Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00165776 Renewal 01/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.51. Special Accommodations: The exit from the right side of the building as you face the front does not have a safe or reasonable way to exit the building and go to the meeting place during a fire drill or an emergency. The exit has a walk way to the parking lot which then has stones that are 3" in dirt, this makes it unsafe for the Individuals in the facility in wheelchairs to exit and go to the meeting place. There was also a car parked on the walk way blocking the stone driveway if there was an emergency. The wheelchairs would need to go through the grass in the neighbor's yard to get to the meeting place.A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL EXTEND A 27 BY 5 SIDEWALK ON THE RIGHT SIDE OF THE BUILDING TO ENSURE THE EXIT ACCOMMODATES A SAFE EGRESS. CONSTRUCTION WILL BEGIN WHEN WEATHER PERMITS BUT NO LATER THAN 4/30/2020. 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL ENSURE EVERY EXIT FROM THE BUILDING ACCOMMODATES A SAFE EGRESS. 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENTS OF ACCOMMODATING A SAFE EGRESS. CSPARK PROGRAM WILL RETRAIN STAFF TO NOTIFY SUPERVISORS OF ANY POTENTIAL EGRESS CONCERNS. (SEE ATTACHMENT #16) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE ALL EXITS CONTINUE TO ACCOMMODATE A SAFE EGRESS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 04/30/2020 04/30/2020 Implemented
2380.111(c)(5)Individual #1's Tuberculin skin test was completed 1/29/2017 and not again until 3/13/2019.This was completed late.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.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK WILL ENSURE INDIVIDUAL #1 HAS A CURRENT TUBERCULIN SKIN TEST COMPLETED WITHIN THE PAST 2 YEARS. (SEE ATTACHMENT #15) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK WILL REVIEW 100% OF ALL INDIVIDUAL RECORDS TO ENSURE TUBERCULIN SKIN TESTING IS COMPLETED EVERY 2 YEARS. (SEE ATTACHMENT #13) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK WILL RETRAIN ALL STAFF THAT A COMPLETE PHYSICAL EXAMINATION IS REQUIRED TO ATTEND DAY PROGRAM. CSPARK WILL RETRAIN ALL STAFF ON THE REQUIREMENTS THAT TUBERCULIN SKIN TESTING IS COMPLETED EVERY 2 YEARS. (SEE ATTACHMENT #14) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE ALL INDIVIDUALS HAVE A TUBERCULIN SKIN TEST COMPLETED EVERY 2 YEARS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.111(c)(8)Physical limitations- Does not have that Individual #2 needs to wear orthopedic shoes with braces. Does not indicated that Individual #2 is a choking risk.The physical examination shall include: Physical limitations of the individual.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL REQUEST AN UPDATED PHYSICAL EXAMINATION FOR INDIVIDUAL #2 FROM HER RESIDENTIAL PROVIDER AND ENSURE IT INCLUDES PHYSICAL LIMITATIONS TO INCLUDE RECOMMENDATIONS FOR ORTHOPEDIC SHOES AND PRECAUTIONS FOR CHOKING. (SEE ATTACHMENT #12) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF ALL INDIVIDUAL RECORDS TO ENSURE THAT PHYSICAL EXAMINATIONS INCLUDE PHYSICAL LIMITATIONS BASED UPON INDIVIDUAL NEEDS. (SEE ATTACHMENT #13) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK WILL RETRAIN ALL STAFF ON THE REQUIREMENT THAT A COMPLETE PHYSICAL EXAMINATION IS NEEDED TO ATTEND DAY PROGRAM. CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENT THAT ALL PHYSICAL EXAMINATIONS DESCRIBE APPROPRIATE PHYSICAL LIMITATIONS BASED UPON INDIVIDUAL NEEDS. (SEE ATTACHMENT #14) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE ALL INDIVIDUAL PHYSICAL EXAMINATIONS INCLUDE PHYSICAL LIMITATIONS BASED UPON INDIVIDUAL NEEDS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.111(c)(11)Diet Instructions: Blank on Individual #2's 12/6/19 physical form. There was a swallowing study completed on 4/10/19 where it was recommended that Individual #2's food be cut into 1-inch size bites, needs to be supervised during meals/snacks, will require cues for slow rate of intake and for alternating bites of food with sips of liquid to improve esophageal clearance. There is a diet protocol dated 7/3/19 that Individual #2 is to be on a 2000 calorie carbohydrate diet with a total of 275 grams of carbs each day. This is not listed on the annual physical.The physical examination shall include: Special instructions for an individual's diet.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL REQUEST AN UPDATED PHYSICAL EXAMINATION FOR INDIVIDUAL #2 FROM HER RESIDENTIAL PROVIDER TO ENSURE IT INCLUDES INSTRUCTIONS FOR HER DIET. (SEE ATTACHMENT #12) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF INDIVIDUAL RECORDS TO ENSURE THAT ALL PHYSICAL EXAMINATIONS INCLUDE INSTRUCTIONS FOR DIET. (SEE ATTACHMENT #13) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK WILL RETRAIN ALL STAFF ON THE REQUIREMENT THAT A COMPLETE PHYSICAL EXAMINATION IS REQUIRED TO ATTEND DAY PROGRAM. CSPARK WILL RETRAIN ALL STAFF ON THE REQUIREMENT THAT ALL PHYSICAL EXAMS MUST INCLUDE DIETARY INSTRUCTIONS. (SEE ATTACHMENT #14) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK FACILITY AT LEAST ONCE ANNUALLY TO ENSURE ALL INDIVIDUAL PHYSICAL EXAMINATIONS INCLUDE DIETARY INSTRUCTIONS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.181(d)INDIVIDUAL #1'S Assessment 3/7/2019 THE Program Specialist did not sign and date.The program specialist shall sign and date the assessment.