| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00202012
|
Renewal
|
03/22/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(e)(1) | Individual #3's Individual plan 1/24/2022 states she carries a $1.00 (usually quarters to program). Her assessment 12/3/2021 does not mention this. | The assessment must include the following information: Functional strengths, needs and preferences of the client. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(1).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(1) (Attachment #1-Training sheet & Attachment #2 -Memo)
Note: when reviewing Individual #3s file and documents, it was discovered that this citation refers to Individual #6, not Individual #3. Assessment date is 09/27/2021, not 12/03/2021.
An Assessment Addendum was completed on 04/06/2022 for Individual #6 revising the 09/27/2021 Assessment to include a statement regarding Individual #6 carrying $1.00 (usually quarters to program). (Attachment #3 Assessment Addendum)
An email was sent on 04/06/2022 to the Supports Coordinator for Individual #3 notifying them of the revisions. (Attachment #4 E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 04/29/2022. |
04/29/2022
| Implemented |
| 2390.151(e)(8) | Individual #3's assessment 12/2/21 states she is independent with fire drills; however, it also states she made need prompts at times. | The assessment must include the following information: The client's ability to evacuate in the event of a fire. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(8).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(8) (Attachment #1-Training sheet & Attachment #2 -Memo)
Note: when reviewing the files, it was discovered that the Assessment date is 12/03/2021, not 12/02/2021.
An Assessment Addendum for Individual #3s was completed on 04/06/2022 to revise the 12/03/2021 Assessment to include assessment of clients ability to evacuate in the event of a fire. (Attachment #5 ¿ Assessment Addendum)
An email was sent on 04/07/2022 to the Supports Coordinator for Individual # 3 notifying them of the revisions. (Attachment #6 E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 04/29/2022. |
04/29/2022
| Implemented |
| 2390.151(e)(9) | Individual #3's assessment 12/2/21 does not state her ability to quickly move away from heat sources. | The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(9).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(9) (Attachment #1-Training sheet & Attachment #2 -Memo)
Note: when reviewing the files, it was discovered that the Assessment date is 12/03/2021, not 12/02/2021.
An Assessment Addendum for Individual #3 was completed on 04/06/2022 to revise the 12/03/2022 Assessment to include her ability to move quickly move away from heat sources, this includes 151(e)(7) and 151(e)(9). (Attachment #5 Assessment Addendum)
An email was sent on 04/07/2022 to the Supports Coordinator for Individual #3 notifying them of the revisions. (Attachment #6 E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 04/29/2022. |
04/29/2022
| Implemented |
| 2390.155(1) | Individual #6's individual plan 2/17/2021 states she must be monitored around sharp objects; it also states she does not need to be monitored around sharp objects. Her individual plan also states to prevent chocking, she needs reminders to slow down when eating. Her assessment 9/27/2021 states she eats independently and is not a choking risk. Individual #6 is currently not being monitored while eating while at program. | The individual plan, including revisions, must include the following: The client's strengths, functional abilities and service needs. | The Vocational Program Specialist is responsible to ensure that the individual plan, including revisions are implemented.
The Vocational Program Specialists and Line Supervisors were trained in the requirements of regulation 2390.155(1). (Attachment #7-Training Sheet & Attachment #8- Memo)
It should be noted that when reviewing Individual #6s file and documents, the following was discovered: Psychosocial Information states that Individual #6 needs to be monitored when around sharp objects because she did cut her finger on an open soda can in the past. The Safety Precaution section states that Individual #6 asks for assistance when using knives, she has difficulty using them properly. Individual #6 does not seek out sharp objects to harm herself or others sharp objects do not need to be made inaccessible to Individual #6.
Due to this discrepancy in the Individual plan, on 04/06/2022 the residential team was contacted clarifying Individual #6s safety/need to be monitored around sharp objects. Individual #6 does not need to be monitored around sharp objects. An Assessment Addendum for Individual #6 was completed on 04/07/2022 to revise the 09/27/2021 Assessment. (Attachment #9 Assessment Addendum)
On 04/07/2022, the Vocational Program Specialist sent an e-mail to the Supports Coordinator clarifying Individual #6¿s ISP sections: Psychological Information and Safety Precaution. (Attachment #10 ¿ Email)
Due to medical condition/procedure, Individual #6 has not attended day program since 02/22/2022. Prior to returning to program a team meeting will be held and an Assessment of current needs will be completed at that time.
It should be noted that when reviewing Individual #6s file and documents, the following was discovered: Individual #6s current Individual Plan dated 02/08/2022 states under Meals/Eating that Individual #6 is independent with eating. Individual #6 does not need to be monitored for choking. The Individual Plan under Adaptive/Self Help states that in Individual #6s SIS information to prevent choking, Individual #6 needs reminders to slow down and take her time when eating, however it later clarifies that there is a SIS discrepancy: Individual #6 does not need reminders to slow down when eating. The 09/27/2021 Assessment correctly states that Individual #6 eats independently and is not a choking risk, therefore Individual #6 does not need to be monitored while eating at program. Since there are no discrepancies between the current individual plan and the 09/27/2021 Assessment changes to the Individual Plan or Assessment are not needed. For clarity, this information was added to the Assessment Addendum for Individual #6 that was completed on 04/07/2022. (Attachment #9 Assessment Addendum)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 04/29/2022. |
04/29/2022
| Implemented |
|
|
|
SIN-00184443
|
Renewal
|
03/08/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.63 | There was no light outside of the kitchen egress. | Rooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents. | The CEO and the Director are responsible to ensure compliance with this regulation. The CEO and Director were trained in the requirements of regulation 2390.63. (Attachment # 1 -Training sheet & Attachment # 2 - Memo)
A motion light-detector was purchased and installed to ensure proper lighting outside the kitchen door (Attachment #3 ¿ Photo). |
03/25/2021
| Implemented |
| 2390.75(a)(4) | The temperature did not rise above 140 degrees at the kitchen dishwasher during the wash cycle. | If the facility provides meals for clients or a food service training facility program in the facility, the following conditions shall be met: (4) Mechanical dishwashers shall use hot water temperatures exceeding 140°F in the wash cycle and 180°F in the final rinse cycle or shall be of a chemical sanitizing type approved by the National Sanitation Foundation. | The Director, Assistant Director, Food Service Supervisor and Production Supervisor are responsible to ensure compliance with this regulation. The Director, Assistant Director, Food Service Supervisor and Production Supervisor were trained in the requirements of regulation 2390.75(a)(4). (Attachment # 5 -Training sheet & Attachment # 6 - Memo)
The Food Service Supervisor (FSS) or Production Supervisor, in the absence of the (FSS) is responsible to follow the Water Temperature Monitoring Protocol (Attachment #7- Protocol).
