Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261003 Renewal 01/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(l)The provider did not hold conversations with the following individuals relating to their preferred community participation and activities as required by ODP Announcement 24-061: Individual #1 Individual #2 Individual #3A client has the right to make choices and accept risks.The vocational director will develop a protocol to address implementing ODP Announcement 24-061. This protocol will explain the process of having and documenting quarterly conversations around preferred community participation and activities. The program specialist and the vocational team leader will be trained on the new protocol to ensure that conversations are had relating to their preferred community participation and activities. 03/10/2025 Implemented
SIN-00237511 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.63The light in the closet located in the bathroom is not operational.Rooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents.Maintenance supervisor replaced the light bulb in the bathroom closet on January 18, 2024. Additionally, a sign was placed on the door asking for the door to be kept locked. Attachment #1 01/18/2024 Implemented
2390.67There was a chair on the floor of the program with a broken back and was unable to be corrected. There was an unsteady table on the vocational program floor.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.Maintenance supervisor removed broken chair and disposed of it and stabilized the unsteady table to ensure safe conditions. 01/17/2024 Implemented
2390.71(a)There was no working ventilation in two of the bathrooms within the building.Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation.Maintenance supervisor contracted with Robaire to repair the shared ventilation system for the two bathrooms cited. Repairs to the ventilation system were completed March 1, 2024. Attachment #3 03/01/2024 Implemented
2390.81The warehouse door #9 was obstructed by a company vehicle disallowing access in case of an emergency. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.Vocational director had the company vehicle that was blocking door #9 during on-site inspection January 17, 2024. On January 18, 2024 a sign was posted on door #9 stating NO PARKING. During vocational staff meeting that was held on February 21, 2024 the staff were re-trained on 2390.81, ensuring that exits are to be unobstructed. Attachments #4 and #5 01/17/2024 Implemented
2390.87Staff #1 was not reinstructed annually in general fire safety and in the use of fire extinguishers. No written record was provided during inspection.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Staff #1 was retrained in fire safety and the use of fire extinguishers by Fire safety trainer on 2/21/24. Attachment #6 02/21/2024 Implemented
2390.151(d)Individual #1 annual assessment dated 11/21/23 was not signed and dated by the Program specialist.The program specialist shall sign and date the assessment.Program Specialist met with Individual #1 on January 18, 2024 to review and sign the annual assessment. Attachment #7 01/18/0204 Implemented
SIN-00218045 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.53The planks in the ramp outside exit door 8 are buckling in toward their middle, causing water to pool in the concave space created. This poses a slip and fall hazard.Outside walkways shall be free from ice, snow, leaves, equipment and other hazards.The ramp outside of exit door 8 will be repaired by Growth Horizons' Maintenace staff. On January 27, 2023, all of the planks were removed from the ramp and replaced with new planks. On January 31, 2023, the ramp was painted with anti-skid paint. This completed the repairs to the ramp outside of door 8 effective January 31, 2023. 01/31/2023 Implemented
SIN-00168538 Renewal 12/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Fire safety training and use of fire extinguishers training for Staff #1, was not completed annually. (The agencies Emergency Preparedness Fire Safety Form was completed but did not indicate if Staff passed or Failed).Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Staff # 1 attended fire safety training on 10/03/10 from 6p to 8pm, she completed the course documentation but did not sign in on the course record sign in sheet. Vocational admin staff were retrained on 01/15/2020 to ensure both course documentation and sign in sheet are part of the training record. Beth Davidson spoke with Fire safety Instructor and he will remove the pass/fail language from future documentation as the class is not Pass/fail. Beth Davidson will email Licensing staff screenshot of Staff #1 time sheet from APD system to verify her attendance at 10/03/19 Fire safety training and also copy of course documentation she completed. 01/21/2020 Implemented
2390.101On employee #1 physical exam dated 4/10/18 the free from Communicable Disease question was left blank.Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician.Employee #1 physical exam was sent back to Occ. med provider to have communicable disease section completed from his notes from the visit. On 1/15/2020 al Voc. admin staff and HR staff were retrained to ensure that forms faxed from the Occ. Med provider contain documentation re: communicable disease and filled out completely. Beth Davidson will email training documentation to licensing staff and updated form for Employee #1. 01/21/2020 Implemented
