Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263828 Renewal 04/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.86On 4/01/2025 at 10:45am there was a portable electric fireplace in the lobby of the building, that was not permanently mounted.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices.On April 4, 2025, the Executive Director and Maintenance Technician removed the portable electric fireplace from the lobby of the building. (Attachment #6.) 04/11/2025 Implemented
2380.181(e)(4)Individual #1's assessment completed 7/10/2024, Individual #2's assessment completed 5/24/2024, and Individual #3's assessment completed 8/09/2024, did not include the individuals' need for supervision at the program.The assessment must include the following information: The individual¿s need for supervision.The Program Specialist immediately updated the individual's treatment assessment to include the individual's need for supervision at the program (Attachment #1), (Attachment #2), and (Attachment #3). The Program Specialist sent the updated assessment to all necessary parties on April 7th & 8th, and the change was made to the individual's ISP (attachment #8), (Attachment #9), (Attachment #10). 04/08/2025 Implemented
SIN-00146514 Renewal 12/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical examination completed on 11/15/16 and then again on 12/19/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist will contact the family provider 45 days prior to the expiration of individual #1's annual physical as she lives at home with her family. Thirty days prior to the due date for the individual #1's annual physical, the Program Specialist will contact the family provider again to obtain confirmation of the date of the physical. If at any time, an individual's physical is out of compliance, individual #1 will not be permitted to attend the 2380 program until her physical is completed. The annual physical for individual #1 was completed per the family provider on 12/17/2018 and she will send paperwork to the office on 12/21/2018. The Executive Director or designee will review 25% of client medical records quarterly to ensure compliance. [Individual #1 had a physical examination completed on 12/17/18. Immediately, the Executive Director shall develop and implement a tracking and notification system to ensure all individuals have physical examination completed, timely. Immediately and continuing at least quarterly for I year, the Executive Director or designated staff person shall audit all individuals current physical examinations and the aforementioned tracking system to ensure all individuals have physical examination completed, timely. (DPOC by AES,HSLS on 1/2/19)] 12/17/2018 Implemented
2380.111(c)(5)Individual #1 had Tuberculin skin testing with negative results completed on 11/6/15 and then again on 1/4/18.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.The Program Specialist will contact the family provider 45 days prior to the expiration of individual #1's tuberculin skin test which should be performed at the annual physical. Thirty days prior to the due date for the individual #1's tuberculin skin test, the Program Specialist will contact the family provider again to obtain confirmation of the date of the physical. If at any time, an individual's physical and TB test are out of compliance, individual #1 will not be permitted to attend the 2380 program until her physical and TB are completed. Contact was made with the family on 12/19/2018 to determine the status of the current TB and Physical. The family provider stated that the annual physical and Tb test for individual #1 were completed on 12/17/2018 and she will send paperwork to the office on 12/21/2018. The Executive Director or designee will review 25% of client medical records quarterly to ensure compliance. [Individual #1 had a physical examination to include Tuberculin Skin Testing completed on 12/17/18. Immediately, the Executive Director shall develop and implement a tracking and notification system to ensure all individuals have physical examination completed, timely. Immediately and continuing at least quarterly for I year, the Executive Director or designated staff person shall audit all individuals current physical examinations and the aforementioned tracking system to ensure all individuals have physical examination completed, timely. (DPOC by AES,HSLS on 1/2/19)] 12/19/2018 Implemented
SIN-00106809 Renewal 01/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The written fire drill record for the fire drill held 12-06-16 did not include the amount of time it took for evacuation. 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 Executive Director reviewed the Fire Drill log and updated the form to include an area for staff initials. Staff initials must be of someone other than the program specialist who conducted the fire drill. These initials will signify that the form was reviewed for completeness and accuracy. To prevent future non-compliance, all fire drill logs will be submitted to the Executive Director for review on a monthly basis to ensure all information is complete. The program specialist received training regarding completion of fire drills and tracking process by the Executive Director on February 10, 2017. A copy of the Fire Drill Log and training log will be attached as Attachment #2. 02/11/2017 Implemented
2380.186(d)The program specialist did not provide Individual #1's 3 month ISP reviews ending on 12-2-16, 9-6-16, 6-9-16 and 3-4-16 to the plan team members. The program specialist did not provide Individual #2's 3 month ISP reviews ending on 11-2-16, 8-16-16, 5-19-16 to the plan team members.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.As of February 10, 2017 the ISP review material for individuals #1 and #2 will be distributed to the teams of each individual, even though they are late. As of February 10, 2017 a review of client records will be completed by the program specialist ensuring that distribution information is up to date for every individual in program. In order to prevent future non-compliance, retraining will be provided on the regulation and expectations surrounding the ISP process. The training will be provided to the program specialist by the Executive Director - this will be completed by February 10, 2017. Quarterly, a compliance audit will be completed by Human Resources and a random sample of client files will be reviewed to ensure that all records are up-to-date and all information is included per regulations. A copy of the training log, quarterly review invitation, review letter, and quarterly review template will be attached as Attachment #1. 02/11/2017 Implemented
SIN-00085576 Initial review 11/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.90(a)The doorway through the hallway between the meeting room and the 1st aid room leading to the front exit did not have a sign bearing the word "Exit" posted above the door.Signs bearing the word "EXIT" in plain, legible letters shall be placed at exits.A sign has been placed over the door bearing the word exit. A photograph of the sign will be emailed to Amy Sharpf. The Program Specialist will monitor the presence of the signs during regularly scheduled monthly fire drills[Documentation of monthly monitorings will be maintained and reviewed by the CEO at least quarterly. (AS 12/8/15)] 12/02/2015 Implemented
2380.90(b)The way to reach the exit at the front of the building is not immediately visible to the individuals from the hallway door. Directional signs were not posted. If the exit or way to reach the exit is not immediately visable to the individuals, access to exits shall be marked with visible signs indicating the direction of travel.Directional signs were placed in the areas of the hallway where the illuminated signs were not visible to direct individuals to the escape route. An email of the photos with the signs placed will be sent to Amy Scharpf. The Program Specialist will monitor the presence of the signs during regularly scheduled monthly fire drills [Documentation of monthly monitorings will be maintained and reviewed by the CEO at least quarterly. (AS 12/8/15)] 12/02/2015 Implemented
SIN-00242258 Renewal 04/03/2024 Compliant - Finalized
SIN-00222944 Renewal 04/20/2023 Compliant - Finalized
SIN-00204968 Renewal 05/12/2022 Compliant - Finalized
SIN-00187834 Renewal 05/20/2021 Compliant - Finalized
SIN-00166172 Renewal 11/13/2019 Compliant - Finalized
SIN-00126267 Renewal 12/21/2017 Compliant - Finalized