The Food Service Supervisor (FSS) or Production Supervisor, in the absence of the (FSS) is responsible to record the temperature on the Water Temperature Log (Attachment #8 -Log).
The Food Service Supervisor (FSS) or Production Supervisor, in the absence of the (FSS) is responsible to immediately notify the Director (or Assistant Director in the absence of the Director) if the water temperature is below 140°F during the wash cycle.
The heating element was replaced on 03/15/2021 by S.J. Eaton Plumbing & Heating. (Attachment #9 Invoice)
The kitchen dishwasher temperature exceeds 140 degrees during the wash cycle. (Attachment #10 |
03/15/2021
| Implemented |
|
|
|
SIN-00159667
|
Renewal
|
09/24/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.51 | Individual # 12, # 13, #14 are deaf and cannot hear the fire alarm system throughout the facility. The strobe light in the enhanced training room was faint and partially blocked by a ceiling pipe. This caused the strobe light to not be visible from the other side of the room. The kitchen is not equipped with a strobe light. When standing in parts of the kitchen, the strobe light from the cafeteria is not visible. | For facilities serving physically handicapped clients, accommodations such as ramping and wide doorways shall be made to ensure the maximum physical accessibility feasible for entrance to, movement within, and exit from the facility, based upon each client's physical characteristics. | The Director or Assistant Director is responsible to ensure compliance with Regulation 2390.51
The Director or Assistant Director were trained in the requirements of regulation 2390.51. (Attachment #51- Training sheet & Attachment #52- Memo)
The strobe light in the enhanced training room was lowered below the ceiling pipe to increase visibility from all areas of the room. (Attachment #53 ¿ Photo Strobe light) A strobe light was added to the kitchen. (Attachment #54 ¿ Photos Strobe light & Invoice) |
11/08/2019
| Implemented |
| 2390.61 | The front cover on the baseboard heater located in the men's bathroom, closest to the kitchen, was not affixed properly to the heater, exposing the heating elements. The lower, left-hand, kitchen cabinet in the kitchen, was not equipped with a cabinet drawer. This left the food items exposed that were stored in the cabinet. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | Although all staff are responsible to report hazards, the Director, Assistant Director are responsible to ensure compliance with Regulation 2390.61.
The Director or Assistant Director were trained in the requirements of regulation 2390.61. (Attachment #47- Training sheet & Attachment #48- Memo)
The front cover of the baseboard heater was affixed to the heater removing the hazard of the exposed heating elements. (Attachment #49 ¿ Photo ¿ Heater). A kitchen cabinet door has been ordered and will be replaced, eliminating the exposure of food items. (Attachment #50 ¿ Photo ¿ Kitchen cabinet door) |
11/13/2019
| Implemented |
| 2390.62 | Both men's bathrooms smelled of urine immediately upon entering the rest rooms. | Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas. | The Safety Monitor, Maintenance staff, Production Manager and Assistant Production Manager are responsible to ensure compliance with regulation 2390.62.
The Director, Assistant Director, Production Manager and Assistant Production Manager were trained in the requirements of regulation 2390.72(c). (Attachment #42 - Training sheet & Attachment #43 -Memo)
The Safety Monitor is the primary staff person to complete at least four bathroom checks each day per the Protocol (Attachment #44 ¿ Protocol) and using the Bathroom Checklist (Attachment #45 ¿ Checklist). In his absence a Maintenance staff person will complete this duty. In both their absence the Assistant Production Supervisor will complete this duty. In the event all three are absent then the Production Supervisor or their designee will complete this duty. The Safety Monitor, Maintenance staff, Production Manager and Assistant Production Manager were trained on the Protocol and use of the Checklist. (Attachment # 46 ¿ Training sheet) |
11/13/2019
| Implemented |
| 2390.72(c) | Individuals #15 and #16 are visual impaired and cannot see the work aisle lines. The work aisles throughout the main program area are not equipped with tactile guides. The enhanced training room was not equipped with marked work aisles. The work aisles throughout the facility are worn through and not a complete 2 inch solid stripe. | 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 Director, Assistant Director, Production Manager and Assistant Production Manager are responsible to ensure compliance with regulation 2390.72(c).
The Director, Assistant Director, Production Manager and Assistant Production Manager were trained in the requirements of regulation 2390.72(c). (Attachment #38 - Training sheet & Attachment #39 -Memo)
The work aisles throughout the main program area are equipped with tactile guides/textured paint. (Attachment #40 ¿ Photo ¿ Tactile painted guided walkways). The enhanced training room was equipped with marked work aisles. (Attachment #41 ¿ Photo ¿ Enhanced training room work aisles) |
11/13/2019
| Implemented |
| 2390.104(4) | Individual #10's allergy medical information pertinent to diagnosis and treatment in case of an emergency is not updated or readily accessible. The individual's 7/25/17 physical examination, found unmarked approximately 1/4th of the way back his client record binder, listed his allergies as, "Penicillin, Ditropan, Benzodiazepines/most tranquilizers, Serax, Ragweed, Grass, Trees, Pollen, House Dust, Feathers (allergic rhinitis)." The individual's record also contained an identification sheet that listed his allergies as, "Penicillin, Ditropam, Serax, Environmental and animal, Allergic Rhinitis required response, contact physician if severe known allergy, most tranquilizers." The Individual's Individual Support Plan (ISP) listed the individual's allergies as, "Penicillin, Ditropan, Serax, environmental and animals, and Benzodiazepines." All the forms referenced in this violation found in the individual's record, were unmarked and not readily accessible. None of the forms agreed on the different forms of allergies for the individual, nor was their clarification from a licensed physician to explain what other form of tranquilizers the individual may be allergic to, of the different forms of environmental or animal allergies the individual may have. | Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.104(4).
