Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249491 Renewal 07/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1, date of admission 06/29/21, had a physical examination completed on 01/09/23 and then again on 01/30/24. This exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Violation was corrected on 1/30/2024. Physical examination was completed on this date. 01/30/2024 Implemented
2380.21(u)Individual #2, date of admission 11/01/22, was informed and explained individual rights on 01/03/23 and then again on 01/08/24. This exceeds the annual requirement.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Violation was corrected on 1/8/2024. New annual rights statement was signed at that time, including a review of individual rights and the process to report a rights violation. 01/08/2024 Implemented
SIN-00229416 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #1's annual physical examination, completed 6/16/2023, did not include a review of the individual's previous medical history. This section was left blank on the physical form.The physical examination shall include: A review of previous medical history.Individual's previous medical history as written in the current assessment was shared with the PCP on 8/29/2023. Program Director will verify receipt and review by PCP. 08/29/2023 Implemented
2380.113(a)Program Specialist #1's biennial physical examinations were completed on 1/9/2020 and again on 1/28/2022.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Program Director met with Operations Director and Compliance/Risk Manager on 8/22/2023 and reviewed regulatory requirements for staff physicals, including internal processes, time frames for completion, and accurate use of the grace period. 08/22/2023 Implemented
2380.181(e)(4)Individual #1's annual assessment, completed 11/1/2022, did not include the individual's need for supervision at the adult training facility. The assessment only indicated individual #1's needs for supervision at home stating that the individual "can be unsupervised at home". Individual #2's annual assessment, completed 1/13/2023, did not include the individual's need for supervision at the adult training facility. The assessment only indicated individual #2's needs for supervision at home stating that the individual "can no longer be unsupervised in the home".The assessment must include the following information: The individual¿s need for supervision.The Program Director created an addendum to the assessments for both individuals. The addendums addressed the individual's need for supervision at the adult training facility, and will be shared with all ISP team members and direct support staff by 8/31/2023. 08/31/2023 Implemented
2380.39(c)(5)Program Specialist #1 did not participate in training to encompass the safe and appropriate use of behavior supports during the 7/1/2022 - 6/30/2023 training year. Direct Support Staff #2 did not participate in training to encompass the safe and appropriate use of behavior supports during the 7/1/2022 - 6/30/2023 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.All program staff have been assigned behavior supports training and will complete the training by 8/31/2023. 08/31/2023 Implemented
SIN-00210990 Renewal 09/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #3 had a physical examination completed on 2/1/21 and then again on 2/17/22.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Director/Supervisor will use ADT Annual Physical Tracking Form (to be submitted) to monitor annual physical due dates. Program Director and Supervisor will review tracking sheet during bi-weekly supervision meetings to ensure early recognition of due dates. 09/16/2022 Implemented
2380.113(c)(2)Individual #1's tuberculin skin test via Mantoux method was read with negative results on 3/26/22 by a medical assistant.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.Program Director will send a letter to all consumer medical providers regarding this regulatory requirement. The letter (to be submitted) will clarify that program regulations do not allow a Medical Assistant to administer or read the tuberculin skin test, and that medical staff who do administer and read the tuberculin skin test must be a licensed LPN, RN, CRNP, PA or physician. 09/19/2022 Implemented
SIN-00153517 Renewal 04/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1, date of admission 7/9/18 was instructed in fire safety on 7/30/18.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.Individual #1 was instructed in fire safety on 7/30/2019 as previously confirmed. Going forward, the program supervisor has created a new consumer orientation check list to ensure all requirements are completed on the first day of admission. Supervisor and operations director or their designee will review the orientation list on the first day of admission to the program and initial that all admission items are present. The Supervisor shall develop and implement a tracking system to ensure all consumers' annual fire safety requirements are completed.. [Immediately, and at least quarterly, the director of operations shall audit the aforementioned tracking system to ensure completion and all individuals are instructed in fire safety, timely. Documentation of the audits shall be kept. DPOC by AES,HSLS on 5/9/18)] 04/12/2019 Implemented
2380.111(c)(5)Individual #1, date of admission 7/9/18 had an initial Tuberculin skin testing completed on 7/30/18.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.Individual #1's TB was completed on 7/30/2019 as previously confirmed. Going forward, the program supervisor has created a new admission packet including a check list of items that need completed to ensure all requirements are completed before admission. Supervisor and operations director will review the packet and initial that all needed items are present before a new consumer is admitted into the program. The Supervisor will use the existing tracking system to ensure all individuals have physical examination including Tuberculin skin testing completed, timely. During regular supervision with the program supervisor the operations director shall routinely audit all individual's physical examinations including Tuberculin skin testing to ensure all individuals have a Tuberculin skin testing completed, as required. 04/12/2019 Implemented
