Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00272018 Renewal 08/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)Fire drills conducted between July 2024 -- July 2025 do not note if there were any problems encountered during the drill. This section is left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.The compliance specialist responsible for completing fire drills at the Day Program has been informed of the required documentation pertaining to regulation 2380.89(c). The fire drill documentation does have a section to note whether or not any problems were encountered during a fire drill. This section will be completed with a yes or no answer in order to document how the fire drill went. Yes, answers will be accompanied by the recognized problem area. N/A is not to be used. (Attachment #1) 08/26/2025 Implemented
2380.111(a)Individual #4 received a physical exam on 9/28/2023, then not again until 11/27/2024.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #4's Program Specialist has been retrained on regulation 111(a) in order to ensure that each individual's physical examination will be completed within 12 months prior to admission and annually thereafter. (Attachment #4) 08/26/2025 Implemented
2380.111(c)(5)Individual #1's date of admission is 10/14/2024. Individual #1 received a tuberculin skin test on 11/14/2022, prior to services starting. Individual did not receive TB testing again until 12/3/2024 and there is no documentation from the health care provider that testing is not indicated for the Individual.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Individual #1's Program Specialist has been retrained on regulation 111(c)(5). The Program Specialist has been made aware of the need for each individual to have a negative tuberculin skin test within 1 year prior to starting services at the Day Program. A tuberculin skin test is then required to be completed every 2 years thereafter with a negative result. If the tuberculin skin test is positive, a chest x-ray with results noted will be required. Repeat testing after initial baseline testing is obtained is not required when there is documentation from the health care practitioner that testing is not indicated for the individual. (Attachment #8) 08/26/2025 Implemented
2380.21(u)All individuals in the sample were not informed of the below listed rights; Individual #1 signed on 4/1/2025, Individual #2 signed on 9/19/24, Individual #3 signed on 5/5/2025, Individual #4 signed on 1/13/2025: 21b, 21c, 21d, 21e, 21f, 21i, 21j in relation to mistreatment, abandonment or subject to corporal punishment, 21l, 21m, 21n, 21o, and 21p.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.An updated Bill of Rights has been created to reflect the addition of regulation 21b, 21c, 21d, 21e, 21f, 21i, 21j, 21l, 21m, 21n, 21o, and 21p. (Attachment #11) 08/26/2025 Implemented
2380.21(v)All individuals in the sample were not informed of the below listed rights; Individual #1 signed on 4/1/2025, Individual #2 signed on 9/19/24, Individual #3 signed on 5/5/2025, Individual #4 signed on 1/13/2025: 21b, 21c, 21d, 21e, 21f, 21i, 21j in relation to mistreatment, abandonment or subject to corporal punishment, 21l, 21m, 21n, 21o, and 21p.The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.An updated Bill of Rights has been created to reflect the addition of regulation 21b, 21c, 21d, 21e, 21f, 21i, 21j, 21l, 21m, 21n, 21o, and 21p. (Attachment #11) The new updated Bill of Rights has been reviewed and signed by Individuals #1, #2, #3, and #4 as well as their guardians. This updated version will be filed in each person's program book as part of their file. (Attachment #12) (Attachment #13) (Attachment #14) (Attachment #15) 09/30/2025 Implemented
2380.39(c)(4)Staff #3 did not complete annual training in 2024 that included recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.A new Human Resource Manager has since been hired as of 1/27/2025. The new Human Resource Manager has been trained on the annual required trainings as part of her orientation including recognizing and reporting incidents related to regulation 2380.39(c)(4). (Attachment #16) 08/26/2025 Implemented
2380.126(d)Individual #2 is prescribed 9 PRN medications. As of 8/18/2025, only 3 are available at the day program: Acetaminophen 325 mg, Albuterol HFA 90 mcg, and Pink Mismouth. The additional 6 PRN medications are not available at the program if the Individual needs them on a PRN basis. Additionally, the 3 medications that are currently available at the day program were not obtained until 8/11/2025, however the Individual has been enrolled since 10/14/2024 with no PRN medications made available to them previously.The directions of the prescriber shall be followed.Individual #2's Program Specialist has been retrained on regulation 126(d) The directions of the prescriber shall be followed. The Program Specialist has requested and received all 9 of Individual #2's PRN medications and is aware of the need to request all PRN medications for those participating in the Day Program. The Program Specialist has also been made aware to document any cooperation issues with caregivers who may not be complying with requests for medications. (Attachment #18) 09/30/2025 Implemented
