Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224693 Renewal 05/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1, date of admission 7/12/2022 completed initial fire safety training on 3/9/2023.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.A new Readmissionc Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist for any individual returning from a hiatus in services, as needed. 06/15/2023 Implemented
2380.111(c)(1)Individual #2's physical examination, completed 1/5/2023, does not include a review of previous medical history.The physical examination shall include: A review of previous medical history.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical, as needed. 06/15/2023 Implemented
2380.111(c)(5)Individual #2 had a Tuberculin Skin Testing by Mantoux Method completed on 12/24/2020 and then again on 2/2/2023.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.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical from any individual, as needed. 06/15/2023 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 6/30/2022, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical from any individual, as needed. 06/15/2023 Implemented
SIN-00206612 Renewal 06/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)Direct Service Worker #1 had a Tuberculin skin test completed 1/31/2020 and then again 5/26/2022.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.The IDD Management Team met on 6/20/22 to establish new procedures and protocols for completing staff physicals in a timely and complete manner. Moving forward from 6/20/22, all staff will be notified via an internal electronic system as well as by mail the due date of their physical 2 months prior to the expiration. They will also be mailed the required physical paperwork to take to the agency's employee physical provider or their own PCP. HR will notify Departmental Managers on the status of the physical, whether if it was completed or if there are issues that need corrected by the employee. Staff who do not send in completed physicals in a timely manner may be suspended until all requirements are met. 06/20/2022 Implemented
SIN-00122165 Renewal 10/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)The two most recent hearing examinations for Individual #1 were completed in August 2015 and on 10/5/16.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The Program Director will continue to follow the process to check physicals in a 2 step process. First, the Program Supervisor will review and initial the physical if it is completed in its entirety. The Program Director will do a second check and initial if it is completed in its entirety before filing. The Program Director will check all other records to ensure that they are completed entirely and within allotted time frames. The Program Supervisor will also send out physical notices to the individual¿s residential provider/family 2 months prior to the due date and will uphold suspensions if physicals are not turned in within that time frame. A new Program Supervisor was hired last month and trained in this process on 11/2/17. A physical that was checked with this process for another individual is included in supporting documentation. The Program Director will audit 10% of physicals monthly to ensure that this process is being followed. 11/02/2017 Implemented
2380.111(c)(5)The two most recent Tuberculin skin tests for Individual #1 were completed on 7/18/15 and 8/9/17.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 Director will continue to follow the process to check physicals in a 2 step process. First, the Program Supervisor will review and initial the physical if it is completed in its entirety. The Program Director will do a second check and initial if it is completed in its entirety before filing. The Program Director will check all other records to ensure that they are completed entirely and within allotted time frames. The Program Supervisor will also send out physical notices to the individual¿s residential provider/family 2 months prior to the due date and will uphold suspensions if physicals are not turned in within that time frame. A new Program Supervisor was hired last month and trained in this process on 11/2/17. A physical that was checked with this process for another individual is included in supporting documentation. The Program Director will audit 10% of physicals monthly to ensure that this process is being followed. 11/02/2017 Implemented
2380.181(f)The program specialist did not provide Individual #'1 assessment completed 1/12/17 to all the plan team members including Individual #1's family member.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 assessment was mailed to the family members on 11/14/17. All records were reviewed and a spreadsheet was created to track team members. A memo was created to attach to all completed reviews so that the Admin Specialist is aware of any team changes, to match the spreadsheet that is kept on site. The Program Director will review 10% of records and correspondence every quarter to ensure that all team members are accounted for, per ISP Meeting Signature Sheets, ISP Invitations, and ISP information. [Documentation of the reviews by the Program Director shall be kept. (AS 11/15/17)] 11/14/2017 Implemented