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL ENSURE INDIVIDUAL #1'S ASSESSMENT IS SIGNED AND DATED BY A PROGRAM SPECIALIST. (SEE ATTACHMENT #6) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF ALL INDIVIDUAL RECORDS TO ENSURE THAT ALL ASSESSMENTS ARE SIGNED AND DATED BY A PROGRAM SPECIALIST. (SEE ATTACHMENT #7) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENTS THAT ASSESSMENTS ARE TO BE SIGNED AND DATED BY A PROGRAM SPECIALIST. (SEE ATTACHMENT #5) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK FACILITY AT LEAST ONCE ANNUALLY TO ENSURE ALL INDIVIDUAL ASSESSMENT ARE SIGNED AND DATED BY A PROGRAM SPECIALIST AT LEAST YEARLY. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.181(e)(9)Functional skills/ medical limitations- -The 5/7/19 assessment for Individual #2 states that n nectar thickened liquid is needed, but this was discontinued 4/10/19 Individual #2's food is to be 1-inch bite size pieces- the assessment says quarter inch size pieces.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL UPDATE INDIVIDUAL #2S ASSESSMENT TO INCLUDE A DISCONTINUANCE OF THICKENED LIQUIDS/CORRECTED .25X.25 BITE SIZED REQUIREMENT RECOMMENDATIONS FROM 4/10/2019. (SEE ATTACHMENT #11) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF ALL INDIVIDUAL RECORDS TO ENSURE THAT ALL ASSESSMENTS ARE UP TO DATE, PARTICULARLY WITH RESPECT TO CHANGES IN MEDICAL LIMITATIONS. (SEE ATTACHMENT #9) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENT THAT ALL ASSESSMENTS INCLUDE CHANGES IN MEDICAL LIMITATIONS WITH PARTICULAR EMPHASIS ON SWALLOWING PROTOCOLS. (SEE ATTACHMENT #5) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK FACILITY AT LEAST ANNUALLY TO ENSURE ALL ASSESSMENTS INCLUDE CHANGES IN MEDICAL LIMITATIONS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.181(e)(13)(i)The Seizure Protocol Documentation dated 4/1/2019 "If Individual #1 has a seizure lasting longer than 5 minutes, a series of seizures, or experiences respiratory distress, 911 will be call immediately." This protocol is not documented in Individual #1's updated assessment 11/7/2019.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.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL REVISE INDIVIDUAL #1 ASSESSMENT TO INCLUDE HER PROGRESS BASED UPON HER SEIZURE PROTOCOL. (SEE ATTACHMENT #3) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF INDIVIDUAL RECORDS AND ENSURE THAT ASSESSMENTS INCLUDE PROGRESS OVER THE PAST 365 DAYS INCLUDING CHANGES IN SEIZURE PROTOCOLS. (SEE ATTACHMENT #9) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENT TO ENSURE THAT ASSESSMENTS INCLUDE PROGRESS OVER THE LAST 365 DAYS WITH PARTICULAR EMPHASIS ON UPDATED SEIZURE PROTOCOLS. (SEE ATTACHMENT #5) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE ALL INDIVIDUAL ASSESSMENT INCLUDE PROGRESS OVER THE LAST 365 DAYS TO INCLUDE SEIZURE PROTOCOLS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.37(a)There is no staff training on Individual #1's Seizure Protocol 4/1/2019.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL TRAIN ALL STAFF ON INDIVIDUAL #1'S SEIZURE PROTOCOL. (SEE ATTACHMENT #8) CSPARK PROGRAM WILL MAINTAIN DOCUMENTATION OF INDIVIDUAL # 1'S SEIZURE PROTOCOL TRAINING. 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF SEIZURE PROTOCOLS AND ENSURE THAT STAFF ARE TRAINED ON ALL INDIVIDUAL SEIZURE PROTOCOLS. (SEE ATTACHMENT #9) CSPARK PROGRAM WILL ENSURE THAT ALL STAFF TRAINING ON SEIZURE PROTOCOLS IS RETAINED. 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: HOPE ENTERPRISES WILL REVIEW CSPARK PROGRAM LEADERSHIP AND SUPERVISION AND, BASED ON THAT REVIEW, WILL MAKE CHANGES TO POLICIES/PROCEDURES/SUPERVISION/TRAINING AND LEADERSHIP TO ENSURE REGULATORY REQUIREMENTS ARE MET WITH RESPECT TO § 2380.37(A). (SEE ATTACHMENT #10) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE THAT STAFF ARE TRAINED ON 100% OF INDIVIDUAL SEIZURE PROTOCOLS AND THAT CSPARK HAS RETAINED THE TRAINING RECORDS TO DEMONSTRATE COMPLIANCE WITH THE RECORD RETENTION REQUIREMENTS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/07/2020 02/07/2020 Implemented
