Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244071 Renewal 05/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.104(4)Individual #1 records did not include medical information pertinent to diagnosis and treatment in case of emergency as this section was left blank.Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency.Individual #1's family has been notified of the omission by the doctor on the physical exam form. They are making plans to have the information included. 05/13/2024 Implemented
2390.151(a)Individual #3 had an annual Assessment completed on 3/21/22, and then their next assessment wasn't completed until 3/15/24. Agency staff #2 reports that Individual was in and out of program for the 2023 year. Licensing representative was provided attendance logs for June 2022, July 2022, August 2022, and September 2022 and June 23. Individual #1 was in attendance approximately weekly in June 22, once in August 2022, they did not attend in September 22, and was in sporadic attendance in June 2023. A 2023 assessment should have been completed for Individual #3.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.Individual #3 quit the program and was out for a year. They were not in the program at the time the annual assessment was due. Discharge was not processed so when they decided to return, a new intake was not completed. Plan of correction will be to discharge individual's who leave and do a new intake (thus new initial assessment) OR do an annual assessment based on information known about the person. 05/13/2024 Implemented
2390.49(c)(1)Staff #1 did not receive annual training in the application of person-centered practices, including community integration, client choice and supporting clients to develop and maintain relationships during the training year 7/1/22-6/30/23.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.Staff #1 completed all required trainings for training year 7/1/22-6/30-23 on 7/26/23. 07/26/2023 Implemented
2390.49(c)(3)Staff #1 did not receive annual training in client rights during the during the training year 7/1/22-6/30/23.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Staff #1 completed all required trainings for training year 7/1/22-6/30-23 on 7/26/23. 07/26/2023 Implemented
2390.124(1)Individual #2's record does not contain his birthplace as this section of his record was left blank.Each client's record must include the following information: The name, sex, admission date, birthdate and place, Social Security number and dates of entry, transfer and discharge.Individual #2's birthplace was added the day of the licensing inspection (5/1/24). 05/01/2024 Implemented
SIN-00224735 Renewal 05/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(6)Individual #1's initial assessment, dated 02/08/2023, does not convey the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. This section of the assessment notes that the individual's level of functioning in this area is "-Yes -No -Maintains Skill," which is a contradictory statement. The narrative section below states that "[The Individual] HAS SAFETY PRECAUTIONS AWARENESS AND DOES NOT USE POISONOUS MATERIALS." This statement, paired with the above description of functional skill level, is unclear, as "safety precautions awareness" could either mean that the individual has the ability to use poisonous materials safely using appropriate precautions or that the individual cannot use poisonous materials safely but has awareness of how to recognize and avoid them. The following statement that the individual does not use poisonous materials does not clarify the individual's functional level because the individual might have the ability to use them but choose not to for other reasons. The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The Program Specialist accidentally selected "yes", "no" and "skill maintained" when the answer was "yes". The individual (1) safely avoids poisonous materials. The format to the assessment has been changed so that only one response is available to avoid multiple responses thus unclear assessment information. Program Specialists will verify content discrepancies of an individual's skill level at home versus at day program and clarify as appropriate. 06/13/2023 Implemented
2390.151(e)(8)Individual #1's initial assessment, dated 02/08/2023, does not convey the individual's ability to evacuate in the event of a fire. When describing if the individual is able to "Evacuate during a Fire Drill," the assessment states "-Yes -Maintains Skill"; however, the narrative section below states "[The Individual] DOES NOT HAVE FIRE SAFETY AWARENESS AND DOES NOT KNOW WHAT TO DO IN THE EVENT OF A FIRE EMERGENCY. [The Individual]···WOULD NEED HELP EVACUATING FROM A BUILDING." These two statements of ability are unclear and are incomplete without further explanation, such as the type of help that the individual needs in order to recognize a fire emergency and to evacuate. The assessment must include the following information: The client's ability to evacuate in the event of a fire.The individual (1) is able to successfully evacuate the building as evidenced during the drill on 6/19/23. He is aware of the alarm sound and knows it means to evacuate and exit outside. The response of "yes" is correct. The Program Specialist included an excerpt from the ISP listing a contradictory statement which should have been clarified that it pertains to home, not day program. 06/13/2023 Implemented
SIN-00266034 Renewal 05/22/2025 Compliant - Finalized
SIN-00204472 Renewal 05/24/2022 Compliant - Finalized
SIN-00186665 Initial review 04/26/2021 Compliant - Finalized