Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00191492 Renewal 08/03/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(a)The First aid area did not contain a privacy screen. The cot bed, and pillow with blankets was in a storage area off of an office but privacy away from the program area could not be ensured. Privacy screen was also not present at the main program building. Privacy screens and appropriate signage were immediately completed and hung after initial physical site review to become compliant.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.A privacy screen was placed with the cot and a sign was posted on the first aid room. See Appendix A. 09/15/2021 Implemented
SIN-00149579 Renewal 01/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)Room 3 has a double door closet that needs cleaning. Room 5 has a floor area which is scuffed in the program area. The outside rear deck has a wooden chair that has a dark substance covering its exterior.Clean and sanitary conditions shall be maintained in the facility.A work order to clean and paint the closets in room 3 was placed (appendix B). The corrective action to identify and prevent the recurrence of this citation is for cleanliness and sanitary conditions to be added to the environmental checklists that are completed on a monthly basis in order to identify any cleaning that needs to occur. This addition to the form will be completed by 4/30/2019. The Director and Assistant Director of the day program will be responsible for making these changes. Appendix: B 04/30/2019 Implemented
2380.58(b)The exterior center door exiting onto the patio was found on its center covered with rust.Floors, walls, ceilings and other surfaces shall be free of hazards.A work order was submitted to repair the exterior door (appendix A). Due to the nature of the work, it will be completed in Spring 2019. The corrective action to identify and prevent the recurrence of this citation is for the exterior building and facility grounds to be added to the environmental checklists that are completed on a monthly basis in order to identify any repairs that need to be made. This addition to the form will be completed by 4/30/2019. The Director and Assistant Director of the day program will be responsible for making these changes. Appendix: A 04/30/2019 Implemented
2380.67(a)Room 2 has one chair with a damaged arm rests.Furniture and equipment shall be nonhazardous, clean and sturdy.This chair was thrown away as it was unable to be repaired. The corrective action to identify and prevent the recurrence of this citation is for condition of the furniture and equipment to be added to the environmental checklists that are completed on a monthly basis in order to identify any repairs that need to be made. This addition to the form will be completed by 4/30/2019. The Director and Assistant Director of the day program will be responsible for making these changes. See Appendix A 04/30/2019 Implemented
2380.72(b)The rear exterior patio wall has damaged plaster coating.The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.A work order was submitted to repair the exterior patio (appendix A). Due to the nature of the work, it will be completed in Spring 2019. The corrective action to identify and prevent the recurrence of this citation is for the exterior building and facility grounds to be added to the environmental checklists that are completed on a monthly basis in order to identify any repairs that need to be made. This addition to the form will be completed by 4/30/2019. The Director and Assistant Director of the day program will be responsible for making these changes. Appendix: A 04/30/2019 Implemented
SIN-00126311 Renewal 12/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(h)Staff #2's medication administration training was conducted on 4/7/16 and the again on 7/17/17.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Staff #2¿s initial med packet (Appendix E) was completed on 4/7/16. Her 2016-2017 med packet (Appendix E1) has 2 med practicum observations and 1 MAR audit completed on time. To remediate the 1 missing MAR audit, one practice activity was completed and attached to the packet. Her 2017-2018 med packet (Appendix E2) includes two med practicum observations completed prior to her 6-month due date. Staff #2 is no longer employed at Melmark. 01/31/2018 Implemented
2380.53(a)The bathroom sink had cleaning supplies unlocked Lysol disinfectant spray 3 bottles, Coppertone sun block lotion 12oz, and clean assist toilet cleaner.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The cabinet is now locked (see Appendix I) and the administrative assistant will complete a walkthrough of the program daily to ensure all items are locked that are necessary using a checklist form (see Appendix J) 01/31/2018 Implemented
2380.55(a)Food residue on kitchen cabinets above and below counter.Clean and sanitary conditions shall be maintained in the facility.A work order has been submitted for the kitchen cabinets to be deep cleaned by December 31, 2017. See Appendix C. 01/31/2018 Implemented
2380.55(d)There was a missing lid from the kitchen trash receptacle.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.A new lid was purchased for the kitchen trash receptacle. See Appendix H. 12/31/2017 Implemented