2380.181(f)Individual #1's IP meeting was held on 2/28/2019. The Assessment was completed and sent out to team members 3/7/2019. The assessment was completed late.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL SEND INDIVIDUAL #1S ASSESSMENT TO TEAM MEMBERS AT LEAST 30 DAYS PRIOR TO THE INDIVIDUAL PLAN MEETING. (SEE ATTACHMENT #6) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF INDIVIDUAL ASSESSMENTS AND ENSURE THAT ALL ARE SENT TO TEAM MEMBERS AT LEAST 30 DAYS PRIOR TO INDIVIDUAL PLAN MEETINGS. (SEE ATTACHMENT #7) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENTS OF SENDING INDIVIDUAL ASSESSMENTS TO TEAM MEMBERS AT LEAST 30 DAYS PRIOR TO INDIVIDUAL PLAN MEETINGS. (SEE ATTACHMENT #5) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE ALL INDIVIDUAL ASSESSMENTS CONTINUE TO BE SENT TO TEAM MEMBERS AT LEAST 30 DAYS PRIOR TO INDIVIDUAL PLAN MEETINGS. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
2380.186plan implementation- This section needs to be updated since it was changed 4/10/19 after a swallowing study was completed and Individual #2 no longer needs liquids thickened. Individual #2 needs monitored for signs/symptoms of aspiration. If Individual #2demonstrates consistent coughing following swallowing of thin liquids he/she should return to nectar thick liquids. Individual #2 should be supervised during meals/snacks and to be cued to alternate bites of food with sips of liquids. Seizure Protocol Documentation 4/1/2019 in Individual #1's record states: "If Individual #1 has a seizure lasting longer than 5 minutes, a series of seizures, or experiences respiratory distress, 911 will be call immediately." This seizure protocol is not in Individual #1's updated IP 12/17/2019. Regarding Individual #1's supervision needs, his/her current IP is not correct throughout: Like and admire- 1:1 STAFFING AT DAY PROGRAM HAS BEEN REDUCED SIGNIFICANTLY OVER THE PAST YEAR Traffic WITHIN ARMS LENGTH WHEN WALKING ACROSS BUSY PARKING LOTS AND STREETS. Individual #1 MAY NOT EXHIBIT ANY REGARD FOR TRAFFIC SAFETY WHEN IN THE COMMUNITY DURING ELEVATED BEHAVIORS AND MAY RUN INTO TRAFFIC WITHOUT CARING FOR HER SAFETY NEEDS. HE/ SHE IS ALWAYS WITHIN ARMS LENGTH OF STAFF WHEN IN A TRAFFIC SITUATION. Stranger Awareness Individual #1 NEEDS TO BE WITHIN EYESIGHT WHEN IN THE COMMUNITY. HE/SHE WILL SAY THAT PEOPLE ARE HIS/HER BEST FRIEND WHEN SHE DOES NOT EVEN KNOW THE PERSON'S NAME. INDIVIDUAL #1 NEEDS TO BE WITHIN ARMS LENGTH SUPERVISION DURING TRAFFIC SITUATIONS. INDIVIDUAL #1 IS NEVER ALONE WITHIN THE COMMUNITY. Day Supervision INDIVIDUAL #1 NEEDS TO BE WITHIN EARSHOT SUPERVISION WHEN AT DAY PROGRAM. INDIVIDUAL #1 REQUIRES 1:1 SUPPORTS TO USE HIS/HER COPING SKILLS IN DIFFICULT SITUATIONS. INDIVIDUAL #1 NEEDS SUPPORTS TO MAINTAIN APPROPRIATE BOUNDARIES WITH HIS/HER PEERS AND STAFF, PREVENT AWOL BEHAVIOR, DISROBING AND MASTURBATING IN PUBLIC, PHYSICAL AND VERBAL AGGRESSION.The facility shall implement the individual plan, including revisions.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGEED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: CSPARK PROGRAM WILL NOTIFY INDIVIDUAL #2S SUPPORTS COORDINATOR TO UPDATE THE ISP TO INCLUDE RECOMMENDATIONS FROM A SWALLOWING STUDY COMPLETED ON 4/10/2019. (SEE ATTACHMENT #1) CSPARK PROGRAM WILL NOTIFY INDIVIDUAL #1S SUPPORTS COORDINATOR TO UPDATE THE ISP TO INCLUDE THE SEIZURE PROTOCOL. (SEE ATTACHMENT #2) CSPARK PROGRAM WILL UPDATE INDIVIDUAL #1S ASSESSMENT REGARDING HER SUPERVISION NEEDS. CSPARK PROGRAM WILL REQUEST INDIVIDUAL #1¿S SUPPORT COORDINATOR TO CONDUCT A TEAM MEETING TO REVIEW AND UPDATE HER SUPERVISION NEEDS WITHIN THE FOLLOWING SECTIONS OF HER ISP: LIKE AND ADMIRE, TRAFFIC, STRANGER AWARENESS AND DAY SUPERVISION. (SEE ATTACHMENT #3) 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: CSPARK PROGRAM WILL REVIEW 100% OF ISPS AND ENSURE THAT ALL ARE IMPLEMENTED AS WRITTEN AND THAT THEY ARE REVISED AS CHANGES OCCUR. (SEE ATTACHMENT #4) 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: CSPARK PROGRAM WILL RETRAIN ALL STAFF ON THE REQUIREMENTS OF IMPLEMENTING ISPS AS WRITTEN AND ON THE REQUIREMENT TO REVISE ISPS AS CHANGES OCCUR. (SEE ATTACHMENT #5) 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEPS 3 TO VERIFY CONTINUED COMPLIANCE: HOPE ENTERPRISES¿ CORPORATE COMPLIANCE DEPARTMENT WILL AUDIT THE CSPARK PROGRAM AT LEAST ONCE ANNUALLY TO ENSURE ALL ISPS CONTINUE TO BE IMPLEMENTED AS WRITTEN AND REVISED AS CHANGES OCCUR. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 02/03/2020 02/03/2020 Implemented
SIN-00145651 Renewal 12/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The stick-on flooring in the movie room and activity room was pulling away from the floor creating a tripping hazard.Floors, walls, ceilings and other surfaces shall be in good repair.On 12/17/2018, Facilities Director Obtained an estimate to replace the movie room and activity room floor to be installed on 1/31/2019 (See Attachment #7). On 12/18/2018, CPS Coordinator trained DSP on regulation 2380.58(a) on utilizing the maintenance system in to ensure floors, walls, ceiling and other surfaces are in good repair to be completed. (See Attachment #6). 12/21/2018 Implemented
