Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256465 Renewal 10/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(l)The provider did not hold conversations with Individual #1, Individual #2, and Individual #3 relating to their preferred community participation and activities as required by ODP Announcement 24-061.A client has the right to make choices and accept risks.All program specialists will have training to review the community inclusion sheet that was approved by the ODP inspectors at the annual inspection. This sheet will be the main document to identify community discussion occurring at a minimum on at least a quarterly basis per ODP Announcement and in conjunction with individual rights. This is to include all persons supported including those in ICF/ID. This sheet needs to be signed by the program specialist and the person supported or their guardian if required by law. Other team members can review and sign if they have it reviewed with them. A blank community inclusion sheet as well as completed sheets for the 4 individuals will be included in the response. A blank community inclusion sheet as well as the 3 completed sheets for the individuals noted will be included in the correction packet. 12/12/2024 Implemented
SIN-00213717 Renewal 10/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.194(b)Medication Refresh Eyedrops prescribed to individual 1 to be taken as needed had expired in September of 2022. Medication was still stored for current use.A prescription order shall be kept current.A lock box labeled "Outdated medication to be returned or destroyed" has been put in place. Site Manager reviewed all of the medication lock boxes, removed all outdated medications, and store them in the new lock box. 10/28/2022 Implemented
SIN-00159028 Renewal 07/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.72(c)The Work aisles throughout the work area were not marked with visible lines at least 2 inches wide. Lines that were originally in work area were worn or disappeared completely making it difficult to ensure area was clear from obstruction at all times.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 Site Manger reinstalled the work aisles on 9/6/19. The site manager added to the Monthly Facility Inspection report " Are the work aisle lines clearly marked".The Vocational Director completed training that the lines are required with the Site Manager and the Maintenance Staff on 9/6/19. Sent as separate documentation will be picture of completed lines, scan of the training record, scan of facility inspection report. Site Manager and Maintenance Staff are responsible for ongoing maintenance of the lines. 09/06/2019 Implemented
SIN-00135300 Renewal 05/22/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(10)Individuals #1, #2, #3, #4, #5's assessments did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.Training for all Program Specialists about keeping the lifetime medical history with the annual assessment was completed and the training was documented. The lifetime medical history will be moved from the medical section of each person's file to be with the annual assessment. Also reviewed was a new file checklist with the lifetime medical history moved to the programming section with the annual assessment. Rehabilitation Manager and/or Site Manager will randomly review files through the year to ensure the lifetime medical history is in the correct location. Supporting documentation will include the training review, the file checklist, and pictures of the lifetime medical history with the annual assessment. 05/30/2018 Implemented
2390.153(7)(i)Individual #2's ISP dated 2/26/18 did not include an assessment of the 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.Training was held on 5/30/18 for all Program Specialists on the need to ensure inclusion of the client's potential to advance in vocational programming in their ISP. The ISP's will be updated as reviews are scheduled for each individual. Rehabilitation Manager and/or Site Manager will randomly review ISP's to ensure follow up. Also a letter was emailed to all Supports Coordinators for persons supported on 5/30/18 stating the need for this information to be in the ISP and that the Program Specialists will review and give updates if it is not. Supporting documentation for the POC will include the training review and the letter sent to Supports Coordinators. 05/30/2018 Implemented
2390.153(7)(ii)Individual #2 and #5 ISP's did not include an assessment for potential to advance in 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.Training was held on 5/30/18 for all Program Specialists on the need to ensure inclusion of the client's potential to advance in community integrated employment is in the ISP, along with the individual's interests and desires of community integrated employment. The ISP's will be updated as reviews are scheduled for each individual. Rehabilitation Manager and/or Site Manager will randomly review ISP's to ensure follow up. Also, a letter was emailed to all Supports Coordinators for persons supported on 5/30/18 stating the need for this information to be in the ISP and that the Program Specialists will review and give updates if it is not. Supporting documentation for the POC will include the training review and the letter sent to Supports Coordinators. 05/30/2018 Implemented
2390.156(e)Individual #1, #2, #3, #4, #5 did not include an option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Training for all Program Specialists was held on 5/30/18 to review the option to decline and that any team member who did accept the option to decline ISP reviews would have their notification placed in the communication section of the individuals file. Also reviewed was the new ISP review document with the option to decline notification on each review. Rehabilitation Manager and/or Site Manager will review files to ensure the new documentation is being used and any options to decline are placed in the communication section of the person's file. Included in the POC support documentation is the signed training document, a copy of the new ISP review form, and two (2) completed ISP reviews that include the option to decline statement that have been completed since the inspection review. 05/30/2018 Implemented