The Vocational Program Specialists were trained in the requirements of regulation 2390.104(4).(Attachment #33-Training sheet & Attachment #34 -Memo)
Individual #10¿s pertinent medical information was updated to include allergies which were confirmed by his physician. Allergies include Penicillin, Cephalexin, Ditropan, Benzodiazepines, Serax, Lorazepam, Ragweed, Grass, Trees, Pollen, Dust, FEA, and Feathers. The General Information sheet, was revised to reflect the current pertinent medical information and the Physician¿s note clarifying the allergies was attached to the Physical. (Attachment #35 ¿ General Information sheet, Attachment #36 ¿ Physician note )
The pertinent medical information is readily accessible and is located to the front of the individual¿s file/binder
An email was sent to Individual #10¿s Supports Coordinator of the clarification in Allergies so the Individual Support Plan can be updated. (Attachment #37 ¿ E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.151(e)(3)(iii) | Individual #10's 4/12/19 assessment does not include his current level of personal adjustment skills. His assessment reads, "current level in personal adjustment: {the individual} continues to want to touch people, and he will lightly slap them on top of the head, the shoulder, or the buttocks and he may even kiss those he likes. Staff continues to role model acceptable and positive behavior at all times. Staff should continue to educate {the individual} about good and bad touching and acceptable work place behavior or deter unwanted touching of others." According to the individual's daily logs completed by direct support staff, the individual has slapped, hit, and punched himself on the head, spit on the floor, kicked doors and walls, kicked items on the floor, slapped coworkers, stole food from staff and coworkers, stole items from the cleaning closet, cleaning cart and laundry, among other behaviors on a weekly basis over the entire last year's annual assessment period. None of these behaviors were captured in the individual's assessment. | The assessment must include the following information: The client's current level of performance and progress in the following areas: Personal adjustment. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(3)(iii).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(3)(iii) (Attachment #7-Training sheet & Attachment #8 -Memo)
An Assessment Addendum for Individual #10¿s was completed to revise the 04/12/2019 Assessment to include his current level of personal adjustment skills to include the following behaviors slapped, hit, and punched himself on the head, spit on the floor, kicked doors and walls, kicked items on the floor, slapped coworkers, stole food from staff and coworkers, stole items from the cleaning closet, cleaning cart and laundry. (Attachment #32 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual #10 ¿ notifying them of the revisions. (Attachment # 31 - E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.151(e)(4) | Assessment dated 11/21/18 doesn't clarify supervision needs for Individual #2 at day program. Supervision needs are conflicting in different areas of the assessment and current individual support plan. Supervision needs while in the community are not addressed in the assessment for individual #2.
Assessment dated 11/21/18 doesn't clarify supervision needs for Individual #2 at day program. Supervision needs are conflicting in different areas of the assessment and current ISP. Supervision needs while in the community are not addressed in assessment.
The assessment dated 2/1/19 did not assess the need for supervision for Individual #3 while in the community.
Assessment dated 2/1/19 doesn't not assess Individual #4's need for supervision while in the community.
The assessment dates on 3/8/19 doesn't assess the need for supervision for Individual #5 while in the community.
The assessment dated 8/8/19 doesn't not assess the need for supervision for Individual #6 in the community.
The assessment dated 5/18/19 doesn't assess the need for supervision for Individual #7 while in the community.
The assessment dated 12/8/18 did not assess Individual #8 need for supervision while in the community.
Individual #10's 4/12/19 assessment does not include his supervision needs when out in the community with Suncom utilizing the Community Participation Supports program. His assessment reads, "{the individual} has a special program at Suncom industries with 1:1 staff support."
The assessment dated 2/1/19 did not assess the need for supervision for Individual #3 while in the community.
Assessment dated 2/1/19 doesn't not assess Individual #4's need for supervision while in the community.
The assessment dates on 3/8/19 doesn't assess the need for supervision for Individual #5 while in the community.
The assessment dated 8/8/19 doesn't not assess the need for supervision for Individual #6 in the community.
The assessment dated 5/18/19 doesn't assess the need for supervision for Individual #7 while in the community.
The assessment dated 12/8/18 did not assess Individual #8 need for supervision while in the community.
Individual #10's 4/12/19 assessment does not include his supervision needs when out in the community with Suncom utilizing the Community Participation Supports program. His assessment reads, "{the individual} has a special program at Suncom industries with 1:1 staff support." | The assessment must include the following information: The client's need for supervision. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(4).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(4) (Attachment #7-Training sheet & Attachment #8 -Memo)
An Assessment Addendum for Individual # 2¿s was completed to revise the 11/21/2018 Assessment to include clarification of supervision needs at the day program and add supervision needs while in the community. (Attachment #10 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 2 ¿ notifying them of the revisions and the need to make the changes in the Individual Support Plan. (Attachment # 12¿ E-mail)
An Assessment Addendum for Individual # 3¿s was completed to revise the 02/01/2019 Assessment to assess the need for supervision while in the community. (Attachment #9 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 3 ¿ notifying them of the revisions. (Attachment # 19 - E-mail)
An Assessment Addendum for Individual # 4¿s was completed to revise the 02/01/2019 Assessment to assess the need for supervision while in the community. (Attachment #20 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 4¿ notifying them of the revisions. (Attachment # 21 - E-mail)
An Assessment Addendum for Individual # 5¿s was completed to revise the 03/08/2019 Assessment to assess the need for supervision while in the community. (Attachment #22 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 5 ¿ notifying them of the revisions. (Attachment # 23 - E-mail)
An Assessment Addendum for Individual # 6¿s was completed to revise the 08/08/2019 Assessment to assess the need for supervision while in the community. (Attachment #24 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 6 ¿ notifying them of the revisions. (Attachment # 25 - E-mail)
An Assessment Addendum for Individual # 7¿s was completed to revise the 05/18/2019 Assessment to assess the need for supervision while in the community. (Attachment #26 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 7 ¿ notifying them of the revisions. (Attachment # 27 - E-mail)
An Assessment Addendum for Individual # 8¿s was completed to revise the 12/08/2018 Assessment to assess the need for supervision while in the community. (Attachment #28 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 8 ¿ notifying them of the revisions. (Attachment # 29 - E-mail)
An Assessment Addendum for Individual #10¿s was completed to revise the 04/12/2019 Assessment to include his supervision needs while out in the community with Suncom utilizing the Community Participation Supports program. (Attachment #30 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual #10 ¿ notifying them of the revisions. (Attachment # 31 - E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.151(e)(5) | Individual #2's assessment dated 11/21/18 doesn't include assessment of self-medicating at work.