2380.89(c)The 10/24/2018 fire drill log did not include the time of the drill.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.On 12/13/2018, CPS Lead Worker completed a fire drill and included the time of the drill (See Attached #5). On 12/17/2018, CPS Director trained CPS Coordinator and Program Specialist on regulation 2380.89(c) to ensure written fire drills include the time of the drill. (see Attachment #3). On 12/18/2018, CPS Coordinator trained DSP on the completion of fire drills to include the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. (See Attachment #6) Facilities Director and Administrative Assistant will review all completed fire drills to ensure compliance. 12/21/2018 Implemented
2380.173(1)(v)A dated photo was not contained in Individual #2's record.Each individual's record must include the following information: Personal information including: A current, dated photograph.On 12/18/2018, CPS Coordinator included Individual #2¿s dated photo within their record (See Attachment #4). On 12/18/2018, CPS Coordinator updated all individual records to include a dated photo (See Attachment #2). On 12/17/2018, CPS Director trained CPS Coordinator and Program Specialist on regulation 2380.173(1)(v) to include a current, dated photograph in each individuals record. (see Attachment #3). 12/21/2018 Implemented
2380.186(a)REPEATED VIOLATION - 10/26/17. Individual #1's ISP Review covering the time period between 1/7/18 and 4/6/18 was completed on 6/8/18.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 individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP.On 12/18/2018, CPS Coordinator ensured that Individual #1¿s ISP Reviews were completed in a timely manner (See Attachment #1). On 12/18/2018, CPS Coordinator reviewed individual records to verify ISP Reviews are completed every 3 months (see Attachment #2). On 12/17/2018, CPS Director trained CPS Coordinator and Program Specialist on regulation 2380.186(a) to include ISP Reviews completed every 3 months (see Attachment #3). CPS Coordinator will be responsible to track and review timely completion of Individual ISP Reviews every 3 months. 12/21/2018 Implemented
SIN-00123100 Renewal 10/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.82On the side walk of the side of the building by the smoking stand the garabage cans blocked the side walk to the front of the building. Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.On 10/27/17, Program Specialist moved the garbage cans blocking the side walk to the front of the building. Program Specialist ensured all stairways, halls, doorways, aisles, passageways and exits from rooms and from the building are unobstructed. (See attachment #12). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.82 to include passageways and exits shall be unobstructed (see Attachment #3). On 11/29/2017, Program Specialist trained staff on regulation 2380.82 to include passageways and exits shall be unobstructed (see Attachment #5). 11/30/2017 Implemented
2380.89(d)The 5/30/17 fire drill held and individual #2 refused to evacuate the facility. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.On 10/27/2017, Program Specialist completed a successful fire drill (see Attachment #11). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.89(d) to include individual evacuating the entire building within 2 ½ minutes (see Attachment #3). On 11/29/2017, Program Specialist trained staff on regulation 2380.89(d) to include individual evacuating the entire building within 2 ½ minutes (see Attachment #5). Individual #2 did not refuse to evacuate the building. Individual GM did not leave the building and is no longer receiving services through CSPARK. 11/30/2017 Implemented
2380.124(a)Individual #1 was prescribed the medicat ibuphefen. The medication log for October 2017 does not indicate the name of the medication or dosage. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.Program Specialist revised Individual #1¿s Medication Log to include the name and dosage of the medication prescribed on 10/27/2017. (see Attachment #10). Program Specialist reviewed individual records to verify medication logs include the name of the medication and dosage on 11/1/2017 (see Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.124(a) to include documentation of the name and dosage of prescribed medications (see Attachment #3). On 11/29/2017, Program Specialist trained Medication trained staff on regulation 2380.124(a) to include documentation of the name and dosage of prescribed medications (See Attachment #5). 11/30/2017 Implemented
