Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00115940 Renewal 06/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1's assessment was completed on 1/4/16 and then again on 1/31/17. 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.A spreadsheet has been developed with all of the consumers listed and the date of the last assessment. All consumers will have an initial assessment within 60 days of admission and their annual assessment will occur within one calendar year of the last. The program specialists will be responsible to ensure these are done timely and the director of programs will monitor to make sure all dates are met. [Within 30 days of receipt of the plan of correction, the Director of Programs shall train the program specialist on the aforementioned tracking spread sheet and the process to competed and update to ensure individuals' assessments are completed, timely. Documentation of the trainings shall be kept. At least monthly for 6 months and continuing quarterly, the Director of Programs shall review the aforementioned tracking spreadsheet to ensure the program specialist completes individuals' assessments, timely. Documentation of the review shall be kept. (AS 7/6/17)] 06/29/2017 Implemented
SIN-00092576 Renewal 06/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.124(1)The records for Individual #1 and Individual #2 did not include place of birth.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.All consumers will have an Individual Demographics page that includes the Place of Birth. The Program Specialists will review all current charts for this compliance. The Program Director will review all Individual Demographic sheets for new consumers as of 6/13/16 to ensure this compliance is being followed through. [Immediately and continuing at least semiannually, the program specialist will review all individuals' records to ensure all required personal information is present including birthplace and will obtain missing information and enter into the individuals' records. Documentation of all reviews shall be kept. (AS 6/24/16)] 06/19/2016 Implemented
SIN-00092639 Unannounced Monitoring 04/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.67On 4/4/16, at 1:30 PM, a white dust was hovering in the air in the work area where individuals were working shredding paper on approximately twenty-five industrial paper shredders. The tables, chairs, paper shredders, desks, computers and floor in the work area where the paper was being shredded were coated with white dust. Individuals who work shredding paper report that the work area is foggy with a lot of dust making them cough and feeling the need to shower when they return home from work. Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.WCBA is in the process of receiving bids for a mechanical exhaust system to be installed in the vocational area. Schaedler yesco is the company and Dan Nobile is the contact. WCBA is estimating this will be installed within 60 days. Also, a protective hood has already been placed over the opening where the shredded material is funneled to the packaging area. In addition, protective barriers will be placed over the conveyor belt that carries the shredded material to the packaging area to help eliminate dust. If this helps reduce the dust, WCBA will install Plexiglas permanently.[On 5/19/16, Exhaust fan supp "GPX2413 24"5460CFM 1/2HP was purchased. Executive Director or director of programs will develop and implement policies and procedures to ensure safe and sanitary conditions are provided for individuals while handling supplies, packaging products and carrying work functions. (AS 5/31/16)] 05/12/2016 Implemented
2390.69The area of where the Individuals work shredding papers produces a white dust throughout the work area. The individuals who were shredding the papers were not wearing personal protective equipment. Personal protective equipment shall be worn by clients if work presents a safety risk to the clients.Additional face masks, safety glasses and safety gloves have been purchased by WCBA. These items are available to all consumers and staff who work in the vocational area. Friendly reminder posters have been placed in the vocational area as a reminder these items are for their use. WCBA will also review this information at the annual ISP meetings with the team and address any concerns from the team members if they should arise. [Within 1 month of receipt of the plan of correction, Executive Director or director of programs will develop, implement and conduct an educational session/training which includes the benefits of wearing personal protective equipment while working in the shredding area; as well as a process to encourage the use of personal protective equipment. (AS 5/31/16)] 05/12/2016 Implemented
2390.71(b)The area of where the Individuals work shredding papers produces a white dust throughout the work area. There is not a mechanical exhaust system in the vocational facility. Production that results in toxic fumes, excessive dust or odor shall be adequately ventilated by a mechanical exhaust system.WCBA is in the process of receiving bids for a mechanical exhaust system to be installed in the vocational area. Schaedler yesco is the company and Dan Nobile is the contact. WCBA is estimating this will be installed within 60 days..[On 5/19/16, Exhaust fan supp "GPX2413 24"5460CFM 1/2HP was purchased. (AS 5/31/16)] 05/12/2016 Implemented
SIN-00074160 Renewal 05/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)Individual #1 had 3 month ISP reviews completed on 3/5/14, 12/11/14 and 3/9/15. 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 will complete both isp's for individuals receiving dual programs. [The CEO/Designee will review all individual records to ensure that 3 month ISP reviews have been completed as required on a monthly basis and develope a tracking system to ensure future ISP reviews are completed with in required time frames. (AS 5/29/15)] 06/06/2015 Implemented
SIN-00057953 Renewal 05/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.35(d)Floor supervisors, Staff #1, Staff #2 and Staff #3, did not meet the education qualifications of the position.A floor supervisor shall meet one of the following qualifications: (1) Possess 30 credit hours from an accredited college or university.(2) Possess a high school diploma or a general education development certificate, and 1 year work experience in industry or rehabilitation.Diploma's were received from all employee's except one who was terminated. copies of diploma's/ged are now required with interview process. 07/06/2014 Implemented
2390.87Individual #1 did not receive fire safety training anually. Individual #1 received fire safety training on 3/13/12 and 11/12/13.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.fire safety video purchased and shown to all consumers and staff. 07/06/2014 Implemented
2390.156(b)The three month review for Individual #2 completed on 8/8/13 was not signed by the program specialist. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.signatures on isp reviews is now part of isp review check list. 07/06/2014 Implemented
SIN-00175953 Renewal 09/09/2020 Compliant - Finalized
SIN-00156077 Renewal 05/29/2019 Compliant - Finalized
SIN-00135888 Renewal 05/30/2018 Compliant - Finalized
SIN-00044931 Renewal 01/28/2013 Compliant - Finalized