Individual #'s 11/1/18 assessment does not include her ability to self-administer medications. Her assessment reads, "{the individual} does not take medication at Suncom or at home." | The assessment must include the following information: The client's ability to self-administer medications. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(5).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(5) (Attachment #7-Training sheet & Attachment #8 -Memo)
An Assessment Addendum for Individual # 2¿s was completed to revise the 11/21/2018 Assessment to include assessment of self-medicating at work. (Attachment #10 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 2 ¿ notifying them of the revisions. (Attachment # 12¿ E-mail)
An Assessment Addendum for Individual # 11¿s was completed to revise the 11/01/2019 Assessment to include her ability to self-administer medications. (Attachment #17 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 11 ¿ notifying them of the revisions. (Attachment # 18¿ E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.151(e)(9) | Individual #9's 12/3/18 assessment does not include his medical limitations. His assessment reads, "{the individual has no medical limitations at this time. {The individual} has arthritis in his knees and may request to work sitting if it is acting up." According to hospital reports in his record, the individual has been seen multiple times each year, over the course of the past few years, for seizures, vision concerns, and knee and back pain. The individual has a Vegus Nerve Stimulator implanted for seizures. He has missed work on many occasions due to these medical limitations, requested different seating arrangements due to his seizures and pain, and can take medication for the pain. This is not included in his assessment.
The individual's record also recorded that he was seen at Geisinger on 8/17/18 for near syncope and dizziness. The assessment then stated that he is not at risk of falling. | The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(9).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(9) (Attachment #7-Training sheet & Attachment #8 -Memo)
An Assessment Addendum for Individual # 9¿s was completed to revise the 12/03/2018 Assessment to include medical limitations information ¿ arthritis in his knees, seizures/VNS, vision concerns, knee and back pain and is considered a fall risk. (Attachment #15 ¿ Assessment Addendum)
An email was sent to the Supports Coordinator for Individual # 9 ¿ notifying them of the revisions. (Attachment # 16¿ E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.151(e)(10) | Individual #2's has an allergy to Shrimp which is listed on her intake application/ face sheet but not listed in current ISP, Assessment or physical. | The assessment must include the following information: A lifetime medical history. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(e)(10).
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(10) (Attachment #7-Training sheet & Attachment #8 -Memo)
An Assessment Addendum for Individual # 2¿s was completed to revise the 11/21/2018 Assessment to include lifetime medical history information - allergy to Shrimp. (Attachment #10 ¿ Assessment Addendum)
A note from the Primary Care Physician of Individual #2¿s was attached to the 11/21/2018 Physical to include her allergy to shrimp. (Attachment #11 -Physician note)
An email was sent to the Supports Coordinator for Individual # 2 ¿ notifying them of the revisions. (Attachment # 12¿ E-mail)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.18(a) | Staff #1 recorded on Individual #10's daily behavior tracking logs, that "{the individual} took a rag from the rag cabinet and slapped a client on the butt" on 1/22/19. Staff #1 did not report this abusive act to the chief executive officer or designee within 24 hours. Upon reviewing the individual's record on 9/24/19 with agency director, Staff #2, she was not aware of the incident recorded in Individual #10's record. Furthermore, more staff entries into the individual's record, read that there were additional incidents of physical abuse with Individual #10 being the target. These incidents were never reported. On 3/25/19, Staff #3 recorded, "{the individual} struck another individual with a slight slap on right shoulder." On 4/10/19, Staff #3 recorded, "{the individual} entered Suncom and hit himself 2 times and slapped another individual on the left shoulder." | The facility shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
(1) Death
(2) A physical act by a client in an attempt to complete suicide.
(3) Inpatient admission to a hospital.
(4) Abuse, including abuse to a client by another client.
(5) Neglect.
(6) Exploitation.
(7) A client who is missing for more than 24 hours or who could be in jeopardy if missing for any period of time.
(8) Law enforcement activity that occurs during the hours of facility operation.
(9) Injury requiring treatment beyond first aid.
(10) Fire requiring the services of the fire department. This provision does not include false alarms.
(11) Emergency closure.
(12) Theft or misuse of client funds.
(13) A violation of client rights. | The Director, Assistant Director, Vocational Program Specialists and Line Supervisors are responsible to ensure compliance with regulation 2390.18.
The Director, Assistant Director, Vocational Program Specialists and Line Supervisors were trained in the requirements of regulation 2390.18 and their obligation to report abusive acts to the CEO or designee within 24 hours of the incident. (Attachment #13-Training sheet & Attachment #14 -Memo)
The Director reviewed Individual #10¿s daily behavior tracking logs that were completed on 01/22/2019, 03/25/2019 and 04/10/2019. The Director spoke with Staff #1 to determine who the potential victim could have been for the 01/22/2019 incident. Based on the documentation and interviews with staff and individuals a victim could not be determined, therefore an incident was not able to be filed. The Director spoke with Staff #3 and the potential victim of the 03/25/2019 alleged incident. The victim stated that ¿the target just touched my shoulder and she wasn¿t sure what the big deal is.¿ She did not feel she was abused by the target, therefore an incident was not filed.
The Director spoke with Staff #3 and the potential victim on the 04/10/2019 alleged incident. The victim stated that ¿both individuals give each other ¿hey buddy -high five slaps¿. He did not feel he was abused by the target, rather this was their way of communicating, therefore an incident was not filed..