2380.124(b)Individual #1's medication Glipzide 5mg 1 tab 4 times daily was not signed/ intitialed by staff on 10/24/17 at 12pm. The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.Program Specialist verified Individual #1¿s Glipizide was administered on October 24th, 2017 at 12pm (see Attachment #10). Program Specialist reviewed individual records to verify medication logs include all medications are logged immediately after each dose of medication by 11/29/2017 (See Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.124(b) to include logging medication immediately after each dose of medication (see Attachment #3). On 11/29/2017, Program Specialist trained Medication trained staff on regulation 2380.124(b) to include logging medication immediately after each dose of medication (see Attachment #5). 11/30/2017 Implemented
2380.132(8)Individal #2 is precribed a fluid restriction diet per doctor order due to low potassium. There is no protocol in the record. If the facility provides or arranges for meals for individuals, the following requirements apply: A prescribed diet for an individual with a medically restricted diet shall be followed. A written record of the prescribed diet shall be kept.Program Specialist reviewed and verified the protocol ¿Choking Precautions and Dietary Orders¿ dated 8/21/17 is in the record. (See attachment #8a). Program Specialist reviewed individual records to verify documentation of prescribed diets 11/17/2017 (see Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.132(8) to include documentation of prescribed diets (See Attachment #3). 11/30/2017 Implemented
2380.186(a)The 7/27/17 ISP reviews for individual #1 is late 7/27/17- 4/8/17. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.On 10/23/2017, Program Specialist completed Individual #1¿s ISP 3 Month Review (see Attachment #1). Program Specialist reviewed individual records to verify ISP Reviews are completed every 3 months by 11/30/2017 (see Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.186(a) to include ISP Reviews completed every 3 months (see Attachment #3). 11/30/2017 Implemented
2380.186(c)(1)Individual #1's record is missing the daily and monthly supports for all of September 2017 and October 2017 1st-8th and 14th to current. The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.On 10/27/2017, Program Specialist implemented Daily Progress Notes for Individual #1 (see Attachment #4). Program Specialist completed a Monthly Progress note for Individual #1 capturing October¿s daily progress notes on 11/29/2017 (see attachment #4a). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.186(c)(1) to include monthly reviews of daily documentation (See Attachment #3). On 11/29/2017, Program Specialist trained staff on regulation 2380.186(c)(1) to include completion of daily progress notes (See Attachment 5). 11/30/2017 Implemented
2380.186(c)(2)Individual #1's ISP reviews 7/27/17, 4/8/17, 1/8/17 did not review seizure potocol, outcome community interactions with social stories. The ISP review dated 9/22/17 for individual #2 did not review the fluid restriction. There is not documentation that is being tracked at the program. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.On 11/22/2017, Program Specialist revised Individual #1¿s 10/23/2017 ISP Review to include a review of her seizure protocol and outcome community interactions with social stories (see Attachment #6). Program Specialist will complete Individual #2¿s 12/22/2017 ISP Review to include a review of his fluid restriction (Attachment #7). On 11/3/2017, Program Specialist reviewed with Individual #2¿s staff the documentation process for his fluid intake to be completed each day on the back of the daily process note (See Attachment #8). Program Specialist reviewed individual records to verify ISP Reviews include a review of outcomes, seizures, and prescribed diets by 11/29/2017 (see Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.186(c)(2) to include a review of each section of the ISP (see Attachment #3). 12/22/2017 Implemented
2380.186(d)Individual #1's 7/27/17 ISP not sent to the behavioral specialist. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Program Specialist reviewed Individual #1¿s record to verify that the 7/27/2017 ISP review was sent to the Behavioral Specialist as noted on the letter sent to team members (see Attachment #9). Program Specialist reviewed individual records to verify ISP Reviews have been sent to all team members by 11/29/2017 (see Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.186(d) to include ISP Reviews sent to all team members (see Attachment #3). 11/30/2017 Implemented
2380.186(e)Individual #1's record did not contain the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.On 11/7/2017, Program Specialist notified Individual #1¿s plan team members of the option to decline the ISP Review documentation (see Attachment #1). Program Specialist reviewed individual records to verify all team members have the option to decline the ISP review documentation by 11/29/2017 (see Attachment #2). On 11/20/2017, Assistant Vice President trained Program Specialist on regulation 2380.186(e) to include all team members have the option to decline the ISP review documentation (see Attachment #3). 11/30/2017 Implemented
