Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248551 Renewal 07/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1, date of admission 7/5/17, was instructed in general fire safety on 3/29/23 then again 4/25/24.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.Annual Fire Safety training was completed on 4.25.2024 by individual in efforts to reinstruct in the area concerning general fire safety and the use of fire extinguishers. A written record of the training was kept by the program supervisor on site. 08/20/2024 Implemented
2390.151(a)Individual #2's most recent assessment was completed 10/11/22. Individual #3, date of admission 5/2/24 does not have an initial assessment. Individual #4, date of admission 4/9/24 does not have an initial assessment.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.Assessments were completed for the three individuals although not in compliance with the regulatory calendar date requirements. (7/30/24, 7/31/2024, and 8/1/2024). Program staff will ensure to routinely utilize the tickler file created by program manager to ensure 2390.151(a) requirements are met. 08/20/2024 Implemented
2390.151(f)The program specialist did not provide an assessment for Individual #2 to the plan team members for the most recent individual meeting on 1/5/24.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Program specialist previously completed assessment on and mailed to Individual #2¿s team members on 8.9.2024. Program specialist will ensure to utilize the tickler file to track completion of needed assessments/ provide said assessments to team members in accordance with the 2390.151(f) regulation. 08/20/2024 Implemented
SIN-00229922 Renewal 08/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Client rights and the process to report a rights violation were explained to Individual #1 on 4/15/2022 and again on 4/17/2023. Client rights and the process to report a rights violation were explained to Individual #2 on 11/23/2021 and again on 11/28/2022. Client rights and the process to report a rights violation were explained to Individual #3 on 11/9/2021 and again on 11/10/2022.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Provider utilizes a monthly due date checklist that supervisors utilize to ensure all annual and quarterly items are completed on time. The Client rights has been added to this checklist to be utilized moving forward. Supervisors were trained on this addition to their monthly checklist. 09/07/2023 Implemented
SIN-00194283 Renewal 10/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #2 had an assessment completed on 8/5/20 and then again on 9/15/21.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.Supervisor¿s, and program specialists trained on regulation 2390.151 A monthly due date checklist form is to be utilized by Supervisors and program specialists to track required due dates for annual assessments. This will be completed on a monthly basis and reviewed by program supervisor with assistant supervisor and program specialists in monthly supervisions. 10/26/2021 Implemented
2390.33(b)(2)Individual #1's 1/25/21 assessment indicates no support is required for understanding the dangers of heat sources. Individual #1's 9/13/21 individual plan states they do not understand the dangers associated with heat sources. Individual #1's 1/25/21 assessment indicates no support is required for them to properly use or avoid poisonous substances and to properly utilize safety precautions around poisonous materials. Individual #1's 9/13/21 individual plan states all poisonous substances should be kept locked away to ensure their health and safety at all times. Individual #1's 1/25/21 assessment indicates no support is required for recognizing sounds of alarms and for evacuating during fire drills. Individual #1's 9/13/21 individual plan states they do not recognize the dangers associated with fire or smoke, cannot recognize a fire alarm, and are unable to use proper evacuation routes without guidance from staff.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.Supervisor¿s, and program specialists trained on regulation 2390.33 (b) (2) 10/26/2021 Implemented
SIN-00154651 Renewal 05/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)The program specialist did not complete and ISP review for Individual #1 for the period of 1/1/19 to 3/31/19. 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.1. On 5/15/19, Program Director trained Supervisor¿s, Assistant Supervisor¿s, and Program Specialists on regulations 2390.156(a)(d). (training sheet will be sent via email) 2. The incomplete ISP review was completed on: 5/7/19. 3. A monthly due date checklist form is to be utilized by Supervisor, Assistant Supervisor and Program Specialists to track required due dates for ISP Quarterly Assessment and review documentation send to SC¿s and team members. This will be completed on a monthly basis and reviewed by the supervisor with the assistant supervisors and program specialists between the 10-13th of each month. This will allow time to ensure all items are completed by the deadline of the 15th each month. (checklist will be sent via email) 4. On a monthly basis a 10% sample of charts will be reviewed utilizing the monthly chart review form to ensure compliance. This will be completed ongoing. (chart review form will be sent via email). All attachments will be sent via email 05/15/2019 Implemented
