I & II will retrain all Program Specialists on how to accurately document client participation in community life on the IWPP quarterly report. All records will be reviewed by Program Specialists in order to ensure compliance with this section on all reports. IWPP training document has been revised to reflect community life inclusion. Individuals #1,#2,#3,#5,#6,#7 were revised to include the community life section. 12/31/2015 Implemented
SIN-00071460 Renewal 11/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.104(4)Individual #14's Individual Support Plan (ISP) stated that they are to take insulin when their blood sugar reached a certain number. After discussion with director of programs, she confirmed that there wasn't a written protocol for medical emergency information should individual #14 need it due to a very high or very low insulin level. 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.Director of Programs will meet with Program Specialist to develop & implement a detailed & specific emergency medical protocol for individual #14 related to the diabetes & what steps to take if levels very high or very low. Director of Programs will train all staff that work with individual #14 on the emergency protocol. Program Specialist will file original in individual #14 file at Lighthouse. Copy will be placed on clipboard in work area for floor supervisor to have ready access to if something should occur. Program Specialist will fax copy to SC and request that a statement be added that an emergency medical protocol is kept on file at Lighthouse. Program Specialist will add statement on the assessment that Lighthouse has an emergency medical protocol for individual #14 in the file. All records were reviewed from the date of licensing through December 31, 2014 to ensure that all files were within compliance. 12/12/2014 Implemented
2390.124(1)The place of birth is missing from Individual #11, Individual #13, and Individual #15's record. Each client's record must include the following information: The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge.Director of Programs will retrain Program Specialists on what each individual¿s record must include upon admission into the program. Program Specialists will obtain the place of birth for individuals #11, #13, #15 and document it on the admission intake form in each individuals file. All records were reviewed from the date of licensing through December 31, 2014 to ensure that all files were within compliance. 12/12/2014 Implemented
2390.124(12)The current physical for Individual #14 states he is to follow a 1800 calorie American Diabetic Association (ADA) diet. Individual #14's Individual Support Plan (ISP) states he is to follow a diabetic diet. Individual #14's ISP states that he is to administer insulin, 1 unit per every 50 points over 120 (sugar). Lighthouse confirmed that they do not have a protocol to follow since Individual #14 moved into a group home from his parent's home. Lighthouse stated they just do what the group home tells them is in the doctor's orders. They did not have a formal protocol in place to assure the correct procedure was being followed. Also, there was no documentation of the Program Specialist informing the SC of the discrepancies between the ISP and physical form.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Director of Programs will retrain Program Specialists in the expectations of reviewing ISP¿s & physical forms for individuals; when to contact SC¿s in order to request correct information when discrepancies found; documentation required through this process. 12/12/2014 Implemented
2390.151(a)Individual #3 had an assessment completed on 5/16/13. She did not have another assessment completed until 7/3/14.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.Director of Programs will retrain Program Specialists on the required time frame allowed for initial & annual assessments to be completed. Monthly calendars will be established & implemented with the dates when assessments are to be completed. all records were reviewed and compliant. 12/31/2014 Implemented
2390.151(e)(5)The assessment for Individuals #3, #14, #16, #1, #4, #2, #5, and #14 did not have their ability to self administer medications. The assessment just stated they do not take medication while attending the program. The assessment must include the following information: The client's ability to self-administer medications.Director of Programs will retrain Program Specialist on how to accurately document on the assessments the ability of individuals to self-medicate. Program Specialists will be asked to develop & implement into assessments individuals #3, #14, #16, #1, #4, #2, #5, #15 their ability to self-medicate. Program Specialists will be asked to review all assessments to ensure that this section is completed accurately for each individual on their caseload. All records were reviewed from the date of licensing through December 31, 2014 to ensure that all files were within compliance. 12/31/2014 Implemented
2390.151(e)(6)The assessment for Individuals #3 and #14 did not have their ability to safetly use or avoid poisonous materials. The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Director of Programs will retrain Program Specialists on how to document potential movement for individuals in the area of vocational programming. Program Specialist will be asked to develop & document potential to advance in the area of vocational programming for individual #16. All records were reviewed from the date of licensing through December 31, 2014 to ensure that all files were within compliance. 12/31/2014 Implemented
2390.151(e)(7)The assessment for Individuals #2 and #14 did not contain their knowledge of the danger of heat source and their ability to move away from the 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.Director of Programs will retrain Program Specialist on how to accurately document on the assessments individuals ability to understand & know about heat sources & how to be safe around them. Completed by 12/12/14. Program Specialists will be asked to develop & implement into assessment for individuals #2, #14 their ability to understand & know about heat sources & how to be safe around them. Completed by 12/12/14. Program Specialists will be asked to review all assessments to ensure that this section is completed accurately for each individual on their caseload. Completed by 12/31/14. All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/31/2014 Implemented
2390.151(e)(13)(i)The assessment for Individual #13 did not have the individual's progress and growth in the area of health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Director of Programs will retrain Program Specialist on how to accurately document on the assessments individuals progress and growth from year to year in the area of health. Completed by 12/12/14. Program Specialist will be asked to develop & implement into assessment individual #13 the progress & growth in the area of health. Completed by 12/12/14. Program Specialists will be asked to review all assessments to ensure that this section is completed accurately for each individual on their caseload. Completed by 12/31/14.All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/31/2014 Implemented