After reviewing all the information, it was determined that Line Supervisors needed further training on how to document on the daily behavior tracking forms. The Director trained the staff on how to properly document Individual #10¿s target behaviors. (Attachment #5 ¿ Training sheet & Attachment #6 ¿ Behavior Tracking Form/Daily Log) |
11/12/2019
| Implemented |
| 2390.151(b) | Per the ISP dated on 8/30/19, Individual #3 had an increase/change in behaviors (Refusing medications, refusing to go to day program, throwing shoes, flipping tables and swearing at staff) and started receiving behavioral supports from a Behavior Support Professional. Assessment was not updated to reflect increased and new behaviors & new service added. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the client shall have an assessment completed as required under the section. | The Vocational Program Specialists are responsible to ensure compliance with regulation 2390.151(b)
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(b) (Attachment #7-Training sheet & Attachment #8 -Memo)
An Assessment Addendum was completed for Individual #3 revising the 02/01/2019 Assessment to include the increased behaviors, new behaviors and new service/behavioral supports that was added to the ISP as a revision on 08/30/2019. (Attachment #9 ¿Assessment Addendum)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
| 2390.156 | Individual #10's current Individual Support Plan (ISP) reads that "if {the individual} displays any "expressions of anxiety" or target behaviors when entering the building, he will be offered the chance to take more time and take a walk around the outside of the building. The 1 on 1 can attempt to bring {the individual} into the building using a different door." The ISP also defines "expressions of anxiety" as, signs that will lead to target behaviors that includes, screaming "no," pacing, picking up items or adjusting something in the room, fussing with the coffee pot repeatedly, or spitting. The ISP defines target behaviors as, "hitting, kicking or any attempt to cause harm to another person, hitting himself on the forehead or any attempt to cause harm to himself, and kicking the wall or some other object."
According to the individual's daily logs completed by direct support staff, the individual has slapped, hit, and punched himself on the head, spit on the floor, kicked doors and walls, kicked items on the floor, slapped coworkers, stole food from staff and coworkers, stole items from the cleaning closet, cleaning cart and laundry, among other behaviors on a weekly basis over the entire last year's annual assessment period. Most of the instances of the expressions of anxiety or target behaviors occurred when entering the building. There is no documentation to indicate that the individual was provided additional time to walk around the building with his 1 on 1 staff in an attempt to ease his anxiety, as his plan directs.
Individual #17's ISP states, "{the individual} does not recognize the dangers of poisonous substances. He would not know how to handle or properly store poisonous substances. He is not aware of danger signs or warning labels." Throughout the entire facility, each work station contained a 64-ounce container of hand sanitizer with a label that warned to contact poison control center if ingested. There were approximately 10 of these containers throughout the facility. | The facility shall implement the individual plan, including revisions. | The Vocational Program Specialist is responsible to ensure that the individual plan, including revisions is implemented.
The Vocational Program Specialists and Line Supervisors were trained in the requirements of regulation 2390.156. (Attachment #1-Training Sheet & Attachment #2- Memo)
The Line Supervisors were trained on the Individual #10¿s Individual Support Plan, specific to ¿expressions of anxiety¿ and target behaviors. (Attachment 3-Training Sheet & Attachment #4- Individual Support Plan)
The Line Supervisors were trained on how to complete Individual #10¿s Daily Logs, specifically how to document that individual #10 was provided additional time to walk around the building with his 1 on 1 staff in an attempt to ease his anxiety, as his plan directs. (Attachment 5-Training Sheet & Attachment #6- Behavior Tracking Form/Daily Log)
Individual #17's ISP stated, "{the individual} does not recognize the dangers of poisonous substances. Individual #17 would not know how to handle or properly store poisonous substances. Individual #17 is not aware of danger signs or warning labels." Due to Individual #17¿s inability to recognize poisons, all work station containers of hand sanitizer were removed and are being stored in locked cabinets.
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/30/2019. |
12/30/2019
| Implemented |
|
|
|
SIN-00143064
|
Renewal
|
09/25/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.34(c) | Staff #1's hire date of 4/3/17 and promotion date to production manager of 5/29/18 did not meet the 4 years of industrial work experience. | A production manager shall meet one of the following groups of qualifications: (1) Possess a bachelor's degree or above from an accredited college or university in Business or Engineering.(2) Possess an associate's degree or its equivalent from an accredited college or university in Business or Engineering; and 2 years work experience in industrial work. (3) Possess a high school diploma or a general education development certificate; and 4 years work experience in industrial work, which includes at least 2 years supervisory experience. | The Director or Assistant Director is responsible to ensure compliance with Regulation 2390.34(c) Production Manager and that the candidates for Production Manager meet the qualifications prior to hire.
The Director or Assistant Director were trained in the requirements of regulation 2390.34. (Attachment #13- Training sheet & Attachment #14- Memo)
At the time of licensing the Assistant Production Manager did not meet the qualifications of the Production Manager and was short of work experience. A Waiver of this regulation is being submitted. In the absence of the Production Manager and until a decision on the Waiver is received, the Assistant Production Manager will work under the direction of the Director and/or Assistant Director whom both meet the qualifications of Production Manager. (Attachment #15 ¿ Waiver) |
12/28/2018
| Implemented |
| 2390.61 | The men's bathroom closest to the warehouse has 1 inch pieces out of the door frame missing. Marks that cover the entire length of the door from the bottom to 1 foot high. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | The CEO, Director and Assistant Director are responsible to ensure compliance with regulation 2390.61 - Hazards. Floors, wall, ceilings and other surfaces shall be in good repair and free of visible hazards.
The CEO, Director and Assistant Director were trained in the requirements of regulation 2390.61. (Attachment #10- Training sheet & Attachment #11- Memo)
The men¿s bathroom door frame and door have been repaired and painted. (Attachment #12 - Photo) |
11/01/2018
| Implemented |
| 2390.64 | The outside handrail is rusted and in disrepair. The steps are crumbling. | Stairways, outside steps, porches and ramps shall have well secured handrails. | The CEO, Director and Assistant Director are responsible to ensure compliance with regulation 2390.64 - Handrails. The outside of the facility shall be well maintained, in good repair and free from unsafe conditions, this includes stairways, outside steps, porches and ramps as well as secured handrails.