2390.156(d)The program specialist provided the ISP review to the plan team members on 3/25/19 for Individual #2 for the ISP review completed on 2/4/19. 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.1. On 5/15/19, Program Director trained Supervisor¿s, Assistant Supervisor¿s, and Program Specialists on regulations 2390.156(a)(d). (training sheet will be sent via email) 2. A monthly due date checklist form is to be utilized by Supervisor, Assistant Supervisor and Program Specialists to track required due dates for ISP Quarterly Assessment and review documentation send to SC¿s and team members. This will be completed on a monthly basis and reviewed by the supervisor with the assistant supervisors and program specialists between the 10-13th of each month. This will allow time to ensure all items are completed by the deadline of the 15th each month. (checklist will be sent via email) 3. On a monthly basis a 10% sample of charts will be reviewed utilizing the monthly chart review form to ensure compliance. This will be completed ongoing. (chart review form will be sent via email). All attachments will be sent via email 05/15/2019 Implemented
SIN-00132969 Renewal 04/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)Individual #1's ISP reviews, end dated 5/31/17, 8/31/17 and 2/28/17 were signed by Individual #1 on 6/21/17, 9/22/17 and 3/29/18, respectively. Individual #2's ISP reviews, end dated 4/30/17, 7/31/17, 10/31/17 and 1/31/18 were signed by Individual #2 on 5/18/17, 8/25/17, 11/29/17 and 2/21/18, respectively. Individual #3's ISP review, end dated 5/31/17 was signed by Individual #3 on 6/29/17. Individual #4's ISP review, end dated 11/30/17 was signed by Individual #4 on 12/27/17. Individual #5's ISP reviews, end dated 10/31/17 and 1/31/18 were signed by Individual #5 on 11/30/17 and 2/21/18, respectively. Individual #6's ISP reviews, end dated 9/30/17 and 12/31/17 were signed by Individual #6 on 10/20/17 and 1/19/18, respectively. Individual #7's ISP reviews, end dated 7/31/17 and 10/31/17 were signed by Individual #7 on 8/24/17 and 11/30/17, respectively. Individual #8's ISP reviews, end dated 7/31/17 and 10/31/17 were signed by Individual #8 on 8/29/17 and 11/30/17, respectively. 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.1. Supervisor's, Assistant Supervisors, and Program Specialists were trained on regulation 2390.156(a) on 4/30/2018 by Karen McKivens, Program Director; attachment sent to [Human Services Licensing Supervisor] via email. 2. A monthly due date checklist form is to be utilized by Assistant Supervisor, Supervisor's, and Program Specialists to track required due dates for ISP Quarterly Assessments. This will be completed on a monthly basis and reviewed with supervisor in monthly staff supervisions. Checklist sent to HSLS via email. 3. On a monthly basis a 10% sample of charts will be reviewed utilizing the monthly chart review form to ensure compliance. This will be completed ongoing. Chart review form sent to HSLS via email 05/04/2018 Implemented
SIN-00113890 Renewal 05/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(d)The program specialist provided the ISP review documentation dated 9/20/16 for Individual #1 to the plan team members on 12/20/16. The program specialist provided the ISP review documentation dated 7/11/16 for Individual #2 to the plan team members on 2/7/17. 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.1. Supervisors, Assistant Supervisors, and Program Specialists were trained on regulation 2390.156 as well as MYCS Policy and Procedures on ISP Development. 2. A monthly due date checklist form is to be utilized by Assistant Supervisor, Supervisor's, and Program Specialists to track required due dates for ISP and Assessment requirements. This will be completed on a monthly basis and reviewed with supervisor in monthly staff supervisions. 3. This deficiency was discovered through an annual audit of charts in December 2016, a full audit of those charts was completed in December 2016, March 2017, and again in May 2017, to ensure full compliance of regulations. 4. On a monthly basis a 10% sample of charts will be reviewed utilizing the monthly chart review form. This will be completed ongoing. 05/25/2017 Implemented