SIN-00102495 Renewal 11/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.88(f)The annual fire safety inspection was not conducted by a fire safety expert; the sprinkler system was only serviced by the Rowe company.Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.Program Supervisor and Facilities Manager will ensure fire extinguishers and fire protection system continue to be inspected on an annual basis. Facilities Manager will ensure an annual onsite fire safety inspection is completed by the local fire chief or another fire safety expert. Electronic calendar reminders have been set for scheduling these inspections. (Attachment #11) The Facilities Manager scheduled an onsite fire safety inspection with the local fire chief on 11/22/16. A copy of a letter from the fire chief is included to verify that inspection was completed. (Attachment #12) On 12/6/16, all staff working at the program were trained to know when these annual inspections need to be scheduled and completed (Attachment #12a). 12/22/2016 Implemented
2380.113(a)Staff #1 date of hire was 7/9/14 and her physical was not complete until 7/9/14.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Documentation of the physical examination date and date of hire for 2 new hires is provided as part of this POC (Attachments #7 and #8). The explanation for this regulation indicates that ¿Prior to employment mean prior to the date of hire/first date the person was paid¿¿ Also included with this POC is documentation indicating that staff person KW had her physical examination completed and completed some pre-employment paperwork on 7/9/14 (Attachment #9). Her first time sheet submitted 7/22/14 indicates that the first day for which she was paid was 7/10/14 (Attachment #10). This satisfies the requirement that the physical examination should be completed prior to employment. 12/22/2016 Implemented
2380.173(1)(iv)Religious affiliation for Individual #1 was left blank. Each individual¿s record must include the following information: Personal information including: Religious affiliation.The program specialist has spoken with Individual #1 and completed the religious affiliation field of his Personal Data Sheet. Remaining individuals¿ charts have been checked to ensure information regarding religious affiliation is present on Personal Data Sheet. (Attachment #4) Between 12/6/16 and 12/16/16, all 2380 regulated program specialists were retrained on this regulation and the need for the religious affiliation field to be completed on Personal Data Sheet for each individual receiving services (Attachment #4a). 12/22/2016 Implemented
2380.173(9)The physical completed on 4/19/16 for Individual #1 listed Metformin as an allergy; however his/her annual Individual Support Plan updated on 9/22/2016 did not list Metformin as an allergy. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program specialist notified Individual #1¿s residential director and supports coordinator of the discrepancy (Attachment #5). Upon receiving updated information such as a physical, the program specialist will review the document and compare it against other sources of information. When discrepancies are found, the program specialist will verify which information is accurate and will notify the supports coordinator and other plan team members as appropriate. Any emails will be printed and placed in the record to document notification of discrepancies. All 2380 regulated program specialists were trained on this process between 12/6/16 and 12/16/16 (Attachment #5a). A document cross-reference has been completed between Individual #1¿s physical and ISP and other discrepancies were found¿diagnoses noted on one or the other document but not on both. A copy of the cross-reference checklist is provided as part of this POC, and a copy has been forwarded to Individual #1¿s supports coordinator and residential program director (Attachment #6). Remaining individuals¿ charts will be checked to ensure consistency and accuracy of information. Checklists will be submitted when complete (no later than 1/13/17). 12/22/2016 Implemented
2380.181(e)(13)(iv)Individual #1's annual assessment completed on 12/3/15 did not indicate progress and growth in the area of socialization. The assessment for Individual #1 completed on 2/10/15 used the same wording in the socialization section as his/her assessment that was completed 12/3/15.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The program specialist has completed a new assessment for Individual #1(dated 11/16/16) as part of the annual ISP review & update process for him. Updated information regarding his progress in the area of socialization over the past 365 calendar days is included. (Attachment #2, Pg. 3-4) A copy of the Socialization section of his 12/3/15 assessment is included to verify that the wording is not the same and the new assessment shows progress over the past year (Attachment #2a). Between 12/6/16 and 12/16/16, 2380 regulated program specialists were retrained on this regulation and the need for the assessment to show progress (Attachment #2b). 12/22/2016 Implemented