2390.151(e)(1)The assessment dated 5/1/19 did not include the individuals functional strengths, needs and preferences for individual #1. The Assessment dated 8/9/19 did not include the functional strengths needs and preferences for individual #2. The Assessment dated 11/4/19 for individual #3 did not include strengths needs and preferences. The assessment did not distinguish the difference between strengths from likes in the assessment.The assessment must include the following information: Functional strengths, needs and preferences of the client.An additional text box was added to the current assessment which will ensure staff include the Individual's functional strengths, needs and preferences in annual assessments. Program Specialist and Vocational staff were retrained on 01/15/2020. Program Specialists has completed 2 assessments on new form. Beth Davidson will email assessments to Licensing staff to demonstrate compliance. 01/21/2020 Implemented
2390.151(e)(13(ii)Progress in health, motor and communication skills, and adjustment was not detailed in the assessment dated 11/4/19 for individual #3.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 were retrained on 01/15/2020 to ensure progress in health, motor and communication skills, and adjustment are detailed in the annual assessment. Program Specialist updated the assessment for Individual #3 and also completed another Individual's assessment to demonstrate compliance. Beth Davidson will email both assessments to Licensing staff. 01/21/2020 Implemented
SIN-00143982 Renewal 10/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59Emergency telephone numbers were not found on the phones in the workshop. Emergency telephone numbers were added to each telephone before the end of the inspection.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneEmergency phone numbers were placed on all phones prior to Inspectors leaving on 10/18/2018.. Vocational Director has revised monthly plant inspection checklist and added this item to the list. He reviewed with all staff who may complete this checklist monthly. Beth Davidson will email documentation of repair and checklist completed on revised form on November 1, 2018 to licensing staff to document compliance.. 11/01/2018 Implemented
2390.61There was a Ceiling tile missing in the last office in the warehouse. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Ceiling tile has been replaced. Vocational Director has revised monthly plant inspection checklist and added this item to the list. He reviewed with all staff who may complete this checklist monthly. Beth Davidson will email documentation of repair and checklist completed on revised form on November 1, 2018 to licensing staff to document compliance. 11/01/2018 Implemented
SIN-00115404 Renewal 05/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.22(d)The Board met on 6/1/16 and 9/14/16 which exceeded the 90 interval betwee board meetings by 2 weeks.The governing body shall meet at least quarterly.A new calendar has been developed and Board meetings are now scheduled every 10-12 weeks. Meeting minutes from the May 2017 Board meeting and New calendar will be emailed to BHSL, the next Board meeting is 07/26/2017 and minutes from that meeting will be forwarded by 08/31/2017 to demonstrate compliance. 08/31/2017 Implemented
2390.101Staff #1 and staff #2 hired 2/16/17 did not have an evaluation from a licensed physician that staff were free from communicable disease.Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician.Agency spoke with occupational med. provided who does pre- employment physicals and physical capacities testing on all new hires. Occ. med provider sent information to Gh staff #2 since her hire was recent. to document free of communicable disease and will continue to use this form for all new hires in addition to other forms utilized. For staff #1 he had to go to Occ. med provider and have a new exam as he is a long term employee. Documentation will be emailed to BHSL to demonstrate compliance. 07/17/2017 Implemented
2390.151(e)(8)Individual #1's annual assessment dated 11/18/16 did not list his ability to evacuate. The assessment must include the following information: The client's ability to evacuate in the event of a fire.Vocational Director reviewed the regulation with program specialist who then updated the assessment with the missing information re: ability to evacuate in the event of fire. Documentation of correction will be emailed to BHSL and also several new completed assessments to demonstrate compliance. 07/24/2017 Implemented
SIN-00091916 Renewal 02/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.22(d)The governing body's previous meeting was held on 5/20/15 and the most recent meeting was held on 11/18/15The governing body shall meet at least quarterly.CEO Beth Davidson revised Board schedule so that meetings will occur quarterly, as part of the Salisbury Management Quarterly Board meetings, governing body met on March 17th, and will meet again June 2016, September 2016 and December 2016. will submit to BHSL via email the schedule for 2016 Board meetings, the Agenda and reports from the March 17th meeting and also the meeting minutes. 03/17/2016 Implemented