SIN-00092573 Renewal 05/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)The program specialist provided Individual #1's assessment, dated 3/31/16 to the plan team members on 3/31/16 for an ISP meeting on 4/14/16. The program specialist did not provide Individual #3's assessment completed 1/28/16 to the entire plan team members including to the Behavior Specialist Consultant. The program specialist did not provide Individual #4's assessment completed 11/17/15 to the entire plan team members including to the Milestone or Citizen's Care.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).1. Supervisors, Assistant Supervisors, and Program Specialists were trained on regulation 2390.151 as well as MYCS Policy and Procedures on Assessments. 2. A due date checklist form will be utilized to assist Supervisors, Assistant Supervisors and Program Specialists in tracking due dates of assessments and ISP's to ensure completion of needed items within regulation guidelines. These will be completed/reviewed on a monthly basis. 3. Supervisors, Assistant Supervisors and Program Specialists will utilize e-mail or US Postal mail to send Assessments to the entire plan team. These will be sent via e-mail or form letter with copies placed in charts. All training and new processes implemented as of 5/24/16. 4. Individual #3 and #4 assessments were sent to the missing team members as noted on the POC. 5. All consumer charts will be checked to ensure this regulation is met. This will be completed by 6/24/16. 6. On a monthly basis a 10% sample of all charts will be reviewed utilizing the monthly chart review form. This will be completed ongoing. [Documentation of tracking and chart reviews shall be kept. (AS 6/2/16) 05/24/2016 Implemented
SIN-00055845 Renewal 04/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)The assessment for Individual # 1 was not completed 1 year prior or within 60 days of admission to the program. The admission date was 7/17/13 and the assessment date was 12/19/13.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.1. Supervisors, Assistant Supervisors, and Program Specialists were trained on regulation 2390.151 as well as MYCS Policy and Procedures on Assessments. 2. A due date checklist form was devised to assist Supervisors, Assistant Supervisors and Program Specialists in tracking due dates of assessments and ISP's to ensure completion of needed items within regulation guidelines. These will be completed/reviewed on a monthly basis. All training and new processes implemented as of 5/9/14. 05/09/2014 Implemented
2390.151(f)In the records of individuals # 1 through # 10, there was no documentation that the assessments were sent to team members other than the Supports Coordinator. 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).1. Supervisors, Assistant Supervisors, and Program Specialists were trained on regulation 2390.151 as well as MYCS Policy and Procedures on Assessments. 2. A due date checklist form was devised to assist Supervisors, Assistant Supervisors and Program Specialists in tracking due dates of assessments and ISP's to ensure completion of needed items within regulation guidelines. These will be completed/reviewed on a monthly basis. 3. Supervisors, Assistant Supervisors and Program Specialists will utilize e-mail or US Postal mail to send Assessments to the entire plan team. A letter was developed to be used in these instances and will be placed in the chart.All training and new processes implemented as of 5/9/14. 05/09/2014 Implemented
2390.156(d)The program specialist did not provide the ISP review documentation to the SC and plan team members within 30 days of the ISP reviews dated 7/17/13 and 11/14/13 for Individual # 5. 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.1. Supervisors, Assistant Supervisors, and Program Specialists were trained on regulation 2390.156 as well as MYCS Policy and Procedures on ISP and ISP Reviews. 2. A due date checklist form was devised to assist Supervisors, Assistant Supervisors and Program Specialists in tracking due dates of assessments and ISP's to ensure completion of needed items within regulation guidelines. These will be completed/reviewed on a monthly basis. 3. Supervisors, Assistant Supervisors and Program Specialists will utilize e-mail or US Postal mail to send ISP/Reviews to the entire plan team. A letter was developed to be used in these instances and will be placed in the chart. All training and new processes implemented as of 5/9/14. 05/09/2014 Implemented
SIN-00211131 Renewal 09/13/2022 Compliant - Finalized
SIN-00178762 Renewal 11/04/2020 Compliant - Finalized
SIN-00074466 Renewal 04/23/2015 Compliant - Finalized
SIN-00043412 Renewal 10/26/2012 Compliant - Finalized