Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00123205 Renewal 10/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)Food residue on top of trash can lid. Orange liquid and food crumbs in bottom of freezer. Clean and sanitary conditions shall be maintained in the facility.This has been corrected - See Appendix D and E pictures 11/21/2017 Implemented
2380.58(b)Paint chipping on door jam of both egresses. 3 foot section of baseboard missing under dry erase board. Baseboard to left of dry erase board pulling away from wall. Wall patch 6 inches in diameter to left of main egress unpainted. Floors, walls, ceilings and other surfaces shall be free of hazards.See attachment F - A work order has been submitted to our facilities department to make the necessary repairs. a new Qware preventative maintenance system has been implemented in order to ensure all regular maintenance needs are carried out. 01/30/2018 Implemented
2380.84Fire Safety Inspection held 03/10/16 and not again until 04/07/17. 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.See Appendix K - Email A new Qware preventative maintenance system has been implemented, which will alert the fire safety expert of when the annual fire safety inspection needs to be completed in order to avoid a lapse in inspection. 11/21/2017 Implemented
2380.111(c)(5)Individual #2's TB test was taken on 06/17/15 and not again until 07/18/17The 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.Nursing staff have been trained on the requirements to ensure the TB test is given every two years, or if the skin test is positive, an initial chest x-ray with noted results. See Appendix R 12/29/2017 Implemented
2380.173(9)Individual # 2's allergies are not consistent across documents. The emergency health form states allergies to eggs and sulfa drugs. The 2017 physical states allergies to sulfa drugs, eggs, supral, Augmentin and bees. The current Individual Support Plan does not include allergy to Augmentin and only the ISP states that he/she should not have the flu shot due to allergy to eggs. His/her profile and ISP are the only documents that state he does not have an epi-pen for his allergies to bees. The Psychological visit dated 07/14/17 states allergy to sulfa drugs, cofixime, amoxicillin/potassium, Clau and egg derived active ingredients. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). Nursing staff will be trained on the on the need to ensure that allergies documented are consistent across all documentation. See Appendix R 12/29/2017 Implemented
2380.181(e)(7)Individual # 2's 10/26/16 assessment does not state Individual # 2's ability to sense and move away from heat sources. The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B The SC has been contacted to add this information to the ISP. See appendix C 12/29/2017 Implemented
2380.183(7)(i)Individual # 2's August 2017 ISP does not indicate 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.A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B 12/30/2017 Implemented
2380.183(7)(iii)Individual # 2's August 2017 ISP does not indicate potential to advance in Competitive Community Integration and 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.A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B The SC has been contacted to add this information. See Appendix C 12/29/2017 Implemented
2380.186(c)(2)Individual # 2's 05/24/17 and 08/28/17 ISP reviews do not include a review of his/her Behavior Support Plan. ISP states individual has BSP and that there have been no changes. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation, including the requirements to include progress on behavior support goals in a 2380 facility (see Appendix A). The BSS will be retrained on documentation and progress monitoring requirements for individuals receiving BS services (see Appendix F). 12/29/2017 Implemented
SIN-00095878 Renewal 09/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.183(4)Individual #1 has 1:1 supervision, but there is no protocol/schedule to achieve a higher level of independence or be without direct supervision. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.The assessment document is being revised to include a section for protocol/schedules for individuals to achieve a higher level of independence by 11/4/16. The assessment for Individual #1 will be updated by 11/11/16 to include a plan to move toward higher independence. Program specialists will be trained by 10/28/16 on the need to include a fading protocol and schedule outlining the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence. 11/11/2016 Implemented
SIN-00077071 Renewal 05/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill records, dated 9/23/14, 6/25/14 and 5/20/14, did not include the exit route used.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.All instructors will be trained in fire drill reporting requirements including requirements to document the exit route used by 8/27/15. In order to ensure the required items are preserved in a record, the completed fire drill record will be scanned and emailed to the director. The Director will take action to address any drill report which does not indicate the exit route used. 08/27/2015 Implemented
2380.181(e)(10)Individual #1's assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.The assessment was revised and the lifetime medical history was revised and updated to include all required areas as specified by the regulations. By 8/27/15, all program specialists will be trained on the requirement to include a completed and thorough lifetime medical history with every assessment. Assessment documents and lifetime medical histories will be audited by program management and QI staff to verify that lifetime medical histories are complete. 08/27/2015 Implemented
2380.181(f)Individual #1's assessment was sent to plan team members on 7/6/14. The Individual Support Plan (ISP) meeting was held on 7/29/14.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).By 8/27/15, Program Specialists will be trained on the requirement that assessments are sent to team members 30 days before the ISP meeting. Training will also involve the expectation that assessments are sent to the supports coordinator specifically not just the ISP team. 08/27/2015 Implemented
SIN-00063314 Renewal 04/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The Croft Building had a fire drill recorded on 2/25/14, but did not indicate the time or 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 Croft building had a successful drill during 2/14. The form with missing information was an error. Procedures for documentation of fire drills will be reviewed with Day Program management. Fire drills will be conducted and documented in accordance with regulations. Records of all drills will be submitted to the Program Director each month prior to the end of the month so that the Director can require additional information or an additional drill to ensure that drill requirements and documentation requirements are met. Documentation of all Day Program drills will be reviewed monthly at the Safety Committee to ensure that drills are conducted and documented according to regulations. 06/20/2014 Implemented
2380.173(1)(ii)Individual #1 did not have any indication of identifying marks in their record. Individual #2 did not have any indication of identifying marks in their record.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Melmark has created a fact sheet form with all required personal information. The form was distributed to all Program Specialists. All Program Specialists will be trained in regulatory requirements for personal information that must be included in the record. Program Specialists will update all records (including the records of individuals 1, 2, and 3) with the new form. A sample of records will be audited by the Program Director and QI Department on a quarterly basis to ensure that required personal information is included. Results of audits will be forwarded to the Program Specialists who will correct any incomplete items. 06/20/2014 Implemented