The CEO, Director and Assistant Director were trained in the requirements of regulation 2390.64. (Attachment #7-Training sheet & Attachment #8 -Memo)
A contractor has been notified to repair these unsafe conditions. (Attachment #9 ¿ Proposal) |
10/29/2018
| Implemented |
| 2390.83(b)-1 | There was no monthly fire alarm check for May 2018. | An employee trained in the operation of the equipment shall check the fire alarm monthly. | The Director, Assistant Director or designee is responsible to ensure compliance with regulation 2390.83(b)(1), that there are monthly fire alarm checks and that they are documented.
The Director, Assistant Director or designee were trained in the requirements of regulation 2390.83(b)(1) (Attachment #4-Training sheet & Attachment #5 -Memo)
Records indicate that the fire alarm was operable and checked on 10/24/2018. (Attachment #6 ¿Fire Drill Report) |
10/24/2018
| Implemented |
| 2390.101 | individual #1's physical dated 8/12/16 states he is not free of communicable disease. | Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician. | The Vocational Program Specialist is responsible to ensure that the client file has documentation that accurately reflects the individual¿s communicable disease status.
The Vocational Program Specialists were trained in the requirements of regulation 2390.101. (Attachment #1-Training Sheet & Attachment #2- Memo)
On 10/01/2018, a note from Individual #1¿s physician was received indicating that the 08/12/2016 physical had a clerical error. Per the Physician, Individual #1 was free from communicable diseases on 08/12/2016. (Attachment #3 ¿ Physician¿s documentation)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2018. |
11/30/2018
| Implemented |
|
|
|
SIN-00109015
|
Renewal
|
04/19/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.123 | Records containing individuals information and activities were on a line supervisors shelf unlocked and unatttended. | Information in the client records shall be kept confidential. Client records shall be kept locked when unattended. | Pre-vocational staff is responsible to ensure that client records, including information and activities are kept confidential and locked when unattended.
2390.123 ¿ Confidentiality - Information in the client records shall be kept confidential. Client records shall be kept locked when unattended.
It is the responsibility of the all Pre-vocational staff to ensure compliance with this regulation and ensure that client records are kept confidential and locked when unattended.
Pre-Vocational staff was trained in the requirements of regulation 2390.123. (Attachment # 18 -Training sheet & Attachment # 19 - Memo) |
06/08/2017
| Implemented |
| 2390.151(e)(4) | Individual #2 has a 1:1 while at facility. Staff maintain line of sight supevision and with in hearing distance while in the facility. Individual #5 can't be nsupervised outside and is only using safety monitor as supervision. | The assessment must include the following information: The client's need for supervision. | Vocational Program Specialists are responsible to ensure the assessment contains all required information per regulation 2390.151(e)(4) ¿ Assessment.
2390.151(e)(4) ¿ Assessment - The assessment must include the following information: The client¿s need for supervision.
It is the responsibility of the Vocational Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s Assessment.
Supervision levels in Assessments should be written in a manner that clearly and concisely identifies an individual¿s supervision level. Additionally, Assessments should not include the Safety Monitor as a form of supervision.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(4). (Attachment # 7 -Training sheet & Attachment # 8 - Memo)
A Vocational Assessment Addendum was completed for Individual #2 on 06/06/2017, revising the 01/11/2017 Assessment with regards to the client¿s need for supervision. (Attachment # 9 ¿ Vocational Assessment Addendum)
An e-mail was sent 06/07/2017 to the Supports Coordinator for Individual # 2 ¿ requesting that the ISP be updated to include the individual¿s Supervision Care Needs section under Day Supervision. (Attachment # 10 ¿ E-mail)
A Vocational Assessment Addendum was completed for Individual #5 on 06/07/2017, revising the 05/07/2017 Assessment with regards to the client¿s need for supervision. (Attachment # 11 ¿ Vocational Assessment Addendum)
An e-mail was sent 06/07/2017 to the Supports Coordinator for Individual # 5 ¿ requesting that the ISP be updated to include the individual¿s Supervision Care Needs section under Day Supervision. (Attachment # 12 ¿ E-mail)
The supervision level information for Individual #5 was added to the Supervision Care Needs, Day Supervision section of the ISP. (Attachment # 13 ¿ Supervision Care Needs section of ISP)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/30/2017. |
06/30/2017
| Implemented |
| 2390.151(f) | Individual #5's assessment dated 7/22/16 was not sent to the SC 30 days prior to ISP dated 8/5/16. | 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). | The Vocational Program Specialist is responsible to provide the assessment to the Supports Coordinator or plan lead, as applicable, and the plane team members at least 30 calendar days prior to an ISP Meeting for the development, annual update and revision of the ISP.
2390.151(f)- Assessment - 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, 6500.152 (relating to development, annual update and revision of the ISP).
It is the responsibility of the Vocational Program Specialist to ensure compliance with this regulation and ensure that Assessment is provided to the plan team members in a timely manner.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(f). (Attachment # 14 -Training sheet & Attachment # 15 - Memo)
Individual #5 ¿ The assessment was completed on 01/03/2017 and was sent to team members on 01/04/2017, which was prior to the 02/16/2017 Individual Support Plan (ISP) Planning meeting. (Attachment #16 ¿ Letter & Attachment # 17 - ISP Signature Form)
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/17/2017. |
06/17/2017
| Implemented |
| 2390.153(5) | Individual #3's ISP did not include a SEEN 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. | Vocational Program Specialists are responsible to ensure the ISP, Annual updates and Revisions include the required information per regulation 2390.153 ¿ Contents of the ISP, specifically (5). All clients who are prescribed medication to treat symptoms of a psychiatric illness shall have a Social Emotional Environmental (SEE) Plan or a Behavioral plan.
2390.153 ¿ Content of the ISP ¿ The ISP, including annual updates and revisions under 2390.156 (relating to ISP review and revision) must include the following 2390.153(5): ¿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.¿
It is the responsibility of the Vocational Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s ISP, when appropriate.