2380.57There was a bulb out in rear stairwell egress by bathroom and room #1.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.A work order has been submitted for the bulb to be replaced. See Appendix C. 01/31/2018 Implemented
2380.58(a)There was a 12 inch crack in both bathrooms and a 12 inch hole in the wall.Floors, walls, ceilings and other surfaces shall be in good repair.A work order has been submitted for the cracks in both bathrooms and the hole in the wall to be repaired. See Appendix C. The wall has been repaired. See appendix L. 01/31/2018 Implemented
2380.84The safety inspection was conducted on 3/10/16 and then again on 4/3/17.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 A new Qware preventative maintenance system has been implemented to schedule fire safety inspections to ensure no further lapse. 12/31/2017 Implemented
2380.111(a)Individual #4 physical dated 11/24/15 and again on 12/16/16.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A training was conducted with the nurses who review the annual physicals to review the 2380 regulations surrounding annual physicals (see appendix R). 12/31/2017 Implemented
2380.111(c)(8)Individual #4 physical dated 12/16/16 did not include the physical limitations.The physical examination shall include: Physical limitations of the individual.A training was conducted with the nurses who review the annual physicals to review the 2380 regulations surrounding annual physicals (see appendix R). 12/31/2017 Implemented
2380.111(c)(9)Individual #4 physical dated 12/16/16 did not include allergies.The physical examination shall include: Allergies or contraindicated medication.A training was conducted with the nurses who review the annual physicals to review the 2380 regulations surrounding annual physicals (see appendix R). 12/31/2017 Implemented
2380.111(c)(10)Individual #4 physical dated 12/16/16 did not include information pertinent in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A training was conducted with the nurses who review the annual physicals to review the 2380 regulations surrounding annual physicals (see appendix R). 12/31/2017 Implemented
2380.155(e)(6)Individual #2's restrictive procedure dated 8/2017 and approved 9/12/17 states amount of time. PMP (up to 6 person person supine) may be applied during all 'waking hours.' Maximum time period for manual restraint may not exceed a total of 30 minutes within any 2 hour period.The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in 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 in a 2380 facility (see Appendix A, A1, and A2). A training was conducted with the behavior specialist on the regulations surrounding restrictive procedures. See appendix D. 12/31/2017 Implemented
2380.181(a)Individual #4 assessment was completed on 5/23/16 and again on 6/8/17.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.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, A1, and A2). 12/31/2017 Implemented
2380.181(e)(7)Individual #4 assessment dated 6/8/17 did not include the 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, A1, and A2) Individual #4 will have an updated assessment to include their ability to sense and move away from heat sources using the updated assessment template (appendix B) by 1/31/2017 01/31/2018 Implemented
2380.181(e)(9)Individual #3 face sheet states he was allergic to face paint. The 10/19/17 physical states he has NKA.The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.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, A1, and A2) 12/31/2017 Implemented
2380.183(4)Individual #3 updated ISP 8/1/17 stated he is still receiving 1:1 staff while attending day program. Currently receiving 1:2 and 1:6 staffing.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.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, A1, and A2). See Appendix G for email sent to the SC requesting the appropriate visual level of supervision be added to the ISP. 01/31/2018 Implemented
2380.183(5)Individual #4 assessment dated 6/8/17 did not include a SEEN plan.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.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, A1, and A2). Individual's Plan of Support (SEEN plan) has been updated. See Appendix F. 01/31/2018 Implemented
2380.183(7)(i)Individual #3 ISP updated 8/1/17 does not include the 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, A1, and A2). An email was sent to individual¿s SC to add potential to advance in the ISP. See Appendix G. 01/31/2018 Implemented
2380.183(7)(iii)Individual #3's ISP updated 8/1/17 does not include the 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.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, A1, and A2). An email was sent to individual¿s SC to add potential to advance in the ISP. See Appendix G. 01/31/2018 Implemented
2380.186(c)(2)Individual #3's ISP review dated 9/27/17 did not review the behavioral plan. The review did not include details of the goal. Only stated if he is up or down for the behavioral plan.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 in a 2380 facility (see Appendix A, A1, and A2). A behavior specialist training was conducted to review regulations regarding documentation on ISP reviews for behavior plans. See appendix D. 12/31/2017 Implemented