2390.53The lid to a 55 gallon drum was found protruding from the ground which presented a tripping hazard outside door number 5. A broken pipe was found outside door number 5. Outside walkways shall be free from ice, snow, leaves, equipment and other hazards.Maintenance Supervisor removed exposed pipe and barrel on 03/08/16 from exterior of building at Door #5, he also filled holes and seeded. CEO Beth Davidson and Vocational Director Gene Hathaway revised the monthly plant inspection form and will now have the Vocational Director and Maintenance Supervisor complete together monthly . A completed form for March using the revised form and both of the above reviewing will be emailed to BHSL along with the documentation that the drum protruding from the ground was taken and ground repaired. 03/08/2016 Implemented
2390.61There were sharp edges on the trash receptacle in the mens bathroom. If there is more than one mens bathroom at the day program, please identify the location of the bathroom in the description. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Maintenance Supervisor order new receptacle and installed in men's room on 03/07/2016 CEO Beth Davidson and Vocational Director Gene Hathaway revised the monthly plant inspection form so and will now have the Vocational Director and maintenance Supervisor complete together monthly . A completed form for March using the revised form and both of the above reviewing will be emailed to BHSL along with the documentation that new trash receptacle was ordered and replaced. 03/07/2016 Implemented
2390.62There were cobwebs on the inside of several windows located in the main workshop.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.All windows were cleaned and cobwebs removed in workshop area by an Dwight Carr's cleaning service on 03/01/2016. Gene Hathaway Vocational Director has also scheduled to have them come in once monthly in addition to our daily cleaning, to complete additional heavy duty cleaning of cafeteria area and workshop floor and windows. This started on 03/01/16 and will be scheduled once monthly. Copy of bill from March 1, 2016 with detailed additional cleaning done will be emailed to BHSL via email. Copy of bill with detailed additional cleaning done will be emailed to BHSL via email. 03/01/2016 Implemented
2390.75(b)(1)There were brownish stains consistent with grease found on several vents located in the lunchroom area.A facility shall have a dining area for lunches and breaks. The area shall be clean and have dining tables and chairs. The dining area shall be clean.The vents were cleaned in cafeteria by an Dwight Carr's cleaning service on 03/01/2016. Gene Hathaway Vocational Director has also scheduled to have them come in once monthly in addition to our daily cleaning, to complete additional heavy duty cleaning of cafeteria area and workshop floor and windows. This started on 03/01/16 and will be scheduled once monthly. Copy of bill from March 1, 2016 with detailed additional cleaning done will be emailed to BHSL via email. 03/01/2016 Implemented
2390.151(c)Individual #1's assessment dated 9/15/15 did not indicate what instruments were used in the development of the assessment. The assessment shall be based on assessment instruments, interviews, progress notes and observations.Assessment was revised by Vocational Director gene Hathaway on 02/19/2016 and now includes line on signature page to indicate what instruments were used in development of the assessment. All program Specialist have revised document and are using. Will submit copies of assessments that have been completed using revised assessment via email to BHSL 02/19/2016 Implemented
SIN-00078666 Renewal 10/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The cafeteria ceiling panels were water stained. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Ceramic tile was installed in the workshop utility bathroom and adjacent utility room. In the future monthly plant inspections will be completed by Vocationa Director and maintenance Supervisor to ensure all repairs/issues are identified immediately and repairs completed timely. Documentation of completion will be emailed to BHSL. 12/29/2014 Implemented
2390.62The unisex bathroom cement floor has ground-in-dirt around the base of the toilet.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.The bathroom cement floor was cleaned to remove the dirt around the base of the toilet. In the future monthly plant inspections will be completed by Vocationa Director and maintenance Supervisor to ensure all repairs/issues are identified immediately and repairs completed timely. Documentation of completion will be emailed to BHSL. 10/29/2014 Implemented
SIN-00055246 Renewal 10/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(a)The first aid area is not used exclusively for first aid purposes.(a) A facility shall have a first aid area that is separate from the work area.Provider has designated an area off the workshop floor that is now utilized only for the 1st aid room. Documentation sent to BHSL documenting on floor plan where room is, plus picture of new area and invoice from Vendor for partitions that were used to construct room 10/30/2013 Implemented
