Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258198 Renewal 11/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1's DOA was 09/23/24 and there was no annual assessment done as of 11/25/24. The assessment is scheduled to be completed in 12/2024.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.The Intake Checklist was revised to include a spot to indicate the due date for the initial assessment. (See Attachment #2). On the admission day into the workshop the Vocational Evaluator will count out 60 days from date of admission and include the due date on the intake checklist that then goes to the Program Specialist. This checklist will be used and completed by the Vocational Evaluator when a new client is admitted. Thereafter, the program specialist will be responsible in having assessment completed by the date indicated on the checklist. 02/21/2025 Implemented
SIN-00235101 Renewal 11/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(a)The First Aid area is not separate from the work area.A facility shall have a first aid area that is separate from the work area.In the 225 Building (Bentley Center) a screen was put up within the nurse's office for privacy and to keep it separated from the rest of the nurse's office. See Attachments #1 and #2. Implemented
2390.87Individual #1 was not reinstructed annually in general fire safety, no record could be located at time of 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.The fire safety certificate for Individual #1 for the training years 2022 and 2023 were not able to be located on November 30, 2023 during the 2390 inspection. It was later discovered that the certificates had been misplaced in the file. The documents were moved to the proper section of the client file. Staff received an email retraining/reiterating proper placement of documents in client files. New protocols have been put in place, specifically: 1) a spreadsheet was generated that documents two years of compliance dates; 2) a file is maintained in the Director of Rehabilitation¿s office with duplicate copies of all certificates; 3) a client signature line was added to the certificate to verify that the individual participated in the fire safety training. This takes effect for 2024 training year. 01/10/2024 Implemented
2390.151(a)Individual #2's annual assessment was completed in August of 2023 which was more than a year from the previous assessment on 7/22/22.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.The citation for Individual #2 stated that the 151 assessment was not completed within one year of the previous report. Upon inspection of the file after receiving the citation document the Director of Rehabilitation noted that the date on the 2023 report was actually July 22, 2023 and therefore written within the proper time frame. However, as a precaution staff members were reinstructed via written email of the proper time frames for completing reports as documented in the training manual received upon hire for the Program Specialist position. 01/12/2024 Implemented
2390.152(c)Individual #2's record contains two assessments completed on 8/2023 and 7/22/22. Both documents are identical from front to back.The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.The citation for Individual #2 stated that the 151 assessment for 2023 was a duplicate of the previous year¿s report. Upon inspection of the file after receiving the citation document the Director of Rehabilitation contacted the Program Specialist who discovered he had printed and placed the wrong report in the file. As a precaution staff members were reinstructed via written email of the proper protocol and time frames for completing reports, as documented in the training manual received upon hire for the Program Specialist position. New reports are written annually based on the progress made during the year. 01/10/2024 Implemented
SIN-00215356 Renewal 11/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.54The kitchen range of this unused kitchen (adjacent to the dining hall) has all pilot lights lit (active flame); this presents a hazard as a combustible substance.Combustible supplies and equipment shall be utilized safely, stored in a fire retardant cabinet or closet and stored away from heating sources.On 1/25/2023 the gas for the gas range was turned off. There is no longer an active flame. 01/25/2023 Implemented
SIN-00150092 Renewal 02/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Staff person #1's annual fire safety training was completed on 1/31/19, and the previous training was completed on 1/12/18, which is more than a year.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 member has been counseled in regard to the importance of meeting annual training dates. Our new computerized training system will assist us with training dates. This will also be monitored by the Directors of each Department and by the Executive Director. 02/22/2019 Implemented
SIN-00125329 Renewal 11/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.72(c)-2Blind and visually impaired individuals attend the vocational facility. The work aisles were not equipped with tactile guides.If visually handicapped clients are served, work aisles shall be marked with tactile guides. No tactile guides - We have located appropriate guidelines and have installed. 02/08/2018 Implemented
2390.85(a)-2The 7/13/17 fire drill log did not indicate the hypothetical location of the fire.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.The oversight has been noted and the preparer counseled. Future logs will be reviewed by the Safety Committee in the future. 12/15/2017 Implemented
2390.111(b)Individual #1's pre-admission interview was completed on 12/29/16. Individual #1 was not notified of his/her acceptance to the facility until 3/24/17.Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. Respectfully disagree. The client and team informed Handi-Crafters near final days of vocational evaluation in December 2016 that they had decided to not continue at Handi-Crafters. When the team changed their mind in March 2017 Handi-Crafters immediately issued the acceptance letter and scheduled a team meeting. 02/08/2018 Implemented