SIN-00226942 Renewal 07/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical dated 08/17/22 reads "Emergency Information Pertinent to Diagnosis -- Independent". Specific Emergency Information is not listed.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1s Program Specialist and the Administrative Assistant were trained on the proper information to be included in the Emergency Information Pertinent to Diagnosis section of the physical (Attachment #1). This training took place on July 20, 2023. The Administrative Assistant contacted Individual #1s Primary Care Physician in order to clarify the Emergency Information Pertinent to Diagnosis section of his/her physical (Attachment #2). This clarification was completed on July 20, 2023. 07/27/2023 Implemented
2380.21(u)Individual #2 received and was informed of her Rights on 2/20/2022 and not again until 7-5-23.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The Administrative Assistant and Program Specialist for Individual #3 were trained on meeting timeframes in regard to informing and explaining individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter (Attachment #3). This training took place on July 20, 2023. 07/27/2023 Implemented
SIN-00208897 Renewal 08/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2's physical was completed on 9/23/2020, then not again until 11/15/2021.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #2s Program Specialist, will be retrained on the timeframes related to physical examinations. (Attachment #1) This training took place on August 9, 2022 and was completed by Director, 08/09/2022 Implemented
2380.126(a)(3)Individual #1's July MAR does not list drug allergies. Individual is allergic to Bactrim and Estrogens.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.Crossroads Services, Inc. has two certified Medication Administration Trainers, who have been retrained by Director, on properly completing an individual MAR. (Attachment #4) Both and have also reviewed all current MAR's for their accuracy and completeness. (Attachment #5) have completed their training presented by Director, and reviewed all current MAR's as of August 10, 2022. 08/10/2022 Implemented
2380.126(a)(13)Individual #1's July MAR does not identify the name of the person administering the medications. Only the staff member's initials are available on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Crossroads Services, Inc.s certified Medication Administration Trainers, n will begin utilizing the back page of the MARs in order to document the name and initials of the person administering the medication for each individuals MAR. (Attachment #7) The names and initials of all staff administering medications have been added to the MAR's as of August 10, 2022. August 2022 MAR (Attachment #8) August 2022 MAR (Attachment #9) August 2022 MAR (Attachment #10) 08/10/2022 Implemented
SIN-00190809 Renewal 08/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.82At the time of the inspection, the Lunch room egress was blocked by a trash can. The door was not able to open the whole way.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Floor Manager, has moved the trash can in the lunchroom that was blocking the lunchroom door egress. Picture (Attachment #1) Director, has placed a sign near the door to remind staff not to block the egress of the door with anything including a trash can. Sign (Attachment #2) 09/01/2021 Implemented
SIN-00176455 Renewal 09/15/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The Scott Hand Soap that is in the dispensers throughout the facility state to contact poison control if ingested. Individual #3 attends this facility and isn't safe around poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Director informed the Floor Manager, to remove all Scott hand soap from the dispensers throughout the facility. Director, also instructed the Floor Manager, to place the backup supply of individual Softsoap at each sink. Crossroads had a small supply of this non-toxic/non-poisonous hand soup in stock as a backup due to delivery/supply issues of the Scott dispenser hand soap during the current COVID pandemic. (Attachment#6 & 7) The non-toxic/non-poisonous Softsoap will be used in place of the wall dispensers moving forward. (Attachment#8) Director, will attempt to locate a comparable non-toxic/non-poisonous replacement to be used in the dispensers if available. 10/07/2020 Implemented
2380.61The telephones in this facility are in the conference room, offices, and front desk. There is not a telephone in the program areas of this facility. The telephones in this facility are not easily accessible to the individuals.The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.Director, purchased a non coin-operated telephone on September 23, 2020 to be installed by PC Works whom provides phone system support at Crossroads Services, Inc. Day Program. (Attachment#3) PC Works installed the new phone line and non coin-operated phone on September 24, 2020. (Attachment#4) The new phone line and phone are located in the main program area of the Day Program in order to be easily accessed by both individuals and staff if needed. (Attachment#5) 09/24/2020 Implemented