SIN-00088094 Renewal 01/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual # 5's previous annual assessment was dated 05/06/2014 and the most recent annual assessment was dated 05/22/2015.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.All Program Specialists have received training that the annual assessment is due within 365 calendar days of the previous assessment and is not based on changes to the plan meeting date, but the calendar date. Sign in sheet for this training completed 2/26/16 will be emailed to BHSL to verify completion. The updated assessment for Individual #5 to be completed by 5/6/16 and emailed to the SC by 5/17/16 which is 30 days prior to the scheduled ISP meeting. Once completed, the updated assessment will be scanned and emailed to BHSL to verify completion. [Going forward the program specialists will implement a tracking tool to ensure assessments for each individual on their caseloads are completed within the designated time frame based on the date the previous assessment was written DS 4.27.16] The completed assessments will then be placed in the individuals file. 05/17/2017 Implemented
2390.156(d)Individual # 1's 3 month ISP review documentation dated 06/07/2015 and 12/07/2015 was not sent to SC and team members Individual # 2's 3 month ISP review documentation dated 04/28/2015, 07/28/2015 and 10/28/2015 was not sent to SC and team members. Individual # 3's 3 month ISP review documentation dated 01/03/2015, 04/03/2015 and 10/03/2015 was not sent to SC and team members. Individual # 4's 3 month ISP review documentation dated 09/15/2015 and 12/15/2015 was not sent to SC and team members. Individual # 5's 3 month ISP review documentation dated 06/01/2015, 09/01/2015 and 12/01/2015 was not sent to SC and 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.[A record audit will be completed within 30 days of receipt of this plan to determine if the 3 month review ISP documentation was sent to the SC and team members. Any records that do not have confirmation of the 3 months ISP review documentation being sent shall be provide the documentataion to the SC and team members DS 4.27.16]. Each Program Specialist will note the date the 3 month review was sent via email or mail on the quarterly review form, or copy of the email, for each individual on their caseload. If reviewed in person, the 3 month review or meeting attendance sheet will be signed. Training for this procedure was completed on 2/26/16. The sign in sheet documenting this training occurred will be emailed to BHSL to verify completion. All documentation for each review will be placed in the individual's file to verify completion. Individual # 2 review is due 4/30/2016. Once completed for Individual #2, the review will be emailed to BHSL to verify compliance. 04/30/2016 Implemented
SIN-00057682 Renewal 10/31/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(b)Individual #3 completed a pre-admission interview on 1/17/13 and was not sent notification of acceptance within 30 calendar days following the interview. The admission date for individual #3 was 6/17/13.(b) Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services.A training was held with the Program Specialists by the Rehabilitation Manager on 12/19/2013 reviewing the need to ensure notification of acceptance is sent within 30 calendar days of the pre-admission interview for all individuals referred for service. Signed acknowledgments were emailed to the licensing inspector. 12/19/2013 Implemented
2390.156(a)The ISP reviews for individual #1 dated 4/6/13, 7/17/13 and 10/23/13 was not completed from the start date of the ISP dated 2/18/13. The ISP reviews for individual #5 dated 5/25/13 and 8/25/13 was not completed from the start date of the ISP dated 4/30/13.(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.A training was held on 12/19/2013 with the Program Specialists by the Rehabilitation Manager reviewing the need to complete ISP reviews every three months after the ISP review date for each consumer on their caseload. Signed acknowledgment forms documenting this training, and two quarterly reviews and the first page of the ISP for these consumers indicating the ISP Update Date, were emailed to the licensing inspector. 12/19/2013 Implemented
2390.156(c)(2)The ISP reviews for individual # 2 dated 10/13/12, 4/12/13 and 7/5/13 did not include a full review of target behaviors for physical aggression, property destruction, stripping, fecal smearing and ripping clothes. The ISP reviews for individual # 4 dated 10/18/12, 1/31/13, and 4/26/13 did not include a full review of target behaviors for verbal/physical aggression, property destruction, soiling self, skin picking and stealing. The ISP reviews for individual #5 dated 11/21/12, 2/22/13, 5/25/13 and 8/25/13 did not include a full review of target behavior for anxiety. (c ) The ISP review must include the following: (2) A review of each section of the ISP specific to the facility licensed under this chapter.A training was held on 12/19/13 with the Program Specialists by the Rehabilitation Manager reviewing the need to include a full review of each target behavior on the quarterly ISP reviews for each consumer on their caseload. Signed acknowledgment forms were emailed to the licensing inspector. Two quarterly reviews for consumers were also emailed to the licensing inspector showing all target behaviors were included in the quarterly review. 12/19/2013 Implemented
SIN-00233589 Renewal 10/31/2023 Compliant - Finalized
SIN-00146290 Initial review 11/28/2018 Compliant - Finalized
SIN-00110998 Renewal 04/05/2017 Compliant - Finalized
SIN-00066799 Renewal 10/27/2014 Compliant - Finalized