The Vocational Program Specialists were trained in the requirements of regulation 2390.153(5). (Attachment # 3 -Training sheet & Attachment # 4 - Memo)
An e-mail was sent 05/01/2017 to the Supports Coordinator for Individual # 3 ¿ requesting that the ISP be updated to include the individual¿s current SEE Plan information. (Attachment # 5 ¿ E-mail)
The SEE plan information for Individual #3 was added to the Behavior Support Plan section of the ISP. (Attachment # 6 ¿ Behavioral Support Plan section of ISP)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/30/2017. |
06/30/2017
| Implemented |
| 2390.154(b) | Individual #5's ISP signature sheet dated 8/5/16 did not include at least three plan team members. | At least three plan team members, in addition to the client, if the client chooses to attend, shall be present for the ISP, annual update and ISP revision meetings. | Vocational Program Specialists are responsible to participate in the development of the Individual Support Plan, including the annual updates and revisions under 2390.154 (relating to ISP review and revision).
2390.154 - Plan Team Participation ¿ Per 2390.154(a) A plan team must include as its members the following: (i) ¿ The client, (ii) ¿ A program specialist or family living specialist, as applicable, from each provider delivering service to the client, (iii) ¿ A direct service worker who works with the client from each provider delivering a service to the client and (iv) ¿ Any other person the client chooses to invite. Per 2390.154(b) ¿, ¿At least three plan Team members, in addition to the client, if the client chooses to attend, shall be present for the ISP, annual update and ISP Revision meetings.¿
It is the responsibility of the Vocational Program Specialist to ensure at least 3 team members are present at ISP, annual update and ISP revision meetings in addition to the client. The Line Supervisor and Vocational Program Specialist should attend. The following staff could also attend; an Assistant Production Supervisor, Production Supervisor, Assistant Director of Rehabilitation, or the Director of Rehabilitation.
The Vocational Program Specialists were trained in the requirements of regulation 2390.154(b). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) |
06/08/2017
| Implemented |
|
|
|
SIN-00094578
|
Renewal
|
05/14/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(e)(13)(i) | Individual #7's assessment did not inlcude progress over the last 365 calendar days and current level 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. | The Vocational Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2390.151 ¿ Assessment.
It is the responsibility of the VPS to ensure compliance with this regulation and ensure that the required information is documented in the Assessment.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e) (13) (i, ii, iii and v). (Attachment #11-training sheet & Attachment #12- memo)
Individual #7¿s assessment was updated on 05/16/2016 to include recommendations for progress and growth in the areas of health, motor and communication skills, personal adjustment, and vocational skills. (Attachment #13) The assessment was sent to the Supports Coordinator and plan team members.
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/17/2016. |
06/17/2016
| Implemented |
| 2390.151(e)(13(ii) | Individual #7's assessment did not inlcude progress over the last 365 calendar days and current level in motor and communication skills. | 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. | The Vocational Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2390.151 ¿ Assessment.
It is the responsibility of the VPS to ensure compliance with this regulation and ensure that the required information is documented in the Assessment.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e) (13) (i, ii, iii and v). (Attachment #11-training sheet & Attachment #12- memo)
Individual #7¿s assessment was updated on 05/16/2016 to include recommendations for progress and growth in the areas of health, motor and communication skills, personal adjustment, and vocational skills. (Attachment #13) The assessment was sent to the Supports Coordinator and plan team members.
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/17/2016. |
06/17/2016
| Implemented |
| 2390.151(e)(13)(iii) | Individual #7's assessment did not inlcude progress over the last 365 calendar days and current level in personal adjustment. | 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. | The Vocational Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2390.151 ¿ Assessment.
It is the responsibility of the VPS to ensure compliance with this regulation and ensure that the required information is documented in the Assessment.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e) (13) (i, ii, iii and v). (Attachment #11-training sheet & Attachment #12- memo)
Individual #7¿s assessment was updated on 05/16/2016 to include recommendations for progress and growth in the areas of health, motor and communication skills, personal adjustment, and vocational skills. (Attachment #13) The assessment was sent to the Supports Coordinator and plan team members.
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/17/2016. |
06/17/2016
| Implemented |
| 2390.151(e)(13)(v) | Individual #7's assessment did not inlcude progress over the last 365 calendar days and current level in vocational skills. | 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. | The Vocational Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2390.151 ¿ Assessment.
It is the responsibility of the VPS to ensure compliance with this regulation and ensure that the required information is documented in the Assessment.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e) (13) (i, ii, iii and v). (Attachment #11-training sheet & Attachment #12- memo)
Individual #7¿s assessment was updated on 05/16/2016 to include recommendations for progress and growth in the areas of health, motor and communication skills, personal adjustment, and vocational skills. (Attachment #13) The assessment was sent to the Supports Coordinator and plan team members.
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/17/2016. |
06/17/2016
| Implemented |
| 2390.153(5) | Individual #2, #3, #6, and #7 ISP's did not include a SEEN 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. | The Vocational Program Specialist (VPS) is responsible to ensure the Individual Support Plan (ISP) including annual updates and revisions include necessary requirements per regulation 2390.153(5) ¿ Contents of the ISP.
