Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00275558 Renewal 10/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(iv)The individual record shall include the individual's religious affiliation. This area of the document reflects unknown.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The Director of Admissions corrected the individual record for individual L.W. to reflect the correct religious affiliation on 10/13/25. Copy will be forwarded. 10/20/2025 Implemented
SIN-00253400 Renewal 11/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical examination dated 3/5/24 did not include medical information pertinent to diagnosis and treatment in case of an emergency as this section of the exam was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical evaluation has been updated and the emergency section has been completed. Completed on 11/19/2024. 11/20/2024 Implemented
SIN-00232486 Renewal 10/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The current annual assessment for Individual #1 was not provided to the support coordinator and team members at least 30 days prior to the individual plan meeting. The individual plan meeting for Individual #1 was held on 6/01/2023 and the annual assessment for the individual was not completed until 6/08/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Assistant Clinical Director reviewed regulatory standards regarding annual assessments with the center¿s clinical on 11/08/2023. 11/08/2023 Implemented
SIN-00158603 Renewal 07/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Modge Podge spray, which contains acetone and is labeled "contact poison control if ingested," was found unlocked, accessible and not in use in the main program area.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Item was removed immediately upon discovery. Assistant manager/Designee will lock up any potential poisons in storage cabinet. Assistant Manager/Designee will check craft supplies storage cabinet daily to ensure that no potential hazardous materials are unsecured. 07/30/2019 Implemented
SIN-00146884 Unannounced Monitoring 11/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16The ISP for Individual #1 states that Individual #1 should be supervised during meals as Individual #1 is a choking risk. On 10/31/18, Individual #1 was attending a party at the adult training facility. Cupcakes were being served to the attendants. Individual #1 was able to access a cupcake of another individual attending the party. This cupcake was not prepared to Individual #1's dietart needs. Staff report that Individual #1 was not being monitored properly at the time of the incident which resulted in Individual #1 choking. Neglect occurred as Individual #1 was not being monitored according to the ISP.This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview 1. An internal investigation occurred and appropriate HR action was taken. Staff will be re-trained on appropriate supervision of individuals by Operations Manager by January 4, 2019. 2. Operations Manager will review the hand-off/supervision procedures with all staff at Links South by January 4, 2019 and then semi-annually in monthly IDT meetings. All reviews will be documented. Assistant Executive Director will be attending the January IDT meeting to emphasize the importance of both procedures. 3. An increase in drop-ins will occur at meal times by clinical and leadership staff to ensure Links South staff are following supervision procedures during meal/snack times. Observations from drop-ins will be documented. The first observation took place by the Assistant Executive Director at snack time on 12/28/18. 01/04/2019 Implemented
SIN-00134523 Renewal 06/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)There was no lifetime medical included in Individual #1's or Individual #3's assessments. The section was left blank in both assessments. Under the section for Lifetime Medical History in Individual #2's file, it stated Medical history is unremarkable. However, in the individual's physical, it states she does have some medical issues such as allergies.The assessment must include the following information: A lifetime medical history.Current assessment will be updated by Program Specialist to include information regarding lifetime medical history, and information on allergies will be added to the appropriate place. Clinical Director will be responsible to make sure additional information is added in the assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(11)Individual #4's current psychological evaluation was not included with his assessment, nor was it addressed in the assessment.The assessment must include the following information: Psychological evaluations, if applicable.Protocol moving forward will ensure that the Program Specialist will forward the psychological evaluation every year with the assessment. Information from the psychological evaluation will be addressed in the assessment annually and will note any changes in the psychological evaluation. Clinical Director will review this protocol with all Program Specialists. 07/13/2018 Implemented
2380.181(e)(13)(i)There was no progress or lack thereof in Individual #2's assessment in the area of health. It only listed current status.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 the assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(ii)There was no progress or lack thereof in Individual #2's assessment in the area of motor/communication skills. It only listed current status.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 in the assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(iii)There was no progress or lack thereof in Individual #2's assessment in the area of personal adjustment. It only listed current status.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 the assessment to ensure no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(iv)There was no progress or lack thereof in Individual #2's assessment in the area of socialization. It only listed current status.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 assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(v)There was no progress or lack thereof in Individual #2's assessment in the area of recreation. It only listed current status.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 the assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.181(e)(13)(vi)There was no progress or lack thereof in Individual #2's assessment in the area of community integration. It only listed current status. It was also not addressed in Individual #4's assessment anywhere.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 the assessment template to ensure that no areas are missed in the future. 08/01/2018 Implemented
