Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274811 Renewal 09/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(g)At time of inspection it was noted that the section to indicate that all individuals evacuated to the designated meeting area was prepopulated with a "yes" on the blank forms in the fire safety book and completed fire drills contained the same prepopulated "yes" as well. The prepopulated information should not have been entered prior to the fire drills as the information is dependent upon completion of the fire drill.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The Day Program Supervisor revised the fire drill form to remove the pre-populated outcome section. A new fire drill was run on 10/30/25. 10/30/2025 Implemented
2380.38(b)(5)Staff #4 has a hire date of 5/12/25. At time of inspection there was no documentation that Staff #4 received training on the restrictive procedure plan in place for Individual #1. The training on job related knowledge and skills necessary to provide services to Individual #1 had not been completed as required.The orientation must encompass the following areas: Job-related knowledge and skills.The Program Specialist trained staff on the RPP. 10/30/2025 Implemented
SIN-00232484 Renewal 10/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.171(b)(2)The name address and telephone number of the individual's physician or source of health care should be on the emergency record. The initial upload of the emergency records for individual #1 and #2 did not include the health care provider's name, address, or phone number. The agency did provide a corrected form at the time of request. However, it was not present on the initial documentation that was provided for the remote inspection.Emergency information for each individual shall include: The name, address and telephone number of the individual¿s physician or source of health care.After identification of noted issues, the center¿s Assistant Clinical Director, and team reviewed all individual information sheets and manually entered the relationship of the noted contact with the individual. Notification of information sheet error was also provided to the National EHR team for correction within the EHR system. 10/18/2023 Implemented
SIN-00213774 Renewal 10/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(a)The first aid area did not have a privacy screen, curtain or door across the entranceway to afford privacy to any persons utilizing the area.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.To correct the identified issue, the center extended the walled area by 12 inches to provide increase privacy, while awaiting the delivery and installation of a privacy curtain 11/30/2022 Implemented
2380.89(c)The written record for the fire drill conducted on 6/06/2022 did not document the exit route used during the drill.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.Further fire drills for the program were reviewed to identify any deficiencies. Documentation requirements were reviewed with team. 10/31/2022 Implemented
SIN-00194508 Renewal 10/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.39(c)(3)Staff #1 did not receive annual training in individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff member has completed their Individual Rights training on 10/27/2021. 10/27/2021 Implemented
SIN-00159490 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)The back door exit was locked and had cobwebs above it making it appear as if it is not used. Staff were questioned if the door is used and reported that staff and individuals did not utilize this exit.Alternate exit routes shall be used during fire drills.All egress doors/exits will be unlocked during program hours All program staff will monitor daily to maintain unobstructed exits are available for clients and staff Alert system ( door chime) will be activated to provide audible alert when exit doors are accessed 08/01/2019 Implemented
2380.113(c)(2)Staff #1's physical from 05-05-17 states he had a negative chest x-ray due to a previous positive TB test. The x-ray was negative. There is nothing in Staff #1's file indicating when or where he read positive for TB. It was discovered that the chest x-ray was done based on the staff simply stating he had a previous TB test.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.People Operations/Designee will ensure that appropriate documentation is gathered at the time of hire when X-Ray is presented in lieu of tuberculin skin test. People Operations/Designee will audit new hire files to ensure all documentation is included in file Documentation for this citation was received and forwarded to C. Hadley on 7/30/2019 08/01/2019 Implemented
SIN-00134524 Renewal 06/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.128(e)A copy of Staff #1's initial Medication Administration Training was not in her file.Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.This documentation is missing and cannot be located. All consecutive documents are available. Regular chart reviews will continue to ensure that all training documents are in the files. Staff will be required to re-take original medication training by 9/1/18. 09/01/2018 Implemented
2380.181(e)(3)(ii)This area was not assessed on Individual #1's assessment dated 10/1/2017. This information was an exact copy of the information in Individual #1's ISP.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication.Program Specialist will update current assessment to include information regarding communication. Clinical Director will add additional information to assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(4)This area was not assessment in Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in taken from Individual #2's ISP.The assessment must include the following information: The individual¿s need for supervision.Program Specialist will update current assessment to include information regarding individuals need for supervision. Clinical Director will add additional information to the assessment template to ensure that no areas are missed. 08/01/2018 Implemented
2380.181(e)(10)Individual #2's assessment dated 9/1/17 did not contain a Lifetime Medical History.The assessment must include the following information: A lifetime medical history.Program Specialist will update current assessment to include information regarding lifetime medical history. Clinical Director will add additional information to assessment template to ensure that no areas are missed. 08/01/2018 Implemented