2380.181(e)(13)(v)Individual #1's annual assessment completed on 12/3/15 did not indicate progress and growth in the area of recreation. The assessment for Individual #1 completed on 2/10/15 used the same wording in the recreation section as his/her assessment that was completed 12/3/15. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The program specialist has completed a new assessment for Individual #1(dated 11/16/16) as part of the annual ISP review & update process for him. Updated information regarding his progress in the area of recreation over the past 365 calendar days is included. (Attachment #2, Pg. 4) A copy of the Recreation section of his 12/3/15 assessment is included to verify that the wording is not the same and the new assessment shows progress over the past year. (Attachment #2a) Between 12/6/16 and 12/16/16, all 2380 regulated program specialists were retrained on this regulation and the need for the assessment to show progress. (Attachment #2b). 12/22/2016 Implemented
2380.181(f)Individual #1's annual Individual Support Plan (ISP) meeting was held on 12/11/15; however the assessment completed on 12/3/15 was not sent out to team members until 12/4/15. The assessment was not sent to team members 30 days prior to ISP meeting.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 program specialist has completed a new assessment for Individual #1(dated 11/16/16) as part of the annual ISP review & update process for him. His annual ISP meeting is scheduled for 12/19/16. A copy of the invitation letter from his supports coordinator is included to confirm the date of his ISP meeting. (Attachment # 3) A copy of his new assessment and the cover letter indicating when it was sent to plan team members (11/16/16) is included (Attachment #2). Between 12/6/16 and 12/16/16, all 2380 regulated program specialists were retrained on this regulation and the need for the assessments to be provided to plan team members at least 30 days prior to an ISP meeting (Attachment #3a). 12/22/2016 Implemented
2380.183(5)The day program does have an active Social, Emotional, and Environmental Support Plan (SEEP) for Individual #2. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The program specialist has forwarded a copy of the Social, Emotional, and Environmental Support Plan (SEEP) for Individual #2 to his Supports Coordinator. A general update of his ISP was completed 11/29/16 to include information from that SEEP (Attachment #1, Pg. 2). Upon receiving updated ISP following any Annual Update or Revision, the Program Specialist will verify that information in the ISP regarding the SEEP is present & accurate. Training records for 2380 regulated program specialists trained on this process between 12/6/16 and 12/16/16 are attached (Attachment #1a). Remaining individuals¿ charts have been checked to ensure information regarding SEEPs (if needed) are complete and accurate. (Attachment #4). 12/22/2016 Implemented
2380.183(7)(i)Individual #2's Individual Support Plan does not include his/her potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.The program specialist forwarded a statement regarding Individual #2¿s potential to advance in vocational programming to his Supports Coordinator. A general update of his ISP was completed 11/29/16 to include his potential to advance in vocational programming (Attachment #1, Pg. 3). Upon receiving updated ISP following any Annual Update or Revision, the Program Specialist will verify that information in the ISP regarding an individual¿s potential to advance in vocational programming is present & accurate. Training records for 2380 regulated program specialists trained on this process between 12/6/16 and 12/16/16 are attached (Attachment #1b). Remaining individuals¿ charts have been checked to ensure information regarding potential to advance in vocational programming is present and accurate. (Attachment #4). 12/22/2016 Implemented
2380.183(7)(iii)Individual #2's Individual Support Plan does not include his/her potential to advance in competitive community integrated employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.The program specialist forwarded a statement regarding Individual #2¿s potential to advance in competitive community integrated employment to his Supports Coordinator. A general update of his ISP was completed 11/29/16 to include his potential to advance in competitive community integrated employment (Attachment #1, Pg. 3-4). Upon receiving updated ISP following any Annual Update or Revision, the Program Specialist will verify that information in the ISP regarding an individual¿s potential to advance in competitive community integrated employment is present & accurate. Training records for 2380 regulated program specialists trained on this process between 12/6/16 and 12/16/16 are attached (Attachment #1c). Remaining individuals¿ charts have been checked to ensure information regarding potential to advance in vocational programming is present and accurate. (Attachment #4). 12/22/2016 Implemented
