Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263801 Renewal 04/01/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.54On 4/1/25 at approximately 12:44pm, numerous combustible materials, including cardboard boxes of various sizes, small plastic plant pots, several pieces of wood of various sizes, were located in the "boiler room", within close proximity to a natural gas fueled hot water tank.Combustible supplies and equipment shall be utilized safely, stored in a fire retardant cabinet or closet and stored away from heating sources.All combustible material was removed from close proximity to the gas fueled hot water tank at the time of inspection. Maintenance staff currently conduct a physical plant inspection monthly. Ensuring that combustible materials are properly stored away from any heating sources will be added to this inspection. 04/01/2025 Implemented
2390.87Individual #1 did not complete fire safety training during their orientation. Individual #2, date of hire 7/11/24, was not provided fire safety training on 7/18/24, 7 days after admission.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.Program Specialist were trained to ensure that the individual dates their orientation paperwork on their first day of admission. Program Specialists were trained to provide fire safety, and fire extinguisher training on the individuals first day of service (Orientation) 04/14/2025 Implemented
2390.111(b)Individual #1's interview was conducted on 6/4/24 but the decision letter was not sent until 8/6/24, exceeding the required 30-calendar-day requirement. Individual #2's interview was conducted on 6/10/24 but the decision letter was not sent until 9/9/24, exceeding the required 30-calendar-day requirement.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.Dates of pre-admission tours and interviews are now held separately. The tour will be conducted as an informational/educational experience, whereas the Interview will be held specifically to discuss the prospective client's needs, wants, and goals. 04/15/2025 Implemented
2390.112(a)Individual #1 had a completed orientation checklist in their record; however, the orientation checklist was not dated.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.Program Specialist were trained to ensure that the individual dates their orientation paperwork on their first day of admission. 04/14/2025 Implemented
2390.151(e)(5)Individual #3 had an assessment completed on 11/11/24; however, the assessment did not address the individual's ability to self-administer mediation. The assessment must include the following information: The client's ability to self-administer medications.Individual #3's assessment was updated to address their ability to self-administer medications. Program Specialists were trained to address an individual's ability to self-administer medications in their assessment even if the individual does not currently receive medications during program hours. 04/17/2025 Implemented
2390.21(u)Individual #2, date of hire 7/11/24, was informed and explained client rights and the process to report a rights violation on 7/18/24, 7 days after admission. Individual #4 had their rights reviewed and signed on 10/30/23, and then again on 11/19/24. This exceeds the annual requirement. Individual #6 had their rights reviewed and signed on 3/1/24, and then again on 3/6/25. This exceeds the annual requirement.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Program Specialists were trained to review individual rights upon admission, at the time of the individual's annual ISP, and at the time of the Individual's Assessment. Informing individuals of their individual rights upon admission and twice per year will ensure that the regulation of annual review is met. 04/14/2025 Implemented
2390.124(1)Individual #1's place of birth was not provided in the client record. Individual #5's place of birth was not provided in the client record. Individual #6's place of birth was not provided in the client record. Individual #7's place of birth was not provided in the client 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.Program Specialists were trained to obtain the Individuals place of birth at the time of admission. All efforts will be made to obtain this information from the individual and/or Supports Coordinator. If this information cannot be found, "Unknown" will be written in this section and the reason will be noted in the assessment. 04/14/2025 Implemented
2390.151(f)Individual #8's individual meeting was held on 6/6/24. Individual #8's assessment was sent to the ISP team on 5/8/24, 28 days prior to the meeting.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 will gather all participants Annual ISP dates as well as Annual Assessment dates. From this information, Program Specialists will create an updated schedule so that CPS Assessments are completed more than 30 days prior to the next ISP. In best practice these will be scheduled approximately 6 months from the anticipated date of the next ISP. 04/14/2025 Implemented
2390.152(b)Individual #2 was admitted to the facility on 7/11/24. Individual #2 does not have an Individual Service Plan (ISP) developed at the time of the inspection. This exceeds the within 90-day requirement of admission to the facility.The initial individual plan shall be developed based on the client assessment within 90 days of the client's date of admission to the facility.A Critical Revision ISP meeting was held on 4/3/2025 where Individual #2's funding source was changed from MH to IDD Base funding. The ISP is being completed by the Supports Coordinator. Program Specialists were re-trained to conduct an ISP within 90 days of admission. Should the individual be absent on the scheduled date of the ISP, the Program Specialist shall Case Note this in the individual's record and conduct the ISP on the next date that the individual is in attendance. 04/14/2025 Implemented
SIN-00242282 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Direct Service Worker #1, date of hire 2/28/2024, was instructed in general fire safety and the use of fire extinguishers 3/01/2024. Direct Service Worker #2, date of hire 9/25/2023, was instructed in general fire safety and the use of fire extinguishers 9/29/2023.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.The staff orientation and the department orientation forms were reviewed and revised on 4/11/2024 by the Director of Compliance to include staff instruction immediately upon day of hire in general fire safety and in the use of fire extinguishers 04/11/2024 Implemented
2390.151(e)(6)Individual #4's assessment completed 1/05/2024 does not assess the individual's ability to use 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.The assessment form was reviewed and revised on 4/10/2024 by the Quality Improvement Specialist to better guide staff writing assessments in appropriately documenting an individual¿s use of poisonous materials. The Program Specialists were trained by the Director of Compliance and the Quality Improvement Specialist on 4/10/2024 concerning proper documentation of an individual¿s ability to use poisonous materials. The corresponding Program Specialists will review and revise as necessary all assessments under their responsibility to appropriately document an individual¿s ability to use poisonous materials. 04/11/2024 Implemented
2390.151(e)(8)Individual #1's assessment completed 3/17/2024, Individual #2's assessment completed 2/16/2024, and Individual #3's assessment completed 3/14/2024 does not assess their ability to evacuate in the event of a fire. The assessments only document that they attend annual fire safety training and participate in evacuation drills. The assessment must include the following information: The client's ability to evacuate in the event of a fire.The assessment form was reviewed and revised on 4/10/2024 by the Quality Improvement Specialist to better guide staff writing assessments in appropriately documenting an individual¿s ability to evacuate in the event of a fire. Staff were trained by the Director of Compliance and the Quality Improvement Specialist on 4/10/2024 concerning proper documentation of an individual¿s an individual¿s ability to evacuate in the event of a fire. The corresponding Program Specialists will review and revise as necessary all assessments under their responsibility in order to appropriately document an individual¿s ability to evacuate in the event of a fire. 04/11/2024 Implemented
2390.151(f)Individual #4's assessment completed 1/05/2024, was provided to the plan team members 1/05/2024, for the individual meeting which occurred 1/30/2024. Individual #5's assessment completed 3/17/2023, was provided to the plan team members 3/17/2023, for the individual meeting which occurred 4/13/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.The assessment form was reviewed and revised on 4/10/2024 by the Quality Improvement Specialist to clearly document the assessment completion date verses the assessment due date. The Program Specialists will gather all participants Annual ISP dates as well as Annual Assessment dates. From this information, Program Specialists will create an updated schedule so that CPS Assessments are completed more than 30 days prior to the next ISP. In best practice these will be scheduled approximately 6 months from the anticipated date of the next ISP. 04/30/2024 Implemented
SIN-00224926 Renewal 04/27/2023 Compliant - Finalized
SIN-00205392 Renewal 05/06/2022 Compliant - Finalized