Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00153071 Renewal 04/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.56The men's and women's bathrooms on the A/B side of the building did not have hot running water.A facility shall have hot and cold running water that is suitable for drinking purposes, in bathrooms and kitchen areas.General manager checked water heater on 4/5 and discovered that it had been turned off. Water heater turned back on; hot water was restored to restrooms 20 minutes later. General manager requested that a locking cover be placed over the toggle switch to prevent the switch from being turned off; this was completed 4/8 (attachment 5). General Manager checked water temperatures 2 times the afternoon of 4/5, daily from 4/8-4/12, once on 4/15 and once on 4/23. Hot water was present in both the men¿s and women¿s bathrooms each time. Safety Committee members were retrained on this regulation on 4/26 (attachment 2). Safety committee representative will check every faucet every month to ensure ongoing compliance. 04/08/2019 Implemented
2390.62The men's and women's bathroom on sides C,D,and E were not clean and had damage in multiple areas.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.General manager submitted request for cleaning and repairs via email (4/5). Cleaning company made aware of areas that needed a deep cleaning; this was completed on 4/6. Maintenance department repaired floors and replaced moldings between 4/8 and 4/19 (attachment 4). Safety Committee members were retrained on this regulation on 4/26 (attachment 2). While all staff are expected to ensure sanitary conditions be maintained at all times in bathrooms, kitchens, dining areas and first aid areas, it is the responsibility of the Safety Committee representative to monitor monthly for ongoing compliance. 04/19/2019 Implemented
2390.67A spray bottle on the work floor area was filled with an unknown substance, and not labeled.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.Quality Assurance staff discarded spray bottles not properly labeled and replaced with new, properly labeled spray bottles on 4/8 (attachment 3). Staff were retrained on 4/23 (attachment 1) that safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions. Cleaning supplies must be properly labeled, stored in designated locked cabinet when not in use and returned to locked cabinet immediately following use. Safety Committee members were retrained on this regulation on 4/26 (attachment 2). While all staff members were retrained and are expected to provide safe and sanitary conditions at all times, it is the responsibility of the Safety Committee representative to monitor monthly for ongoing compliance. 04/08/2019 Implemented
2390.72(a)The work aisles and passageways were obstructed with equipment throughout the work floor area.Passageways and work aisles shall be unobstructed at all times.Associate Director walked all aisles after the exit interview on 4/5 and moved all stanchions out of the passageways. Staff were retrained on 4/23 (attachment 1) that all passageways and work aisles shall be unobstructed at all times. Placement of table within the work area was adjusted to reduce or eliminate the risk of stanchions being bumped into the passageways and work aisles as Individuals are working and walking around the work area. Production Leaders will complete hourly checks of passageways and aisles to ensure ongoing compliance starting 4/24. Director of Habilitation will also research (by 5/17) methods of "anchoring" the stanchions so that they are not so easily pushed into the passageways and aisles. In addition, Safety Committee members were retrained on this regulation on 4/26 (attachment #2) and will monitor monthly for ongoing compliance. 04/24/2019 Implemented
2390.72(c)The work lines on the work floor were worn or not visible in multiple areas.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.On 4/5, General Manager submitted request for lines to be repainted. New paint/epoxy was purchased and lines were repainted the morning of 4/6. However, the paint/epoxy was bad and did not adhere properly. Lines will be scraped and repainted with a different batch of paint/epoxy by 5/10/19. General manager will provide photos upon completion. Safety Committee members were retrained on this regulation on 4/26 (attachment #2) and asked to ensure that work aisles are marked with visible lines that are at least 2 inches wide. General Manager, Program Specialists and Production Leaders were also retrained on this regulation on 4/23/19 and on reporting procedures if lines need repair (attachment #1). While all staff members were retrained and are expected to report disrepair immediately upon discovery, it is the responsibility of the Safety Committee representative to monitor monthly for ongoing compliance. 05/10/2019 Implemented
2390.151(e)(12)Individual #1's assessment dated 4/17/18 did not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.Program Specialists were retrained on 4/23/19 (attachment # 1) that all assessments must include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. Each Program Specialist will review the most recent assessment for everyone on their caseload by 5/3/19. If any other assessments are noted to be missing information, the assessment will be revised and redistributed to team members by 5/10/19. Associate Director will randomly select and review 10 assessments per FY quarter (6/30/19, 9/30/19, 12/31/19, 3/31/20) to ensure ongoing compliance. 05/03/2019 Implemented