2380.186(e)Individual #3's record did not include an option to decline.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.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, A1, and A2). 01/31/2018 Implemented
SIN-00101717 Renewal 09/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's physical exam dated 8/25/16 did not document a vision screening. The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialists will monitor all physical examination forms for their caseloads and ensure that they are submitted to Melmark's nursing department. Program specialists will be trained by 10/28/16 on the requirements to have physical forms thoroughly completed to include a review of vision and hearing. The program specialists will complete quarterly audits of the book to ensure that all areas of the physical forms are complete including hearing and vision. Results of the chart audits will be reported to the Director or designee. The Director of Healthcare and the management team will also complete random audits of physical forms. 10/28/2016 Implemented
2380.111(c)(9)Individual #2's physical exam dated 12/31/15 did not document allergies.The physical examination shall include: Allergies or contraindicated medication.Program Specialists will monitor all physical examination forms for their caseloads and ensure that they are submitted to Melmark's nursing department. Program specialists will be trained by 10/28/16 on the requirements to have physical forms thoroughly completed to include allergies or contraindicated medication. The program specialists will complete quarterly audits of the book to ensure that all areas of the physical forms are complete including hearing and vision. Results of the chart audits will be reported to the Director or designee. The importance of completing all documentation on the physical form was reviewed with all nurses in September, 2016 and will be reviewed again in October, 2016. The Director of Healthcare and the management team will also complete random audits of physical forms. 10/28/2016 Implemented
2380.111(c)(10) Individual #2's physical exam dated 12/31/15 did not document information pertinent to diagnoses and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialists will monitor all physical examination forms for their caseloads and ensure that they are submitted to Melmark's nursing department. Program specialists will be trained by 10/28/16 on the requirements to have physical forms thoroughly completed to include information pertinent to diagnosis and treatment in case of emergency. The program specialists will complete quarterly audits of the book to ensure that all areas of the physical forms are complete including medical information pertinent to diagnosis and treatment in case of an emergency. Results of the chart audits will be reported to the Director or designee. The importance of completing all documentation on the physical form was reviewed with all nurses in September, 2016 and will be reviewed again in October, 2016. The Director of Healthcare and the management team will also complete random audits of physical forms. 10/28/2016 Implemented
2380.181(f)Individual #1's annual ISP was held on 8/8/16 and the annual assessment was sent on 7/21/16. 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).By 10/28/16, Program Specialists will be trained on requirements for completion of assessments and providing the assessment to the SC or plan lead and plan team members at least 30 days prior to the ISP meeting. Due dates of assessments will be tracked by Records Coordination who will send monthly updates to program directors so that compliance with assessment due dates can be monitored. Directors will address non-compliance with due dates with responsible program specialists. Quarterly chart audits will be completed to ensure that assessment due dates are monitored and that the assessment is sent to all team members at least 30 days prior to the ISP meeting. Results of chart audits will be reviewed by Director or designee. 10/28/2016 Implemented
2380.183(4) Individual #2 has 2:1 supervision, but there is no protocol/schedule to achieve a higher level of independence or be without direct supervision. Individual #3 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 #2 and Individual #3 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-00076675 Renewal 05/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill logs, dated 7/8/14, 5/21/14, 7/22/14 and 8/14/14, 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. 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
2380.171(b)(2)Individual #2's emergency information did not include the name of the physician or source of health care.Emergency information for each individual shall include: The name, address and telephone number of the individual¿s physician or source of health care.By 8/27/15, Program Specialists will be trained on the requirements to include the name of the physician or source of health care on each individual's emergency information. Quarterly chart audits will be completed to ensure that the emergency information is up to date and includes all required fields. Results of chart audits will be reported to the Director. 08/27/2015 Implemented