2380.184(a)(1)(ii)Individual #3's date of admission to the program was 06/07/17. The ISP meeting was held on 09/25/17. The program specialist did not attended the ISP meeting.The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision). A plan team must include as its members the following: A program specialist or family living specialist, as applicable, from each provider delivering a service to the individual.Program Specialist will communicate the importance of Devereux's involvement in the ISP meeting to the school and Supports Coordinator to ensure we are invited to future ISP meetings. ((Program Specialist will ensure an assessment is sent to the ISP team. The Program Specialist will send to the ISP team recommendations on outcomes, specific areas of training, and the health and safety needs of the individual while attending the Adult Training Facility. The Program Specialist will review the ISP and ensure that all pertinent information to the Adult Training Facility is included. The Program Specialist will request any necessary corrections or updates to the ISP in writing to Supports Coordination or the Plan Lead, as applicable. -CH 6/29/2018)) 07/15/2018 Implemented
SIN-00116036 Renewal 07/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #2 had fire safety training on 4/1/2016. Individual #2 did not have fire safety training in 2017.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 #2 was provided with fire safety training. (Please see attachment #3). The Operations Manager and or delegated staff member will ensure develop a tracking system/report to ensure that all individual are trained annually. This system will capture absenteeism. 07/14/2017 Implemented
2380.111(c)(2)This section wasn't included on Individual #4's physical exam. The physical examination shall include: A general physical examination.The Director of Nursing identified areas that should be included in the General Physical Exam and they have been added to the current template on 7/11/17. (Please see attachment 2). 07/11/2017 Implemented
2380.111(c)(4)This section wasn't on the physical exams for Individual #1, Individual #2, Individual #3, and Individual #4.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The Director of nursing has revised the current template on 7/11/17 for the General Physical Exam to include vision and hearing screening and will review all physicals for completeness. Please see attachment #2 as noted above. 07/11/2017 Implemented
2380.111(c)(7)Need for bloodwork wasn't on the physical exam for Individual #4.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The Director of Nursing revised the template on 7/11/17 for the General Physical exam to include assessment of health maintenance needs, medication regimen and need for blood work at recommended intervals. Please see attachment 2 as noted above. 07/11/2017 Implemented
2380.111(c)(10)This section was left blank by Individual #1's doctor on her physical exam. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Director of Nursing revised the physical form to include medical information pertinent to diagnosis and treatment in case of emergency. Additionally, all physical exams will be reviewed by the nursing department for completeness. Please see attachment #2 as noted above. 07/11/2017 Implemented
2380.181(e)(12)This area wasn't evaluated on Individual #2's assessment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The Devereux integrated assessment will be implemented at the Links south program which will include vocational and training recommendations. This will begin to be implemented at the individuals next annual assessment date to be rolled out over the next 12 months 07/24/2017 Implemented
SIN-00101214 Renewal 07/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual 1s physical dated 9/21/2015 states, "see attached" in the medical history section. However, there is no attachment to the physical. The physical examination shall include: A review of previous medical history.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter will be submitted by 10/31/16 as attachment #02. Devereux nurses under the direction of the director of nursing as well as the program specialists will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately 10/31/2016 Implemented
2380.111(c)(10)Individual 1s physical dated 9/21/2015 was blank in the area of information pertinent to diagnosis in case of emergency. Individual 3s physical dated 5/6/2016 was blank in the area of information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter will be submitted by 10/31/16 as attachment #02. Devereux nurses under the direction of the director of nursing as well as the program specialists will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately. 10/31/2016 Implemented
2380.111(c)(11)Individual 1s physical dated 9/21/2015 was blank in the area of special diet instructions. The physical examination shall include: Special instructions for an individual's diet.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter will be submitted by 10/31/16 as attachment #02. Devereux nurses under the direction of the director of nursing as well as the program specialists will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately. 10/31/2016 Implemented
2380.173(1)(iv)Individual 4s record was left blank in the area of religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.Devereux¿s identification document has a section for `religious affiliation.¿ The clinical director reviewed this document with the program specialists on 8/3/16. The program specialists were reminded to complete all sections of the identification document. Religious affiliation has been added to individual 4¿s identification card (see attachment # 01.) The Clinical director and quality management director will continue to do random audits of the consumers¿ charts to ensure that all sections are completed accurately and in a timely manner. Effective immediately. 08/03/2016 Implemented
2380.181(a)Individual 2s annual assessment was completed on 7/16/2014 and not again until 8/11/2015 (25 days late). Individual 4s annual assessment was completed on 4/21/2015 and not again until 5/21/2016 (1 month late). 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.The clinical manager met with all program specialists on 8/3/16 and 9/1/16, to determine the due dates for monthly, quarterly and annual assessments and create a data tracker. 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. 09/01/2016 Implemented