All clients who are prescribed a medication to treat the symptoms of a psychiatric illness shall have a protocol to address the social, emotional and environmental needs of the client. It is the responsibility of the VPS to ensure compliance with this regulation and ensure that the required information is documented in the ISP. Additionally, the VPS is responsible to ensure the following statement is in the ISP, when medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. ¿The individual has a diagnosis of __________ and takes the following medication(s) _____________________.¿
The Vocational Program Specialists were trained in the requirements of regulation 2390.153(5). (Attachment #1-Training sheet & Attachment #2- Memo)
Individual #2 ¿ An email was sent on 05/26/2016 to the Supports Coordinator to add the following statement into the Psychosocial Information section of the ISP. Individual #1 is diagnosed with Bipolar Disorder and takes the following medications: Seroquel and Haloperidol.¿Individual #1 is diagnosed with Depression and takes the following medications: Citalopram and Effexor.¿ (Attachment #3 ¿ Email)
Individual #3 - An email was sent on 05/26/2016 to the Supports Coordinator to add the following statement into the Psychosocial Information section of the ISP. Individual #2 has a diagnosis of Anxiety and takes the following medication: Fluoxetine HCL .¿ Attachment #4 ¿ Email)
Individual #6 - An email was sent on 05/25/2016 to the Supports Coordinator to add the following statement into the Psychosocial Information section of the ISP.Individual #6 has a diagnosis of Schizoaffective Disorder and takes the following medication: Risperdal, Ativan, and Loxitane.¿ (Attachment #5 ¿ Email)
Individual #7 - An email was sent on 05/26/2016 to the |
06/17/2016
| Implemented |
| 2390.153(7)(ii) | Individual #4 and #5 ISP's did not include 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. | The Vocational Program Specialist (VPS) is responsible to ensure the Individual Support Plan (ISP) including annual updates and revisions include necessary requirements per regulation 2390.153(7) ¿ Contents of the ISP. It is the responsibility of the VPS to ensure compliance with this regulation and that the necessary information is documented in the ISP.
The Vocational Program Specialists were trained in the requirements of regulation 2390.153(7) (ii). (Attachment #7-Training sheet & Attachment #8- Memo)
Individual #4 - An email was sent on 05/25/2016 to the Supports Coordinator to add the client¿s potential to advance in competitive community-integrated employment into the Educational /Vocational section of the ISP (Attachment #9 ¿ Email)
Individual #5- An email was sent on 05/25/2016 to the Supports Coordinator to add the client¿s potential to advance in competitive community-integrated employment into the Educational /Vocational section of the ISP (Attachment #10 ¿ Email)
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/17/2016. |
06/17/2016
| Implemented |
|
|
|
SIN-00080468
|
Renewal
|
06/05/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.70(d) | The first aid kit did not include antiseptic. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | The Program Specialist is responsible to ensure that first aid kits contain all required items per regulation 2380.70(d). The Program Specialists were trained in the requirements of regulation 2380.70(d). (Attachment #1-Training sheet & Attachment #2 - Memo) Program Specialists are responsible to check all first aid kits periodically (perhaps following monthly fire drills) to ensure the kit contains all required items. Antiseptic was added to the first aid kit on 06/08/2015. (Attachment #3- Photo)
|
06/08/2015
| Implemented |
| 2380.111(c)(9) | Individual #1's physcial did not include buspar and Loratadine. | The physical examination shall include: Allergies or contraindicated medication. | The Program Specialist is responsible to ensure that the physical examination contains all the required items per regulation 2380.111(c), specifically 111(c)(9) allergies and contraindicated medications. The Program Specialists were trained in the requirements of regulation 2380.111(c). (Attachment #4- Training sheet & Attachment #5- Memo)
Individual #1 ¿ The citation stated that the physical did not include buspar and loratadine. Claritin (the brand name for loratadine) is listed on the physical form under Allergies/Sensitivities/Contraindicated Medications and on the Lifetime Medical History. This is consistent with the current Individual Support Plan therefore; loratadine was not added to the physical form. (The physical examination was updated (06/17/2015) to include the allergies and contraindicated medications. Buspar was added to the physical. Attachment #6- Physical Examination)
The Program Specialist is responsible to ensure that the physical examination checklist is completed upon receipt of a physical examination form. The Program Specialists were trained on how to complete the Physical Examination Checklist form. (Attachment #7- Training sheet &Attachment #8- Memo)
Individual #1 ¿ The physical examination checklist was completed (06/17/2015). (Attachment #9- Physical Examination Checklist)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/09/2015.
|
10/09/2015
| Implemented |
|
|
|
SIN-00062662
|
Renewal
|
04/16/2014
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(e)(13(ii) | The Annual Assessment 1/3/14 for Individual #6 did not have the progress and growth over the last 365 calendar days in the following areas: Motor & Communication, Personal Adjustment and Vocational Skills. | 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. | The Vocational Program Specialist is responsible to ensure that the required information is documented in the assessment. The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(13)(i-v). (Attachment A-training sheet & Attachment B- memo)
Individual #6¿s assessment was updated to include recommendations for progress and growth in the areas of health, motor and communication skills, personal adjustment, socialization and vocational skills. (Attachment C)
A Progress and Growth chart was developed to assist the Vocational Program Specialists gather the information needed to complete sections of 151(e)(13)(i-v). (Attachment D)
|
05/29/2014
| Implemented |
| 2390.158(b) | The ISP reviews for Individual's #1, #3, #4, #5 & #6 did not review opportunities for Individuals to participate in community life, including community-integrated employment that the facility is to provide. | The facility shall provide opportunities and support to the client for participation in community life, including competitive community-integrated employment. | The Vocational Program Specialist is responsible to ensure that the required information is documented in the ISP review including data and information during the prior 3 months with regards to providing opportunities and support for individuals to participate in community life, including competitive community- integrated employment. The Vocational Program Specialists were trained in the requirements of regulation 2390.158(b) (Attachment E-training sheet & Attachment F- memo)
The Vocational Program Specialist completed an ISP Review Addendum for Individuals #1 & #3 including information on opportunities and support for participation in community life, including competitive community-integrated employment. (Attachments G & H respectfully)
The Vocational Program Specialist completed an ISP Review for Individuals #4, #5, #6 including information on opportunities and support for participation in community life, including competitive community-integrated employment. (Attachments I, J & K respectfully)
|
05/30/2014
| Implemented |
|
|
|
SIN-00264871
|
Renewal
|
05/06/2025
|
Compliant - Finalized
|
|
|
SIN-00244344
|
Renewal
|
05/21/2024
|
Compliant - Finalized
|
|
|
SIN-00225209
|
Renewal
|
05/30/2023
|
Compliant - Finalized
|
|
|
SIN-00064503
|
Initial review
|
06/12/2014
|
Compliant - Finalized
|
|
|
SIN-00048024
|
Renewal
|
04/05/2013
|
Compliant - Finalized
|
|