2390.61The hallway leading toward the exit door has missing baseboards, worn floor mats and stained ceiling tiles. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Estimates obtained for repair of drainage issue in men's room that is creating issues in the cafeteria hallway. Work scheduled for 11/28-12/01/13 then replacement of floor will be completed. Documentation sent via email to BHSL. 10/30/2013 Implemented
2390.62The flooring in the hallway leading toward the exit door and dining area needs cleaning. The walls are stained above baseboard. Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Once repairs done to correct drainage issue and floor in cafeteria replaced then the entire cafeteria will be pained. Documentation emailed to BHSL. 10/30/2013 Implemented
2390.151(e)(2)The assessment for individual #1, dated 3/18/13, did not include the individual¿s likes and dislikes.(e) The assessment must include the following information: (2) The likes, dislikes and interest of client, including vocational and employment interests of the client.Assessment for Individual#1 has been redone and now includes likes, dislikes and interest of client , including voactional and employment interests. Assessment sent via email to BHSL. 10/30/2013 Implemented
2390.151(e)(5)The assessment for individual #1, dated 3/18/13, did not include the individual¿s skills for self-medicating.(e) The assessment must include the following information: (5) The client's ability to self-administer medications.Assessment for Individual #1 has been redone and now includes informationre: client's ability to self-administer medication. Assessment sent via email to BHSL. 10/30/2013 Implemented
2390.151(e)(7)The assessment for individual #1, dated 3/18/13, did not include the individual¿s understanding of the dangers of heat sources.(e) The assessment must include the following information: (7) 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.Assessment for individual #1 has been redone and now includes information on the client's knowledge of danger of heat sources and ability to sense and move away from heat sources which exceed 120 degrees F and are not insulated.Assessment sent via email to BHSL. 10/30/2103 Implemented
2390.151(e)(8)The assessment for individual #1, dated 3/18/13, did not include the individual¿s ability to evacuate in the event of a fire. (e) The assessment must include the following information: (80 The client's ability to evacuate in the event of a fire.Assesment for Individual #1 has been redone and now includes information as to the client's ability to evacuate in the event of a fire. Assessment sent via email to BHSL. 10/30/2013 Implemented
2390.151(e)(12)The assessment for individual #1 dated, 3/18/13, did not include recommendations for specific areas of training.(e) The assessment must include the following information: (12) Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.Assessment for Individual#1 has been redone and now includes recommendations for specific areas of vocational training or placement and competitive community integrated employment. Assessment sent via email to BHSL. 10/30/2013 Implemented
2390.156(a)The ISP review for individual #2 dated 5/9/13 exceeded ninety days. The previous review was dated 2/1/13.(a) 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.All ISP reviews will be completed every 3 months or more frequently if client's needs change. Database that generates cover page of Quarterlies has been corrected. 12 month reviews for 2 consumers have been sent to BHSL to demonstrate compliance via email. 10/30/2013 Implemented
SIN-00043191 Renewal 10/09/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62STRONG URINE SMELL IN THE MEN'S BATHROOMSanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Provider maintenance staff powerwashed mens room on 10/17/12,and developed schedule to do on a monthly basis. Vocational Director purchased Odoban cleaning product on 10/18/12 and it is being used by janitorial vendor on a daily basiswhen cleaning the mens room. documentation to be sent to regional office 12/04/12 via email. 10/18/2012 Implemented
2390.156(a)THE 3 MONTH REVIEWS FOR 5 INDIVIDUALS DID NOT LIST OVERALL PROGRESS FOR THE QUARTERLY PERIOD.(a) 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 specialist has sent copies of completed quarterly reviews for several other individuals receiving services to demonstrate that the review now includes all services and expected outcomes. Quarterly reviews were emailed to ws from licensing for review and validation. 01/24/2013 Implemented
2390.156(c)(1)MONTHLIES DO NOT REFLECT ALL SERVICES INDIVIDUALS RECEIVE DURING DAY PROGRAMS EG. IMPLEMENTATION OF THE BEHAVIOUR PLAN(c ) The ISP review must include the following: (1) 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 specialist has sent copies of completed Monthly progress reviews for several other individuals receiving services to demonstrate that the reviews now include all services and expected outcomes. monthly reviews were emailed to ws from licensing for review and validation. 01/24/2013 Implemented