2380.181(e)(13)(i)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Program Specialist will update current assessment to include information regarding health. Clinical Director will add additional information to assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(ii)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Program Specialist will update current assessment to include information regarding motor and communication skills. Clinical Director will add additional information to assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(iii)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Program Specialist will update current assessment to include information regarding personal adjustment. Clinical Director will add additional information to assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(iv)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialist will update current assessment to include information regarding socialization. Clinical Director will add additional information to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(v)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Program Specialist will update current assessment to include information regarding recreation. Clinical Director will add additional information to assessment template to ensure no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(vi)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Program Specialist will update current assessment to include information regarding community integration. Clinical Director will add additional information to assessment template to ensure no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(14)This area wasn't assessed on Individual #1's assessment dated 10/1/2017 & Individual #2's assessment dated 9/1/2017. This information was an exact copy of the information in both of their ISP's.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Program Specialist will update current assessment to include information regarding water safety and the ability to swim. Clinical Director will add additional information to assessment template to ensure no areas are missed in the future. 08/01/2018 Implemented
2380.181(f)Individual #2's ISP meeting was held on 9/27/2017. His assessment wasn't sent to his team members until 9/1/2017.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).Protocol will be reviewed by Clinical Director and followed by Program Specialists moving forward, ensuring that all members of the team receive the assessment 30 days prior to the ISP meeting. 07/13/2018 Implemented
SIN-00116037 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)The section pertaining to medical history in Individual #2's file was left blank.The physical examination shall include: A review of previous medical history.The recently revised physical form and procedure will continue to be implemented. All areas on the form which can be completed prior to the exam will be completed by the assigned Program Specialist. Families will be reminded to ensure the form has been totally completed with all medical information prior to leaving the physician¿s office. The Program Specialist will review the form for completeness when it is and returned and any discrepancies will be addressed by the nursing department. Target date: 8/31/17 and ongoing 09/04/2017 Implemented
2380.186(a)Individual #1 had a late quarterly. 08-02-16 to 11-28-16.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.The Program Specialist will develop a tracking system for target dates to ensure the timely completion of all quarterlies. This will be overseen by the Clinical Director. Target date: 9/15/17 and ongoing 09/15/2017 Implemented
SIN-00095650 Renewal 07/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)Staff #1 was hired on 9/14/2015. He didn't have his TB test until 9/21/2015.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.Devereux¿s HR team will continue to utilize the individual document checklist (attachment #6) to ensure that new hires complete the pre-employment requirements before the start of orientation. New hires will also receive a letter from HR reminding them to complete the pre-employment physical exam with TB screening before starting orientation. A sample of the letter sent to new hires will be submitted via e-mail as attachment #7. Effective immediately. 08/03/2016 Implemented
2380.181(a)Individual #1 was admitted to the program on 2/1/2016. Her initial assessment wasn't completed until 6/24/2016, which exceeds the required 60 days.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.When a new individual is admitted, the clinical manager and the clinical director will identify the critical dates for assessments and reviews. These dates will be added to Devereux¿s electronic data tracker. Upcoming assessments will be reviewed at the weekly clinical meetings. The clinical team will also be utilizing the ODP checklist (Attachment #5 sent via e-mail) to ensure that all reviews and assessment are completed in a timely manner. Effective immediately. 08/03/2016 Implemented
2380.186(a)Individual #2 had an ISP Review on 12/10/2015 and not again until 3/31/2016, which exceeds the required 3 months.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 clinical manager will conduct scheduled training for program specialists to determine all the due dates for the monthly, quarterly and annual assessments. A training for all program specialists was done on 8/3/16 , 9/1/16 and 9/2/16. Attachments #1, #2, #3 & #4 showing the training agenda and attendance list will be sent via e-mail. In addition, the clinical team will continue to review all ISP and the data tracker to ensure accuracy of the due dates for all reports. Effective immediately. 08/03/2016 Implemented
SIN-00077555 Renewal 08/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical dated 8/27/2013 and again on 9/18/2014. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.2380.a The Program Manager or designee will run an electronic report (profiler) one quarter in advance to see which physicals, TB or requirements will be due. The individual and/or families will be notified in writing of the due date of these requirements as well as the policy that they will not be able to attend program if these requirements are not met. The Program Manager or Designee will update this report monthly and continue to run this report monthly to check for compliance. Notifications for any continued noncompliance will be made the month of the due date by phone and admittance to the program will be denied if the requirement is not met. Target date: September 30, 2015 09/30/2015 Implemented
SIN-00253402 Renewal 10/18/2024 Compliant - Finalized
SIN-00210861 Renewal 09/09/2022 Compliant - Finalized
SIN-00061646 Renewal 04/09/2014 Compliant - Finalized