2380.186(d)The program specialist did not provide the ISP reviews completed 12/ 20/16, 3/21/17, 6/20/17 and 9/20/17 for Individual #1 to all the plan team members including Individual #1's family member. The program specialist did not provide the ISP reviews completed 12/13/16, 3/9/17, 6/20/17 and 9/12/17 for Individual #2 to all the plan team members including Individual #1's family member.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.The reviews were mailed to the family members on 11/14/17. All records were reviewed and a spreadsheet was created to track team members. A memo was created to attach to all completed reviews so that the Admin Specialist is aware of any team changes, to match the spreadsheet that is kept on site. The Program Director will review 10% of records and correspondence every quarter to ensure that all team members are accounted for, per ISP Meeting Signature Sheets, ISP Invitations, and ISP information. [Documentation of the reviews by the Program Director shall be kept. (AS 11/15/17)] 11/14/2017 Implemented
2380.186(e)The program specialist did not notify all the plan team members including family members for Individual #1 and Individual #2 of 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.The reviews were mailed to the family members on 11/14/17, with a declination from on the front sheet. All records were reviewed and a spreadsheet was created to track team members. A memo was created to attach to all completed reviews so that the Admin Specialist is aware of any team changes, to match the spreadsheet that is kept on site. The Program Director will review 10% of records and correspondence every quarter to ensure that all team members are accounted for, per ISP Meeting Signature Sheets, ISP Invitations, and ISP information. [Documentation of the reviews by the Program Director shall be kept. (AS 11/15/17)] 11/14/2017 Implemented
SIN-00102300 Renewal 10/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical examination, completed 9/28/16, did not include medical information pertinent to diagnosis and treatment in case of an emergency; this section on the physical examination form was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1's physical was returned for completion. The physicals of the other individuals at New Horizons were reviewed to ensure that they are filled out in their entirety. Any physicals that have blanks will be returned to the Residential Provider for completion. All incoming physicals will be reviewed and initialed by the Program Director. The Program Supervisor will review the physical for a 2nd time and also intial the physical prior to filing. Any physical that is incomplete will be returned to the Residential Provider and a memo to chart will be written in the individual's Electronic Health Record. The Program Supervisor was trained on this process on Oct. 31st. [Individual #1's physical examination was updated on 10/27/16 to include medical information pertinent to diagnosis and treatment in case of an emergency. (AS 11/4/16)] 11/03/2016 Implemented
2380.181(f)Individual #1's assessment, dated 1/4/16, was sent to the plan team members on 1/14/16; the ISP meeting was held on 2/9/16.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The Monthly ISP review spreadsheet was updated to include the Functional Assessment due date and an Annual Meeting date column, which will be utilized by the Director to indicate when the assessment needs to be mailed by the Program Specialist. The Instructors and Program Specialists were trained on this process Oct. 31st. The addition of the Annual Meeting date will be effective 11/1/16. [At least quarterly for 1 year, the Director will review the aforementioned monthly ISP review spreadsheet and a 25% sample of correspondence to plan team members to ensure that all individuals' assessments are sent to the plan team members within the required timeframes. (AS 11/4/16)] 11/03/2016 Implemented
SIN-00052661 Renewal 09/10/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)The facility did not alternate exit routes used during monthly fire drills conducted from January 2013 to August 2013. The fire drill log indicated that the Front Main Door and the Front Side Door were used for all the drills during the aforementioned time period.(e)  Alternate exit routes shall be used during fire drills.The exit that is used for evacuation by an individual does vary or alternate from month to month based on their location in the program when the alarm is sounded. Effective 9/25/13, the New Horizon Program Director and/or Program Specialist-Supervisor will ensure that each month, during the fire drill, that alternate exits are used, by documenting the exit utilized by each individual. The fire drill documentation has been updated to include this information and the updated logs have been sent to Cynthia Graham at BHSL via e-mail on 9/25/13 09/27/2013 Implemented
SIN-00264842 Renewal 04/29/2025 Compliant - Finalized
SIN-00244410 Renewal 05/13/2024 Compliant - Finalized
SIN-00188827 Renewal 06/15/2021 Compliant - Finalized
SIN-00162643 Renewal 09/09/2019 Compliant - Finalized
SIN-00141385 Renewal 09/12/2018 Compliant - Finalized
SIN-00106228 Unannounced Monitoring 12/07/2016 Compliant - Finalized
SIN-00083905 Renewal 10/09/2015 Compliant - Finalized
SIN-00067832 Renewal 10/20/2014 Compliant - Finalized