2380.186(c)(2)Not all areas of the ISP, pertaining to the 2380 program are being covered within the agency's ISP reviews. The ISPs for individuals 1, 2, 3, and 4 all contain information regarding the outcomes established and progress on the outcomes and medical information. However, the ISP reviews do not contain information regarding behavioral or safety areas that affect the services provided to the individuals at the program. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The program specialists have been using the ODP ISP checklist to ensure that each section of the ISP is being reviewed during the monthly, quarterly and annual assessments. This requirement was reviewed with the program specialist on 8/3/16. The Clinical director and quality management director will do random audits of the consumers¿ charts to ensure that all sections are completed accurately and in a timely manner. Effective immediately. 08/03/2016 Implemented
SIN-00095648 Renewal 06/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Direct Service Worker (staff 1) did not have 24 hours of training for the calendar (training) year of 2015. Staff 1 had 21.25 hours for 2015. Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.Managers will continue to review upcoming and mandatory staff training requirements during the monthly team meetings. Progressive disciplinary action will be taken for staff who do not comply with the training requirements. Individual feedback to staff #1 was done on 6/16/16 due to failure to meet training requirement. 09/16/2016 Implemented
2380.89(d)Individual 6 was unable to evacuate the building during the fire drill on 5/26/2016 at 11:58am. This individual refused to evacuate due to significant arthritis pain on this date. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Individual 6 was unable to evacuate the building during the fire drill on 5/26/16 due to arthritis pain. This individual has been able to evacuate the building during fire drill every month since then. Fire drill reports for June, July and August 2016 will be submitted via e-mail as attachment 4, 5 and 6 respectively. Individual 6 is scheduled to have hip replacement on 9/27/16 due to severe chronic arthritis. 09/16/2016 Implemented
2380.111(c)(10)Individual 2's physical dated 1/27/2016 was left blank in the area of information pertinent to diagnosis in the case of emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter (attachment #3) will be submitted by 10/31/16. Devereux nurses under the direction of the director of nursing will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately. 10/31/2016 Implemented
2380.111(c)(11)Individual 1's physical dated 3/23/2016 had a blank in the area of special diet instructions. The physical examination shall include: Special instructions for an individual's diet.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter (attachment #3) will be submitted by 10/31/16. Devereux nurses under the direction of the director of nursing will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately. 10/31/2016 Implemented
2380.173(1)(ii)Individual 4's record does not contain information on identifying marks. The identifying marks field was left blank in her 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.Devereux¿s identification document has a section for `identifying marks.¿ The clinical director reviewed this document with the program specialists on 6/15/16. The program specialists were reminded to complete all sections of the identification document. The Devereux¿s identification card (attachment #2) will be submitted via e-mail. Clinical director and quality management director will do random audits of the consumers¿ charts to ensure that all sections are completed accurately and in a timely manner. Effective immediately. 06/15/2016 Implemented
2380.183(1)Individual 4's ISP was not revised when her needs and services changed on 3/30/2016. Individual 4 stopped attending the Devereux Links program in March of 2016. She began to attend Devereux Clubhouse on 3/30/2016 however, there was no change made to her ISP nor was an ISP review completed to indicate the change in her needs and services. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual¿s plan team.The Clinical team will ensure that ISP revision is completed when an internal transfer happens. The clinical director will monitor internal transfers and coordinate meetings with team members including the supports coordinator to revise the ISP. This is effective immediately. The admission and transfer checklist will be modified to add a section for ISP revision for internal transfers. The modification of the checklist will be completed by 10/31/16. This will be submitted as attachment #1. 10/31/2016 Implemented
SIN-00077525 Renewal 07/31/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.69(d)The 2 single, private bathrooms were recently made into 2 unisex bathrooms instead of one restroom for the men and one restroom for the women. These 2 unisex bathrooms are the only bathrooms in the program. If the facility serves 18 or more individuals at one time, there shall be separate bathrooms for men and women.The two restrooms at the facility had initially been a men's restroom and a woman's restroom but were recently changed due to the center wide initiative to become culturally competent including working with LGBTQ individuals. Due to the regulatory requirements, the restrooms were changed back to an individual men's restroom and a woman's restroom on the day of inspection as witnessed by the inspector on July 31st and will remain so. Implemented
2380.91(a)On 10/27/2014, Individual #1 was admitted to the program. However, Individual #1 received fire safety training on 11/13/2014.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.A new client admission checklist has been developed to be used by all managers (or designee) for new admission/transfers to ensure all items related to new admissions/transfers are completed within required time frames, including instruction in fire safety. (please see attachment A). Target date 9/1/15 09/15/2015 Implemented
SIN-00212596 Renewal 10/20/2022 Compliant - Finalized
SIN-00194509 Renewal 10/21/2021 Compliant - Finalized
SIN-00047917 Renewal 05/24/2013 Compliant - Finalized