SIN-00132716 Renewal 04/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)The program specialist did not sign and date Individual #1's October 2017 monthly documentation of participation and progress toward outcomes. [Repeat violation 4/26/17]The program specialist shall be responsible for the following:  Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.The Program Specialist will ensure that all monthly ISP documentation is reviewed, signed, and dated for all consumers. All consumer charts will be reviewed for compliance, signed, and dated by the Program Specialist by May 9, 2018. The Operations Director will review a sample of the monthly reviews on a minimum of a quarterly basis for the next year. [Within 15 days of receipt of the plan of correction, upon hire and as needed, the CEO or designated management staff person shall educate the program specialist(s) of the responsibilities of the program specialist position as per 2380(b)(1)-(19). Documentation of the training shall be kept. Immediately, at least monthly for 3 months and then continuing quarterly, the CEO or designated management staff person shall audit all individuals monthly documentation of participation and progress toward outcomes to ensure the program specialist is reviewing, signing and dating the monthly documentation. Documentation of the audits shall be kept. (AS 4/25/18)] 05/09/2018 Implemented
2380.111(c)(10)Individual #2's physical examination completed 2/1/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency; this section was left blank. [Repeat violation 4/26/17]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical was returned to the doctor's office on 4/9/2018 and the cited section was completed. The Supervisor will reeducate staff, families, and caretakers in regards to the necessary information required for the physical exams. The Supervisor will also make physical contact with the physician offices in our area to discuss the physical exam requirements. A contact person will be identified at each of the local offices in order to ensure the documentation is accurate and fully complete before the consumer/family leave the office. A sample of completed physicals will be reviewed by the Operations Director on a quarterly basis. [Within 15 days of receipt of the plan of correction, staff persons responsible for reviewing individuals' physical examinations shall be educated by the CEO or designee as to the requirements of individuals' physical examinations as per 2380.111(c)(1)-(11) and that required areas can not be left blank. Documentation of the training shall be kept. Immediately and within 5 days of submission, the CEO or trained designee shall audit all individuals' physical examinations to ensure all required information is included and there are not any required areas left blank and doctors orders are followed for the health and safety of the individual. Missing information shall immediately be obtained. Documentation of audits shall be kept. (AS 4/25/18)] 05/09/2018 Implemented
2380.113(c)(2)Direct Service Worker #1's most recent Tuberculin skin testing was read on 1/15/16.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.Direct Service Worker #1 received a Tuberculin skin test on April 12th 2018, with negative results. The Supervisor will utilize a new tracking system to monitor physical and TB test due dates. This will be reviewed quarterly with the Operations Director. Due dates will also be entered into an electronic tracking system that will provide advanced email alerts of due dates to both the employee and the Supervisor. [Immediately and at least quarterly for 1 year, the CEO or designee shall review all staff persons' physical examinations/Tuberculin skin testing to ensure completion, timely. (AS 4/25/18)] 04/12/2018 Implemented
2380.186(a)The program specialist completed an ISP review for Individual #1 for 4/1/17 through 6/30/17 and then for 10/1/17 through 12/31/17. [Repeat violation 4/26/17]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.The 3-month ISP reviews will be completed, signed, and dated by the Program Specialist on a quarterly basis for all consumers in the months of January, April, July, and October. The Operations Director will review a sample of the charts on a minimum of a quarterly basis for the next year. [Within 15 days of receipt of the plan of correction, upon hire and as needed, the CEO or designated management staff person shall educate the program specialist(s) of the responsibilities of the program specialist position as per 2380(b)(1)-(19). Documentation of the training shall be kept. Immediately then continuing quarterly for 1 year, the CEO or designated management staff person shall audit all individuals ISP reviews to ensure the program specialist is completing ISP reviews for all individuals. timely. Documentation of the audits shall be kept. (AS 4/25/18)] 04/20/2018 Implemented
2380.186(e)The program specialist did not notify Individual #1's plan team members 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 Program Specialist will notify the plan team members of the option to decline the ISP review documentation. The Program Specialist will update all team members at the annual ISP meetings to ensure all members have been given the option to decline the ISP review documentation. The Program Specialist will send a declination option letter to Individual #1's team member by 4/23/18.[Within 15 days of receipt of the plan of correction, upon hire and as needed, the CEO or designated management staff person shall educate the program specialist(s) of the responsibilities of the program specialist position as per 2380(b)(1)-(19). Documentation of the training shall be kept. Immediately then continuing quarterly for 1 year, the CEO or designated management staff person shall audit all individuals records to ensure the program specialist has notified all individuals' plan team members of the option to decline the ISP review documentation. Documentation of the audits shall be kept. (AS 4/25/18)] 04/23/2018 Implemented