SIN-00115546 Renewal 10/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87There is no documentation for individual #3 fire safety training.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.There was a signed fire safety training (FST) record in the file. However, it was not dated. Staff were retrained on FST documentation and the importance of including the date as well as the signature. In addition, the last FST was completed on 10/26/17. A random sampling of 20% of client files were checked for documentation; all records in sample were signed, dated and the current FST training was completed within 365 days of the previous FST. 12/05/2017 Implemented
2390.124(10)Individual #10 did not have a current copy of his ISP in his record.Each client's record must include the following information: A copy of the current ISP.Program Specialists have been retrained re: this regulation. This individual was a new admittance. There has been one other new admittance so that record was reviewed. The current ISP for that individual is in the record (program start date 11/27/17, ISP in record updated 11/21/17). 12/05/2017 Implemented
2390.151(e)(5)Assessment does not state individual 1, 2,3,4,5,6,7,8,9 or 10's ability to administer medications. The assessment must include the following information: The client's ability to self-administer medications.We believe we have met the minimum standard of the regulation. This is item #6 of our assessment and was completed for each individual in the sample. APS entrance criteria includes that Individuals are able to self-medicate, if medication is needed during program hours. Staff will be retrained on this regulation. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 assessments per FY quarter. 04/20/2018 Implemented
2390.151(e)(10)The medical history was not in the individual's assessment nor attached to the individual's assessment for individual 1, 2,3,4,5,6,7,8,9,and 10.The assessment must include the following information: A lifetime medical history.Program Specialists have been retrained that the lifetime medical history is part of the assessment and is to be reviewed, updated and distributed to the team as per our assessment process/timeline. A random sample of 5 records each FY quarter will be reviewed to monitor for ongoing compliance. 12/05/2017 Implemented
2390.151(e)(13)(i)Each assessment for individuals 1, 2, 3,4,5,6,7,8,9, and 10, do not assess progress and growth related to 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.We believe we have met the minimum standard of this regulation. This is item #10 on our assessment and was completed for each individual in our sample. Staff will be retrained to more clearly document progress over the last 365 days and current level of functioning. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 assessments per FY quarter. 04/20/2018 Implemented
2390.151(e)(13(ii)Each assessment for individuals 1, 2, 3,4,5,6,7,8,9, and 10, do not assess progress and growth in the areas of 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.We believe we have met the minimum standard of the regulation. These are items #11 (motor skills) and #12 (communication) on our assessment and were completed for each individual in the sample. Staff will be retrained to more clearly document progress over the last 365 days and current level of functioning. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 assessments per FY quarter. 04/20/2018 Implemented
2390.151(e)(13(iv)Each assessment for individuals 1, 2, 3,4,5,6,7,8,9, and 10, do not assess progress and growth in the area of socialization. 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.We believe we have met the minimum standard of the regulation. This is item #13 on our assessment and was completed for each individual in our sample. Staff will be retrained to more clearly document progress over the last 365 days and current level of functioning. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 assessments per FY quarter. 04/20/2018 Implemented
2390.151(e)(13)(v)Each assessment for individuals 1, 2, 3,4,5,6,7,8,9, and 10, do not assess progress and growth In the area of 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.We believe we have met the minimum standard of the regulation. This is item #14 on our assessment and was completed for each individual in our sample. Staff will be retrained to more clearly document progress over the last 365 days and current level of functioning. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 assessments per FY quarter. 04/20/2018 Implemented
2390.153(5)Individual #6 did not have a SEEN plan in his current ISP.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.We believe that we have met the minimum standard of this regulation. Diagnoses, symptoms of diagnoses and support strategies are listed in both general health and safety and in psycho-social sections of this individual¿s ISP. This individual¿s SEES Plan was also in the record and reviewed by the inspectors. Staff will be trained to look for (and request) SEES Plan information in the Behavior Support Plan section of the ISP. For individual #6, an email will be sent by 4/20/18 requesting that SEES Plan information be added to the BSP section of the ISP. To monitor for compliance, the Associate Director will randomly select and review 5 ISP¿s per FY quarter. 04/20/2018 Implemented