SIN-00086077 Renewal 11/04/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The antiseptic located in the first aide kit in the first aide room was not locked. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The program specialist locked the hydrogen peroxide in the first aid kit the day of licensing. The lead worker at the site will be responsible to ensure that all poisonous materials are kept locked in the future. Staff will check all first aid and cleaning materials to ascertain which are potentially poisonous and ensure they are secured. Staff will use the internet to check the potential for poisoning and print the material safety data sheets for products used at the program. As new products are purchased for the site, staff will research the MSDS and print for all staff to read. These will be maintained at the site. Additionally, a procedure (attachment #1) has been developed to become part of the Staff Site Orientation to be reviewed with current and all new staff ; program staff were trained (Attachment #2) on 11/19/2015. Staff in other agency 2380 regulated programs will be trained on the procedure on 12/31/2015. A copy of the revised Site Orientation will be submitted upon the next hired staff¿s orientation. Implemented
2380.84Annual fire inspection occured on 3/16/14 and then again on 7/20/15. The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.Program Supervisor and Lead Worker will create a system to remind them of the need to have the fire safety inspection completed within the annual time frame. This may involve an electronic-based calendar (attachment #3) or a paper reminder to set up the inspection. Both of these staff will track the need to complete this. All staff working at the program were trained (attachment #4) to know when the annual inspection needs to be scheduled and completed. Implemented
2380.173(9)Individual #1's physical states allergic to motrin, ibuprofen, and penicillian. The ISP does not state penicillian. Individual #2's physical states allergic to haldol, tegretol, zyprexa, and symmetel. ISP states they take Lortadine for allergies but does not state what the allergie is. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The program specialist, upon receiving up-dated documentation such as a physical, will review the document and compare it against other sources of or references to the information. When discrepancies are found, the program specialist will verify which information is accurate and notify the SC if it is in the ISP or will correct agency documentation. The program specialist will review all individual files for the program for any documentation that is expected to be the same and if discrepancies are found will notify by e-mail the source of the information or correct if it is his/her error. Any e-mails will be printed and placed in the record to document notification of discrepancies. All 2380 regulated program specialists were trained on this process on 11/20/2015 (attachment ##6). One individual¿s chart was checked to ensure consistency (attachment #5)) and the remaining charts are being checked (completed checklists will be submitted when complete). Implemented
2380.181(a)Individual #2's assessment was not completed 60 calendar days from admission to the facility. Each individual 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 were trained on the regulation on 11/20/2015 (attachment #8). At this time there are no assessments that demonstrate compliance to the regulation. Individual MP transferred to the program on 11/16/2015 and his assessment will be done and submitted by 12/31/2015. Refer to attachment #8 for reminder to complete the assessment prior to the allowed 60 days. Implemented
2380.187Individual #1's ISP meeting was on 3/26/15 and approvel letter was received on 6/1/15. Individual #2's ISP meeting was on 7/21/15 and did not receive the approval letter to date. A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP annual update and ISP revision meetings.Due to the date of inspection, 30 days has not passed so no reminders/requests have been made. One person in this program had a transition meeting on 11/05/2015. The program specialist will monitor (attachment #8) and if necessary will request a copy of the letter. All program specialists were trained on the need to track and follow-up receipt of the letter using an electronic calendar or paper method on 11/20/2015 attachment #8). Once a program specialist requests a letter, the request will be submitted for the plan of correction. Implemented
SIN-00197879 Renewal 01/25/2022 Compliant - Finalized
SIN-00069378 Initial review 10/06/2014 Compliant - Finalized