SIN-00112871 Renewal 04/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(10)The program specialist did not review, sign and date monthly documentation for Individual #1 for the months of March 2017, December 2016, September 2016 and June 2016. The program specialist did not review, sign and date monthly documentation for Individual #2 for the months of January 2017, October 2016, July 2016 and April 2016. The program specialist did not review, sign, and date monthly documentation for Individual #3 for the months of January 2017, July 2016 and April 2016.The program specialist shall be responsible for the following:  Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.Program Specialist reviewed, signed, and dated the monthly reviews for those citations on May 9, 2017. In the future, Program Specialist will ensure that all monthly ISP documentation is reviewed, signed, and dated for all consumers. The remaining charts are being reviewed for compliance by the Program Specialist and will all be reviewed, signed, and dated by May 26, 2017. C.O.O. will review a sample of the monthly reviews at a minimum of quarterly basis for the next year. 05/26/2017 Implemented
2380.64(a)A ramp on the side of the facility does not have a handrail.Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.On 4/29/2017, Program Specialist spoke to the landlord regarding the need for a railing on the side exit. The landlord reported that the railing would be installed by 5/31/2017. Direct Care Staff will check the railing for safety/stability on a minimum of a quarterly basis for the next year. [Program specialist will ensure the landlord installs handrail on the ramp outside the facility and will follow up as necessary. Documentation of quarterly facility checks to ensure each ramp and interior stairway and outside steps exceeding two steps have a well-secured handrail shall be kept. (AS 5/19/17)]. 05/26/2017 Implemented
2380.111(a)Individual #1's most recent physical examination was completed 2-1-16. Individual #2's most recent physical examination was completed 3-31-17 and the previous examination was completed 3-11-16.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The physical in question was completed on May 3, 2017. In the future, the families will be notified via letter by the Program Specialist 3 months prior to the physical due date. C.O.O. will review a sample of physicals at a minimum of a quarterly basis for the next year. The submitted tracking document will be utilized by the Program Specilaist and staff to ensure physicals are completed on time. Program Specialist trained direct care staff on physical completion/tracking on May 6, 2017. 05/26/2017 Implemented
2380.111(c)(10)Individual #3's physical examination did 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.The physical in question was returned to the doctor's office on 4/29/17 however the office would not add additional information to the physical for it had been 6 months since it was performed. ADT Supervisor is discussing with providers the importance of completing the physicals in their entirety for all consumers. All of the providers/doctor's offices will be notified of the need for completion of all sections of the physical by May 26, 2017. C.O.O. will review a sample of physicals at a minimum of a quarterly basis for the next year. 05/26/2017 Implemented
2380.186(a)The program specialist completed a 3 month ISP review for Individual #2 with an end date of 6-30-16, and the next 3 month ISP review has a start date of 8-1-16. The program specialist completed a 3 month ISP review for Individual #3 with an end date of 6-30-16, and the next 3 month ISP review has a start date of 8-1-16.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.Compliance Officer retrained Program Specialist on the regulations on May 3, 2017. The 3-month reviews will be completed, signed, and dated by ADT Supervisor on a quarterly basis in January, April, July, and October to follow the calendar year for all consumers. C.O.O. will review a sample of the charts on a minimum of a quarterly basis for the next year. The citations in question were completed, signed, and dated by ADT Supervisor on 5/9/2017. 05/26/2017 Implemented
SIN-00092744 Renewal 04/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62The telephone numbers of the nearest police department, fire department, and ambulance were not posted on or by the telephones in the kitchen or program area of the facility. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.The list of emergency telephone numbers has been revised to include the telephone numbers of the nearest police department, fire department, and ambulance. This list will be forwarded to the licensing inspector. The list will be posted on or by the telephones in the kitchen and program areas, as well as by each telephone in the facility with an outside line. The list will be posted at the facility by Kelly Flint-Lathrop, Supervisor, before the anticipated move-in date of 5/28/16. Kelly will continue to ensure that telephone numbers are posted as required by completing regular internal site inspections and through daily observations while at the facility.[At least quarterly, internal site inspections shall be completed by the supervisor or designated staff person and documentation of the site inspections shall be kept to ensure telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are posted on or by each telephone in the facility with an outside line. (AS 4/19/16)] 05/16/2016 Implemented
2380.90(b)The exits from the facility are not visible to the individuals from the activity room, kitchen and all areas of the main program area; access to the exits were not marked with visible signs indicating the direction of travel to the exits. If the exit or way to reach the exit is not immediately visable to the individuals, access to exits shall be marked with visible signs indicating the direction of travel.An exit sign will be posted above the partition on the wall in the activity room. It will be immediately visible to the individuals and will clearly indicate the direction of travel that is needed to exit the building using the front door. The sign will be posted by Kelly Flint-Lathrop, Supervisor, before the anticipated move-in date of 5/28/16. Kelly will continue to ensure that all exits are visibly marked through completion of regular internal site inspections and daily observations. [At least quarterly, the supervisor or designated staff person shall complete site inspections and documentation shall be kept to ensure all exits that are not immediately visible are marked with a visible sign indicating the direction of travel. (AS 4/19/16)] 05/16/2016 Implemented
SIN-00192873 Renewal 09/14/2021 Compliant - Finalized
SIN-00172399 Renewal 03/12/2020 Compliant - Finalized