Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00275337 Renewal 10/17/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(l)The provider did not hold conversations with Individual relating to their preferred community participation and activities as required by ODP Announcement 24-061 quarterly within the past year with exception to a conversation held on 9/26/2024 and 9/11/2025. Conversations are missing from the fourth quarter of 2024, first quarter of 2025 and second quarter of 2025 for Individual #1. The provider did not hold conversations with Individual relating to their preferred community participation and activities as required by ODP Announcement 24-061 quarterly within the past year with exception to a conversation held on 9/11/2025 for Individual #2.A client has the right to make choices and accept risks.Post inspection, Rehabilitation Manager and Vocational Director met with all employees devoted to case management at BPSW. During this retraining, Rehabilitation Manager or Vocational Director provided education on citation referenced in this violation summary, particularly focused on ODP Announcement 24-061 pertaining to community participation requirements for regulatory compliance (See Attachment #1 for training sheets). Additionally, missing quarterly community discussions have been held and documented on inclusion sheets which have been collected (See Attachment #2 for inclusion sheets). Community inclusion discussions have been held for Individual's #1 and #2 referenced in this citation. 10/31/2025 Implemented
SIN-00253692 Renewal 10/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Fire safety training for individual Three was completed on 7/31/23 and then completed most recently on 8/5/24. This exceeds the annual requirement.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.On 11/21/24, vocational director, Jordan Pfister, met with the site manager to discuss and provide training on regulation 2390.87 related to individuals¿ annual fire safety training. (See attachment 6). It was explained that the term ¿annual¿ directly means 365 days, not calendar year. Therefore, BARC shall instruct staff and clients, as appropriate, upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. Furthermore, a written record of the training shall be kept; preferably one with literal signatures from individuals participating in training as opposed to a transposed ¿site record.¿ 11/21/2024 Implemented
2390.21(u)Individual rights were reviewed with individual One on 9/18/23 and then were reviewed again most recently on 10/8/24. The one year and 20-day time span between the two dates exceeds the annual requirement. Individual Rights have not been discussed with Individual Four annually. The agency did not complete/provide a signed copy of Individual Rights for 2023.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.On 11/21/24, rehabilitation manager, Sarah Holesworth, with the support of vocational director, Jordan Pfister, met with all personnel involved in case management to discuss and provide training on regulation 2390.21(u) related to individuals¿ rights. (See attachment 1, 2, 3, and 4). It was explained that the term ¿annual¿ directly means 365 days, not calendar year. Therefore, BARC shall inform and explain individual rights and the process to report any rights violations to the individual, and persons designated by the individual, upon admission and annually thereafter, within a rolling 365 calendar days of the previous year¿s explanation of rights. 11/21/2024 Implemented
SIN-00213270 Renewal 10/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.63The program area interior exit door light fixture did not contain any light bulbs.Rooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents.The program area interior exit door light fixture has been replaced with an LED light fixture with a cover over the light bulb (Attachment #5). 11/30/2022 Implemented
SIN-00161526 Renewal 07/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(d)The program specialist did not sign the assessment dated 04/12/2019 for Individual #1.The program specialist shall sign and date the assessment.The program specialist for Individual #1 corrected this violation on the assessment sheet. A line has been added to the assessment page so now the assessment requests the name of the program specialist who prepared the assessment, and then prompts the program specialist to sign the assessment. This regulation requirement was reviewed with the program specialists on 9-19-19. 09/19/2019 Implemented
2390.124(8)The agency did not provide a copy of the ISP signature sheet for individual #2, the ISP meeting was to be held on 4/16/2019.Individual plan documents as required by this chapter.The ISP signature sheet for individual #2 was received. The program specialist will request a copy of the ISP signature sheet at the closing of the ISP meeting. If, for some reason, this cannot be obtained, the program specialist will email the supports coordinator weekly until the signature sheet is received. A copy of all requests for documentation will be kept in the individual's file. This regulation requirement was reviewed with all of the program specialists on 9-19-19. 09/19/2019 Implemented
SIN-00090682 Renewal 01/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The medication administration room had a storage closet with a loose left door. The right exit door in the lunch room had a hinge that was separating from the door frame.Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The cabinet in the medication administration room has been replaced. The double doors leading into the lunch room have been replaced. The Monthly Safety Inspection Report has been amended to include a specific inspection for doors and hinges to be in good repair, a copy of which will be sent to the Licensing Administrator, along with photos of the new cabinets and doors to verify completion of this plan of correction.[Quality Assurance or Program Designee will complete quarterly audits of the Monthly Inspection Report to ensure that all surfaces are in good repair. The implementation of tis review will begin within 15 days receipt of this plan of correction DD 7.6.16]. 06/02/2016 Implemented
2390.104(3)Individual 2's record did not have consents for emergency medical treatment. Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Written consent from the client, parent or guardian for emergency medical treatment.Training was completed on 5-31-16 and 6-2-16 with the rehabilitation manager and program specialists to ensure their understanding of this regulation. An audit of 5 client files per month will be completed by the rehab manager to ensure compliance with this regulation. The corrected consent for emergency medical treatment for Individual # 2 and an example of a completed consent for emergency medical treatment form for someone who started in our program after our 1-20-16/1-21-16 licensing will be included with the plan of correction as documentation. 06/02/2016 Implemented
2390.151(e)(5)Individual #1 assessment, dated 8/1/2015, did not indicate progress on his ability to self administer medications.The assessment must include the following information: The client's ability to self-administer medications.Training was completed on 5-31-16 and 6-2-16 with the rehabilitation manager and program specialists to ensure their understanding of this regulation. An audit of 5 assessments per month will be completed by the rehab manager to ensure compliance with this regulation. The corrected assessment for individual # 1 and an example of an assessment written correctly after our 1-20-16/1-21-16 licensing will be included with the plan of correction as documentation. 06/02/2016 Implemented
2390.151(e)(6)Individual #3's assessment, dated 12/9/15, did not indicate her ability to safely use poisons.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.Training was completed on 5-31-16 and 6-2-16 with the rehabilitation manager and program specialists to ensure their understanding of this regulation. An audit of 5 assessments per month will be completed by the rehab manager to ensure compliance with this regulation. The corrected assessment for individual #3 and an example of an assessment written correctly after our 1-20-16/1-21-16 licensing will be included with the plan of correction as documentation. 06/02/2016 Implemented
SIN-00066802 Renewal 10/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(c)Fire drills dated 1/8/14, 1/31/14 and 1/31/14, not all clients evacuated the building. Clients shall evacuate the entire building during each fire drill.The Site Manager and facility Safety Representative have ensured that all sugsequent monthly fire drills for February, March, April, May, June, July, August, September, and October 2014 have resulted in all individuals evacuating the building during each fire drill, which was verified during the annual licensing inspection by the inspector. It should also be noted, the individual who did not leave the building during the fire drills in January 2014 no longer attends the program as they have retired. The Site Manager and Safety Representative will continue to ensure all individuals evacuate the facility for each monthly fire drill. The Program Specialists for each individual will discuss the importance and requirement to leave the building during a fire drill at each team meeting for the individuals on their caseload. 11/12/2014 Implemented
SIN-00111000 Renewal 03/29/2017 Compliant - Finalized