Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235643 Renewal 12/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(b)The first aid did not contain a bed or cot. (The item was a stretcher type component that was 2 inches off the floor)The first aid area shall have a bed or cot, a blanket and a first aid kit.Director of habilitation reviewed cot with facilities coordinator whom confirmed cot was ordered from a camping company which was specifically for individuals with varying body types and sizes. 01/12/2024 Implemented
2390.60(d)The first aid kit #1 did not contain tweezers (corrected) The first aid kit #2 did not contain tape. (corrected)First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors.Upon discovery tweezers and tape were placed in first aid kit by program specialist. 01/12/2024 Implemented
2390.87Staff #1 has not been reinstructed annually in general fire safety.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.Individual selected works the evening shift (without clients present). Director of Habilitation and Associate Director must coordinate a day and time to have this completed with staff. 01/12/2024 Implemented
2390.87Individual 4's last fire safety was dated 10/18/22. There was no current fire safety in the record.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.Upon discovery, client was trained in fire safety from program specialist. 01/12/2024 Implemented
2390.87There was no fire safety training in the record for individual #1 in the record.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.Upon discovery, client was trained in fire safety by the program specialist. 01/12/2024 Implemented
2390.102There is not at least one staff person certified in first aid techniques present at bldg. #365 when clients are at that facility/building. (In event of an emergency a certified person trained in first aid would have to be notified and go to the other building)At least one staff person certified in first aid techniques within the past 3 years shall be present when clients are at the facility. There shall be written documentation of the certification.Director of Habilitation retrained production manager on first aid training requirements for 2390 facilities. 01/12/2024 Implemented
2390.112(a)Individual #3 left APS in November of 2022. The reason stated was due to behavioral issues. When individual returned in November of 2023. No orientation records were in their record for return to APS.Upon admission, a client shall be oriented to the facility and to the services offered. Director of habilitation retrained associate director and program specialists on completing orientation for clients out of program for extended period. 12/05/2023 Implemented
2390.125Individual #4's file did not contain a physical. One was requested.There shall be a written policy governing access to, duplication of and dissemination of information from the records. This policy shall designate staff authorized to have access to the files.Director of Habilitation was able to locate physical in client's record, and unsure of this citation. 01/12/2024 Implemented
2390.151(a)404 days elapsed between individual #2's 1/14/22 assessment and 02/21/23 assessment, which exceeds the annual (365 day) requirement.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 habilitation and associate director were retrained on assessment dates during licensing inspection. 01/12/2024 Implemented
2390.151(a)The 2022 and 2023 annual assessments for individual #1 are identical and therefore do not show progress over the last 365 days. Individual #3's current assessment was requested and an assessment from 5/27/2022 was provided with the name of the client written differently than on other documents in the file. Also, the assessment provided is outdated.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.Upon discovery, program specialist completed new assessment for client. 01/12/2024 Implemented
2390.151(d)Individual #4's annual assessment was dated 11/15/22 which at the time of inspection was beyond the regulatory time frame. In addition, the assessment provided was not signed by the program specialist.The program specialist shall sign and date the assessment.Upon discovery, the program specialist signed the assessment. 12/05/2023 Implemented
SIN-00163639 Renewal 10/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)The Alarm Test Record for Plant #1 located at 325 Andrews Road, dated 09/12/19 was held past 90 calendar days.A fire drill shall be held at least every 90 calendar days. This area of non-compliance was identified on the day of the fire drill, which was the 91st day after the previous fire drill. Director of Habilitation immediately retrained Program Specialists on this regulation and a corrective action plan was implemented (please see attachment 1). The attached documentation was reviewed by licensing staff during the inspection. 09/12/2019 Implemented
2390.151(a)Individual#1, started the program on 6/11/2019 the initial assessment was not completed until 8/19/2019. Assessment not completed 60 calendar days after admission to the facility.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 were retrained on this regulation and specifically that there is no grace period for the initial assessment. All other new client records for the past 12 months were reviewed and all Initial Assessments were completed within 60 days. At this time, there are no new clients for whom an initial assessment is still pending. Going forward, when a new client starts the program, the Associate Director will put a reminder in the calendar 2 weeks prior to the initial assessment due date and confirm that assessment has been completed at least one day prior to due date. 10/31/2019 Implemented
SIN-00141185 Renewal 07/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.56The single men's restroom on the program floor did not have hot water at the time of the inspection.A facility shall have hot and cold running water that is suitable for drinking purposes, in bathrooms and kitchen areas.Work order submitted on 7/31/18, system checked on 8/1/18 and everything was in working order (attachment #7). The issue could not be duplicated. All faucets were checked on 8/1, 8/2, 8/3, 8/9 and 8/13; the water was hot within 30 seconds at each faucet during each check. Both the building manager and Associate Director checked the faucets several more times during the remainder of August and throughout September. Again, there were no issues noted. Water temperature checks were added to monthly building checklist (attachment #2). Safety committee representative will ensure water checks are completed with monthly building inspection starting in October. (Note: Director of Habilitation participated in the August Safety Committee meeting and requested that "hot water checks" be added to the building inspection form. The Safety Committee chair was absent for this meeting so the Secretary noted the request, but deferred any further action until the Chair was present. On September 12 the Committee voted on the motion to revise the form; the motion carried and the form was revised on October 5. There is no completed form yet to include for documentation, so the blank form is being submitted. See attachment #8.) While the issue could not be duplicated, we have decided to replace our current water heaters with a high capacity, "on demand" system to ensure that there are no future issues. The third and final estimate for this process should be received in October and the new system should be installed by mid-November. 10/05/2018 Implemented
2390.59On the program floor at station #2 there were no emergency numbers posted by the telephone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneAssociate Director posted emergency numbers at each landline phone and in various locations around the work floor (attachment #1). Associate Director will ensure numbers are still posted during completion of quarterly fire drills. Staff were retrained regarding this regulation and oriented to the location of each posting (attachment #5). 08/02/2018 Implemented
SIN-00256538 Renewal 12/03/2024 Compliant - Finalized
SIN-00215768 Renewal 12/02/2022 Compliant - Finalized