2380.181(a)The assessment for Individual #1 was not completed in the regulatory timeframe. An assessment was completed on 3/24/14. A 2015 assessment was not completed at the time of the inspection.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.By 8/27/15, Program Specialists will be trained on requirements for completion of assessments annually. Due dates of assessments will be tracked by Records Coordinator who will send monthly updates to program directors so that compliance with assessment due dates can be monitored. Directors will address non-compliance with due dates with responsible program specialists. 08/27/2015 Implemented
2380.181(e)(9)Individual #2's annual assessment, dated 5/12/14, did not include the individual's disability. The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.Individual #2's assessment, dated 5/12/14, will be updated to include the individual's disability. By 8/27/15, all program specialists will be trained on the requirement to include, in the assessment, the individual's disability. Assessment documents will be audited by program management and QI staff to verify that progress on personal needs with or without assistance from others is included. 08/27/2015 Implemented
2380.181(e)(10)The assesment for Individual #3, dated 11/3/14, did not include a completed 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(e)(14)The assessment for Individual #3, dated 11/3/14, did not include the individual's knowledge on water safety.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.Individual #3's assessment, dated 11/3/14, will be updated by 9/15/15 to include the individual's water safety ability. By 8/27/15, all program specialists will be trained on the requirement to include, in the assessment, the individual's water safety ability. Assessment documents will be audited by program management and QI staff to verify that an individual's water safety ability is reflected. 08/27/2015 Implemented
2380.185(a)The Individual Support Plan (ISP) for Individual #2, dated 7/19/14, was not implemented by the start date. The ISP review from May to July of 2014 overlappped the previous ISP.The ISP shall be implemented by the ISP's start date.By 8/27/15, Program Specialists will be trained on requirements for implementation of Individual Support Plans (ISPs) at the required start date. Due dates of ISPs and quarterlies will be tracked by Records Coordinator who will send monthly updates to program directors so that compliance with implementation and due dates can be monitored. Directors will address non-compliance with due dates with responsible program specialists. 08/27/2015 Implemented
2380.186(a)Individual #3's Individual Support Plan (ISP) reviews were not completed in the regulatory timeframe. The ISP annual review update date is 2/21/15. The review from May to July of 2014 was signed on 8/21/14. The review from August to October of 2014 was signed on 12/2/14. The review from November to January of 2015 was signed 2/24/15. The three ISP reviews exceeded the 15 day grace period.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.By 8/27/15, Program Specialists will be trained on requirements for completion of Individual Support Plan (ISP) reviews on a quarterly basis. Due dates of quarterlies will be tracked by Records Coordinator who will send monthly updates to program directors so that compliance with quarterly due dates can be monitored. Directors will address non-compliance with due dates with responsible program specialists. 08/27/2015 Implemented
SIN-00063316 Renewal 04/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's annual physical dated 7/26/13 did not have all the required content. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #1 will have an updated annual physical with all required content. The Program Director will ensure that physical examination forms contain all required content. The Program Director will communicate required content of annual physicals to primary care physician for all individuals. Annual physicals will be submitted to the program nurse who will review for content and communicate with the primary care physician to ensure that any missing content is completed. The nurse and program staff will be trained in required content of annual physicals and procedures for review of annual physicals. Documentation of training will be submitted to DPW. 07/01/2014 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 Individual #3 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. Documentation of training will be submitted to DPW. Program Specialists will update all records 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
2380.186(a)Individual #2 was missing a 3 month review for 5/13. 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.Management will provide training on requirements for timely completion of ISP reviews to program specialists. Documentation of training will be submitted to DPW. The Program Director and Melmark's QI Department will monitor completion of ISP reviews by due dates and send monthly reports of documents due to program specialists. The Program Director will address any instances of non-compliance with due dates with the Program Specialist through re-training or counseling. 06/20/2014 Implemented