2390.151(e)(13(ii)The assessment for Individual #13 did not have the individual's progress and growth in the area of motor and communication skills.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.Director of Programs will retrain Program Specialist on how to accurately document on the assessments individuals progress and growth from year to year in the area of motor & communication skills. Completed by 12/12/14. Program Specialist will be asked to develop & implement into assessment individual #13 the progress & growth in the area of motor & communication skills. Completed by 12/12/14. Program Specialists will be asked to review all assessments to ensure that this section is completed accurately for each individual on their caseload. Completed by 12/31/14.All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/31/2014 Implemented
2390.151(e)(13(iv)The assessment for Individual #15 did not have the individual's progress and growth in the area of socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Director of Programs will retrain Program Specialist on how to accurately document on the assessments individuals progress and growth from year to year in the area of socialization. Completed by 12/12/14. Program Specialist will be asked to develop & implement into assessment individual #15 the progress & growth in the area of socialization. Completed by 12/12/14. Program Specialists will be asked to review all assessments to ensure that this section is completed accurately for each individual on their caseload. Completed by 12/31/14. All records were reviewed from the date of licensing through December 31, 2014 to ensure that all files were within compliance. 12/31/2014 Implemented
2390.151(f)The assessment for Individual #16 was not sent to team members. The area to be filled out as to who the assessment was sent to and the date it was sent, was left blank in both spots. 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).Director of Programs will retrain Program Specialists on the process once an assessment is completed the time frame that is required for the assessment to be sent to all team members; documentation of how assessment sent to all team members. The responsible staff will be Program Specialists I and II. All records were reviewed and compliant. 12/12/2014 Implemented
2390.153(5)The Individual Support Plan (ISP) for Individuals #1, #12, #14, and #16 did not have a protocol to address the social, emotional and environmental needs of the individuals who are all diagnosed with psychiatric illnesses. REPEATA protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Director of Programs will retrain Program Specialist on the process of how to report when an individual is on a SEEN plan in order for it to be incorporated into the ISP correctly. Program Specialists will develop statement for individuals #1, #12, #14, #16 and fax to SC¿s requesting that the information be added to the individual¿s psychosocial section of their ISP¿s. Program Specialists will also request that an update be sent for each individual for Lighthouse¿s records & to ensure that it has been completed accurately. Documentation will be completed in form of a case note in each individuals file. All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/12/2014 Implemented
2390.153(7)(i)The Individual Support Plan (ISP) for Individual #16 did not contain her potential to advance in the area of vocational programming. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.Director of Programs will retrain Program Specialists on how to document potential movement for individuals in the area of vocational programming. Program Specialist will be asked to develop & document potential to advance in the area of vocational programming for individual #16. All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/12/2014 Implemented
2390.153(7)(ii)The Individual Support Plan (ISP) for Individuals #13, #14, and #16 did not contain their potential to advance in the area of community-integrated employment. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.Director of Programs will retrain Program Specialists on how to document potential movement for individuals in the area of community integrated employment. Program Specialists will be asked to develop & document potential to advance in the area of community integrated employment for individuals #13, #14, and #16. All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/12/2014 Implemented
2390.156(a)Individual #15 had an Individual support plan review on 4/9/14 and not again until 7/31/14. 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.Director of Programs will retrain Program Specialist to review the time frame for meetings to be scheduled and implement a master calendar to ensure that individuals and time frames are being met. Program specialists will ensure all ISP reviews are done on a 90 day time frame. All records were reviewed 12/31/2014 Implemented
2390.156(c)(2)Individual #16 had a physical in August of 2014 where she started taking Concerta for ADHD. Individual #16 did not have a plan to address their social, enviornmental, and emotional needs nor is it being reviewed on their Individual Support Plan (ISP) reviews. The ISP review this effects is 10/28/2014. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Director of Programs will purchase a DSMV to be able to reference when diagnosis & medication is in question. Program Specialist will develop & implement a SEEN plan for individual #16 as of 12/12/14. Director of Programs will review the SEEN plan & sign off on the plan. Director of Programs will have Program Specialist contact SC to ask that the new medication & SEEN plan be added to the individuals ISP in order for the team to keep track of individual¿s progress on the SEEN plan. Program Specialist will document through case notes the progress of the communication with the SC. Director of Programs will retrain Program Specialists in the process of any medication changes that would require Lighthouse to develop a SEEN plan; notification to SC of the change; developing statement for psychosocial section to be faxed to SC; requesting update of ISP once SEEN plan added to ISP; documentation of all communication. All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/12/2014 Implemented
2390.159(3)(ii)The vocational evaluation for Individual #11 did not contain employment objects for the individual. If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The employment objectives for the client.The director of programs will retrain Program Specialists in the process of writing and reviewing the document to ensure that all areas of the vocational evaluation is completed in detail and with accuracy. The Program Specialist will be asked to develop and document employment objectives for individual #11. All records were reviewed from the date of licensing through December 31, 2014 to ensure that the files were within compliance. 12/12/2014 Implemented
SIN-00167902 Renewal 11/30/2020 Compliant - Finalized