2380.115(3)The Emergency Medical Plan does not include an emergency staffing plan.The facility shall have a written emergency medical plan listing the following: An emergency staffing plan.Crossroads Services, Inc. has updated the Emergency Medical Plan to include the staffing procedures and those individuals to be contacted during an emergency situation within the agency. (Attachment#1) This plan was updated on September 21, 2020 by Director. All staff have been trained on the updated Emergency Medical Plan. (Attachment#2) Note: Staff has been on vacation during this time. Staff will be placed on a 14 day quarantine upon returning due to leaving the state and the current COVID pandemic. Staff will be trained on the new Medical Emergency Plan once she has returned to work. This will take place by October 26, 2020. 10/26/2020 Implemented
SIN-00157440 Renewal 06/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)The following citation is in reference to individual # 2. On most recent physical dated 7/26/18 the physician stated that vision and hearing could not be completed due to the individual being, "non-verbal/cannot access". Regulations specify that the physical examinations shall include vision and hearing screenings annually for individuals over the age of 18. There was no information in the chart that indicates the individual was referred out to see a specialist who could provide these screenings.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Administrative Assistant is responsible to request and collect all program participants annual physical. Upon receiving the physical, the Administrative Assistant will review it for completion and accuracy. If the physical has an area indicating that the participant could not have a medical evaluation (such as hearing or vision) due to intellectual disability or being non verbal , the administrative assistant will be responsible to request the correction. She will contact the participants family or person responsible for their care verbally and follow up in writing. The Administrative assistant will request that the participant be seen by a specialist that can complete the medical evaluation needed. The Administrative assistant will also email the participants program specialist of the missing information on the physical. The Program specialist will then follow-up by emailing the team members of the participant to ensure all team members are aware of the needed information. Attachment# 4 & 5 07/26/2019 Implemented
2380.176(a)A daily tracking sheet including an individual's name was left outsider of the binder and unlocked in a filing cabinet.Individual records shall be kept locked when they are unattended.A cabinet with a locking mechanism has been added to our program area. The cabinet is now utilized for any paperwork, folders, or anything with identifying information. The cabinet is locked at all times and staff must request our floor manager to open the cabinet when needed. Attachment#3. All other cabinets that may have identifying information will be locked at all times and are currently in working order. Floor manager will be responsible to check the cabinets daily to ensure they are locked and working properly. If a lock is not working, Floor manager will put in a work order for our maintenance department for repair. Any identifying information in the broken cabinet will be placed in a locked area until the cabinet is repaired or replaced. 07/26/2019 Implemented
2380.173(1)(i)Individual #2 was originally admitted on 8/10/13 and then left the program and was readmitted on 11/19/18 but the individuals face sheet still reflects the original admission date. At time of inspection, there was no indication anywhere else in the chart that indicated the new admission date.The name, sex, admission date, birthdate and Social Security number.Administrative Assistant is responsible to ensure accuracy on our client record book cover. She will review the client book covers at least quarterly. During this review she will ensure that the admission date is correct and current. Additional information pertaining to admission and retirement/termination of services date will be added to our book cover. The current book cover lists only the admission date. For anyone who discontinues services for any reason, the administrative assistant will add the service end date to the cover. If someone then returns to our day program an additional notation entitled ¿re-enrollment date¿ will be added to the client record book cover. Attachment #1 The Administrative Assistant will complete a training on the above changes provided by the Director. Attachment#2. 07/26/2019 Implemented
SIN-00249718 Renewal 08/13/2024 Compliant - Finalized
SIN-00133881 Initial review 05/03/2018 Compliant - Finalized