2390.122Individual #5's 2016 assessment was purged from the record.Client records shall be kept at the facility while the client is being served.The PS was counseled to not purge files in the future. 12/15/2017 Implemented
2390.124(10)Individual #4's record did not contain a current Individual Support Plan.Each client's record must include the following information: A copy of the current ISP.Agree. #4 PS will receive intensive training. 01/12/2018 Implemented
2390.151(a)Individual #5's assessment was completed on 8/8/17. The 2016 assessment was purged from the record. It cannot be determined if the assessment was completed annually.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.The PS has been counseled to not purge the prior assessment in the future. None of the other PS purged. 12/15/2017 Implemented
2390.151(e)(2)Individual #1's 5/24/17 assessment did not include his/her vocational likes and dislikes.The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.PS #1 being intensely trained. 01/12/2018 Implemented
2390.151(e)(3)(ii)Individual #1's 5/24/17 assessment did not include his/her ability to receive, retain, and carry out instruction.The assessment must include the following information: The client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions.PS being intensely trained. 01/12/2018 Implemented
2390.151(e)(5)Individual #2's 4/27/17 assessment, Individual #4's 3/18/17 assessment, and Individual #7's 8/17/17 assessment did not include his/her ability to self-administer medications. The assessment must include the following information: The client's ability to self-administer medications.We respectfully disagree regarding #2 and 7. The #2 Assessment states that the individual does not self-administer medications. #7 is not taking any medication, #4 PS being extensively trained. 01/12/2018 Implemented
2390.151(e)(7)Individual #1's 5/24/17 assessment did not include his/her knowledge of heat sources. Individual #2's 4/27/17 assessment, Individual #5's 8/8/17 assessment, Individual #6's 2/1/17 assessment, and Individual #7's 8/17/17 assessment did not include his/her ability to move away from heat sources. Individual #8's 6/5/17 assessment did not include his/her knowledge of heat sources or his/her ability to quickly move away.The assessment must include the following information: 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.#1 Agree. The knowledge and ability to move away will be better documented in the future. PS being extensively trained. 01/12/2018 Implemented
2390.151(e)(10)Individual #1's 5/14/17 assessment did not include an updated lifetime medical history. The medical history in the file was dated October 2017, after the assessment was completed. Individual #5's 8/8/17 assessment and Individual #7's 8/17/17 assessment did not include a lifetime medical history. Individual #4's 3/18/17 assessment did not include an updated lifetime medical history.The assessment must include the following information: A lifetime medical history.Agree #1 and #4 this PS will be extensively trained. We respectfully disagree with both #5 and #7 each of these files included correspondence requesting updated Medial History. We will, in the future, extract from the latest ISP if our request is not addressed as recommended by the Licensing Inspector. 01/12/2018 Implemented
2390.151(e)(13)(i)Individual #1's 5/24/17 assessment did not include current level of health. This section of the assessment was not completed. Individual #3's 4/1/17 assessment and Individual #4's 3/18/17 assessment did not include progress or regression over the past year in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Agree this will be emphasized in our training. 01/12/2018 Implemented
2390.151(e)(13(ii)Individual #2's 4/27/17 assessment, Individual #3's 4/1/17 assessment, Individual #6's 2/1/17 assessment, and Individual #7's 8/17/17 assessment did not include progress or regression in motor and communication skills. Individual #6 and #7's assessment contained the same information as the 2016 assessment.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.We respectfully disagree in regard to #2 and #7. #3 and #6 have been counseled to provide better documentation in the assessment. 01/12/2018 Implemented
2390.151(e)(13)(iii)Individual #2's 4/27/17 assessment, Individual #3's 4/1/17 assessment, Individual #6's 2/1/17 assessment, and Individual #7's 8/17/17 assessment did not include progress or regression over the past year in personal adjustment skills. Individual #6 and #7's assessment contained the same information as the 2016 assessment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.We respectfully disagree in regard to #2 and #7. #3 and #6 have been counseled to provide better documentation in the assessment. 01/12/2018 Implemented
2390.151(e)(13(iv)Individual #1's 5/24/17 assessment did not include his/her current level of socialization skills. This section of the assessment was not completed. Individual #2's 4/27/17 assessment, Individual #3's 4/1/17 assessment, Individual #4's 3/18/17 assessment, Individual #6's 2/1/17 assessment, and Individual #7's 8/17/17 assessment did not include progress or regression over the past year in socialization skills. Individual #6 and #7's assessment contained the same information as the 2016 assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.The PS is receiving intensive training and monitoring. 01/12/2018 Implemented