2390.153(7)(i)Individual's 2,4, and 6 current ISP does not include their 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 believe that we have met the minimum standard of this regulation. This information is on page one of our assessment under ¿recommendations for specific area of vocational programming and community-integrated employment¿. This was section completed for each individual in our sample. For Individuals #2, 4 and 6, the ISP references the APS assessment in the ¿Non-medical Evaluation¿. For Individual #2, the ISP ¿Outcome¿ section also references the APS Assessment. Staff will be retrained to look for (and request) that the APS Assessment be referenced in the Outcome section of the ISP under ¿relevant assessments linked to outcome¿. For Individuals #4 and #6, an email requesting this information be added to the ISP will be sent by 4/20/18. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 ISP¿s per FY quarter. 04/20/2018 Implemented
2390.153(7)(ii)Individual's 2,4, and 6 current ISP does not include their potential to advance in vocational programming and competitive community 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 believe that we have met the minimum standard for this regulation. This information is on page 1 of our assessment under ¿recommendations for specific area of vocational programming and community-integrated employment¿. This section of the assessment was completed for each individual in the sample. Staff will be retrained to look for (and request) that the APS Assessment be referenced in the Outcome section of the ISP under ¿relevant assessments linked to outcome¿. For Individuals #4 and #6, an email requesting this information be added to the ISP will be sent by 4/20/18. To monitor for ongoing compliance, the Associate Director will randomly select and review 5 ISP¿s per FY quarter. 04/20/2018 Implemented
2390.156(c)(2)For individuals 1, 2, 3,4,5,6,7,8,9, and 10 each ISP review does not include a review of each section of the ISP. Individual #3 ISP reviews for the last annual review year states, ISP reviewed'. Individual #7 has a behavioral support plan in place. His 8/15/2017 ISP review does not include the implementation of the plan and status. During the quarter of 8/15/2017, the program specialist also has not kept any documentation per the plan's instructions. Individual #2 also has a SEEN plan in place that was not reviewed in any of his ISP reviews. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Our current practice is to review every section of the ISP each quarter. However, the documentation of this practice was not clear. Program Specialists have been retrained on the requirement to review each section of the ISP specific to the facility licensed under this chapter and provide more specific documentation. A random sample of 5 records will be reviewed each quarter to monitor for ongoing compliance. 12/05/2017 Implemented
SIN-00095482 Renewal 04/25/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62The floor in the ladies bathroom of the main production floor area was dirty and appeared to be unsanitary.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Cleaning Company was immediately contacted and floors received a ¿deep & thorough cleaning¿ paying special attention to the edges where dirt accumulates. Habilitation and safety committee staff who are responsible for regular inspections of bathrooms were retrained on acceptable levels. Photos sent via email. 05/02/2016 Implemented
2390.124(5)Individual #1's record did not include a physical exam.Each client's record must include the following information: Physical examinations.Associate Director and Program Specialists were retrained on intake/annual paperwork requirements. No new clients should be accepted without a physical. All program specialists will document efforts to receive a copy of ongoing annual physicals. This will be monitored through a random sampling of records at least annually. A copy of the physical for the first consumer to start after our review in April was on June 20. Sample emailed. 06/20/2016 Implemented
2390.156(a)Individual #2's 3 month ISP review dated 4/11/15-7/11/15 was completed on 7/27/15. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.Program Specialists were retrained on completing the quarterly reviews. Program Specialists will complete and sign the quarterly ISP review within 14-days of the scheduled review date even if the consumer is not present to sign it. Associate Director will review annually to insure compliance. 05/02/2016 Implemented
SIN-00071700 Renewal 12/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #3's, admitted on 2/11/14, did not have an initial assessment completed. 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.Program Specialists will be retrained on new hire process and regulations including completing the assessment within 60-days after admission. Training completed on 1/7/15. The Program Specialist completed the assessment for Individual #3 and will review all newly admitted residents records to ensure than an assessment has been completed within 60 days of admission. The Program Specialist will conduct an audit of all resident records to ensure that assessments have been completed for all participants within 30 days of receipt of this plan of correction. [SW 1.9.15] 01/07/2015 Implemented