2390.151(e)(13)(v)Individual #3's 4/1/17 assessment, Individual #6's 2/1/17 assessment, and Individual #7's 8/17/17 assessment did not include progress or regression over the past year in vocational skills. Individual #6 and #7's assessment contained the same information as the 2016 assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Respectfully disagree. It is clearly stated that these clients have maintained vocational skills. 02/08/2018 Implemented
2390.151(f)Individual #1's 5/24/17 assessment was not sent to his/her family or residential provider. Individual #2's 4/27/17 assessment was not sent to his/her residential provider. There was no documentation in the record to show Individual #4's assessment was sent to plan team members. Individual #5's 8/8/17 assessment was not sent to his family, supports coordinator, or residential provider.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).All PSs have been counseled. We will assure that ISP reviews will be provided to all team members and will be documented even when hand delivered or sent via email. 01/12/2018 Implemented
2390.153(1)Individual #4 does not have an outcome in his/her ISP for the vocational facility.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Services provided to the client and expected outcomes chosen by the client and client's plan team.PS being intensely trained. 01/12/2018 Implemented
2390.153(5)Individual #3's, Individual #4's, and Individual #8's Individual Support Plan (ISP) did not include his/her social, emotional, environmental needs plan.A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.PS #3, 4, 8. We have prepared the SEEP but it was not included in the ISP by the SC. We will be more diligent with our follow-up with SC in the future. 01/12/2018 Implemented
2390.153(7)(i)Individual #1's Individual Support Plan (ISP), Individual #3's ISP, Individual #4's ISP, and Individual #5's ISP did not include his/her 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.We will emphasize the importance of better documentation in our training. 01/12/2018 Implemented
2390.153(7)(ii)Individual #1's Individual Support Plan (ISP), Individual #3's ISP, Individual #4's ISP, and Individual #5's ISP did not include his/her potential to advance in competitive 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.We respectfully disagree with findings for #3. It is clearly documented in the file. We do, however, agree that proper documentation for #1, #4 and #5 was omitted. The PS is being further trained. 01/12/2018 Implemented
2390.154(a)(1)(iii)A direct care worker was not present or did not provide input towards the annual ISP updates for Individual #2, #3, #5, #6, #7, or #8. The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2390.156 (relating to ISP review and revision). A plan team must include as its members the following: A direct service worker who works with the client from each provider delivering a service to the client.We respectfully disagree. Direct care workers are always consulted prior to each ISP meeting but not always needed to attend the meeting. We utilize an "Annual Workshop Assessment" form as a tool to collect information, which is included in the client file. Additionally, the Direct Care worker provides the PS with monthly progress reports which, in addition to outcomes, includes a worker profile checklist and comments. The PS for #6 is blind and cannot read a handwritten document but includes verbal information in her assessment prep based upon her brail notes. 02/08/2018 Implemented
2390.156(a)Individual #1 was admitted to the program on 3/24/17. An Individual Support Plan (ISP) review was not completed until 9/29/17. Individual #2's ISP review covering April through June of 2017 was not completed until 8/9/17. The ISP review covering July through September of 2017 was not completed until 11/8/17. Individual #3's ISP review covering August through October of 2016 was not completed until 12/5/16. Individual #3's ISP review covering November 2016 through January 2017 was not completed until 3/4/17. 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.#1 We agree and have counseled the PS of the need to complete all reviews on a timely basis. She will receive additional training and will be closely monitored. #2 We respectfully disagree. The date cited is incorrect. The actual due date was 7/10/17 and the ISP review was completed by 8/9; within the required 30 days. The other finding was also incorrect, the proper due date was 10/10/17 which was completed by 11/8/17. #3 We respectfully disagree. The period covered was through February not January. The ISP review was completed on 2/5/17 but not signed by the client until 3/4/17 due to her absence from Handi-Crafters. 01/12/2018 Implemented
2390.156(c)(1)Individual #1's 9/29/17 Individual Support Plan (ISP) review did not include progress on the ISP outcome of earn a paycheck. Individual #1 does not have a measurable goal. The ISP review must include the following: 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.The PS has been counseled and will receive additional training and will be closely monitored. 01/12/2018 Implemented
2390.156(c)(2)Individual #1's 9/29/17 Individual Support Plan (ISP) review did not review his/her 1:1 supervision needs or his/her social, emotional, environmental needs (SEEN) plan. Individual #2's, #3's, #4's, and #8's ISP reviews did not include a review of the SEEN plan or behaviors/symptoms shown throughout the quarter. Individual #5's, #6's, and #7's ISP reviews only reviewed the outcome. The rest of the ISP was not reviewed. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.#3,#4,#8 RE: SEEP Review#3,4. We agree with the findings. The SEEP review should have been better documented. This will be improved in the future. We respectfully disagree in regard to #2. #2 does not have SEEP. She has a Behavior Plan which has been appropriately followed and documented. 5,6,7 - The Quarterly Review did include a review of the ISP but was not specifically documented. We have immediately implemented a procedure which will better document that each section of the ISP pertaining to Handi-Crafters has been reviewed. 01/12/2018 Implemented