2390.151(e)(13(ii)Individual #2's assessment dated 12/2/14 did not include progress and growth in the area of motor and communication.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.Individual #2's assessment was corrected on 12/1/14. Program Specialists will be retrained on completing assessments to be in compliance with regulations. The training was completed on 1/7/15. The Program Specialist will audit all resident assessments to ensure that progress and growth is included in all areas within 30 days of receipt of this plan of correction. Prior to sending the annual assessments, the Program Specialist will review each area to ensure all of the requirements of an assessment is addressed for all individuals serviced by the provider within 30 days of receipt of this plan of correction. [SW 1.9.15] 01/07/2015 Implemented
2390.151(e)(13(iv)Individual #1's assessment, dated 7/14/14, did not include progress and growth in the area of socialization. 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.Individual #1's assessment was corrected on 12/18/14. Program Specialists will be retrained on completing assessments to be in compliance with regulations. The training was completed on 1/7/15. The Program Specialist will audit all resident assessments to ensure that progress and growth is included in all areas within 30 days of receipt of this plan of correction. The Program Specialist will review each area of the assessment to ensure all of the requirements of an assessment is addressed for all individuals served by the provider within 30 days of receipt of this plan of correction. [SW 1.9.15] 01/07/2015 Implemented
SIN-00057705 Renewal 12/04/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The plastic baseboards in the large lunch room were not adhered to wall. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The baseboard was reattached to the wall. 12/09/2013 Implemented
2390.62The tile floors in the large lunch were worn, scuffed, stained by black floor mat/runner and had black ring impressions. The tile floors in the main ladies bathroom were worn, scuffed with several tiles cracked or missing. One of the stalls in the bathroom was inoperable and there was a hole in the wall by the paper towel dispenser. Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Bids were obtained and a provider chosen to replace floors in cafeteria and ladies room. Installation will be completed on 1/4/14. The inoperable toilet and hole in the wall of ladies bathroom was patched and repaired on 12/5/13. 03/04/2014 Implemented
2390.124(10)The file record for individual #1 did not include a current ISP for 10/27/13 to 10/26/14.Each client's record must include the following information: (10) A copy of the current ISPProvider has created SOP to insure that Program Specialists are adding the new plan on the ISP date. Current ISP was filed in individual record on 12/3/13. 12/20/2013 Implemented
2390.151(a) The assessment dated 12/2/13 for individual #2 was not completed sixty days from the admission date of 4/22/13. The assessment for Individual #3 was completed on 9/7/12 and the next assessment dated 10/28/13 exceeded the annual requirement. (a)  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.Program Specialists have been retrained on new hire process. All annual assessments will be completed at the second quarterly review to insure annual dates remain consistent and don't fluctuate with plan meeting dates. 12/23/2013 Implemented
2390.151(d)The Program Specialist did not sign the assessment for individual # 4 dated 7/22/13 and individual # 6 dated 3/28/13.(d)  The program specialist shall sign and date the assessment.Program Specialist will sign (not type or print) all assessments. All assessments were signed by Program Specialist. 12/06/2013 Implemented
2390.151(e)(5)The assessment for individual #1 dated 9/12/13, individual # 4 dated 7/22/13 and individual # 6 dated 3/28/13 did not include skills level for the self-administration of medication.(e) The assessment must include the following information: (5) The client's ability to self-administer medications.Assessment forms have been updated to include client's ability to self-administer medications. 12/13/2013 Implemented
2390.151(e)(12)The assessment for individual # 1 dated 9/12/13, individual # 4 dated 7/22/13, individual # 5 dated 10/15/13 and individual # 6 dated 3/28/13 did not include specific areas of vocational training.(e) The assessment must include the following information: (12) Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.Program Specialists retrained on "specific areas of vocational training". All assessments were corrected to include specific areas of training. 12/13/2013 Implemented
2390.151(f)There was no documentation that the assessment dated 3/28/13 for individual # 6 was sent to Support Coordinator thirty days prior to ISP meeting date 7/18/13.(f) 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).Program Specialists will document distribution of the assessment to the team 30-days prior to the team meeting. 12/13/2013 Implemented
SIN-00088321 Renewal 01/21/2016 Compliant - Finalized