2390.156(d)Individual #1's 9/29/17 Individual Support Plan (ISP) review and Individual #2's ISP reviews were not sent to his/her residential provider. Individual #5's ISP reviews were not sent to his/her family, supports coordinator, or residential provider. 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.We will assure that all ISP reviews will be sent and documented to all team members even when hand delivered or emailed and copies will be included in the client file. 01/12/2018 Implemented
2390.156(e)An option to decline the Individual Support Plan (ISP) review documentation was not provided to plan team members of Individual #1, #3, #5, #6, #7. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.We will assure that all team members will be notified of their option to decline. Implemented
2390.159(3)(i)Individual #1's vocational evaluation reviewing the period of time between 12/29/16 and 1/16/17 did not include his/her current level of vocational functioning.If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's current level of vocational functioning.We respectfully disagree. The narrative states that she was unable to perform work sample functions during vocational evaluation functions and was assigned to a workshop where "she needs hand-over-hand assistance with a 1:1". We will, however, include a new document we have developed which will specifically address each requirement as a supplement to our narrative. 12/15/2017 Implemented
2390.159(3)(iii)Individual #1's vocational evaluation reviewing the period of time between 12/29/16 and 1/16/17 did not include his/her vocational interests.If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The vocational interests of the client.We respectfully disagree. The narrative states that she was unable to complete evaluation test including the Vocational Interest Inventory due to her limitations and that her vocational interest is limited at this time to working at Handi-Crafters with assistance from a 1:1 so she can earn a paycheck. We will, however, include a new document we have developed which will specifically address each requirement as a supplement to our narrative. 12/15/2017 Implemented
2390.159(3)(iv)Individual #1's vocational evaluation reviewing the period of time between 12/29/16 and 1/16/17 did not include his/her level of personal and social adjustment skills.If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's level of personal and social adjustment.We respectfully disagree. The narrative states that she is friendly and eager to stay in the workshop with her team. We will, however, include a new document we have developed which will specifically address each requirement as a supplement to our narrative. 12/15/2017 Implemented
2390.159(3)(v)Individual #1's vocational evaluation reviewing the period of time between 12/29/16 and 1/16/17 did not include his/her work attitude.If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's work attitude.We respectfully disagree. The narrative specifically states that she is eager to work and has a "never quit attitude." We will, however, include a new document we have developed which will specifically address each requirement as a supplement to our narrative. 12/15/2017 Implemented
2390.159(3)(vi)Individual #1's vocational evaluation reviewing the period of time between 12/29/16 and 1/16/17 did not include his/her fatigue levels.If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's fatigue levels.We respectfully disagree. The narrative states that she is able to work in the workshop without difficulty from approximately 9:30 to 3:00 with assistance from a 1:1. We will, however, include a new document we have developed which will specifically address each requirement as a supplement to our narrative. 12/15/2017 Implemented
2390.159(3)(viii)Individual #1's vocational evaluation reviewing the period of time between 12/29/16 and 1/16/17 did not include his/her recommendations for training or placement.If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: Recommendations for specific areas of training or placement.We respectfully disagree. The narrative indicates that "training and working wither her 1:1 may help to the point where the 1:1 may be able to fade in the future." We will, however, include a new document we have developed which will specifically address each requirement as a supplement to our narrative. 12/15/2017 Implemented
SIN-00080148 Initial review 06/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(b)Individual #1's preadmission interview was on 4/24/14 and the notification of acceptance was on 9/19/14, exceeding the 30 calendar day timeframe. Individual #2's preadmission interview was on 9/18/13 and the notification of acceptance was on 9/22/14, exceeding the 30 calendar day timeframe.Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. Both of these individuals were students. It was our procedure for the Director of Employment & Youth Services to await notification of acceptance for students when the student start date was determined by the school and the student. Our POC is to have the Vocational Evaluator prepare the acceptance letter immediately upon completion of the evaluation which will include an open-ended start date for students contingent upon notification from the school and/or the student. 06/19/2015 Implemented
2390.152(a)Individual #3 did not have an ISP. A client shall have one ISP.The ISP for Ind. #3 was completed and reviewed with the client on 6/15/15. The Program Specialist has been counseled. All current client files will be reviewed and corrective action made, if necessary, and submitted to the Director of Rehabilitation Services by 8/17/15. In addition, all future clients will be closely monitored as a part of our enhanced tracking system to assure a timely completion of the ISP. 06/26/2015 Implemented