Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00212774 Renewal 11/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(b)-2The monthly fire alarms check that occurred on 1/21/22 did not document whether or not the alarm was operative.A written record shall be kept showing the date checked, the name of the person checking the alarm and whether or not the alarm was operative.The Program Manager will educate the program¿s Facilities staff on monthly alarm testing. Since the program completes fire drill monthly the alarms are always tested, January 2022, we did not complete one due to the bitter cold. 12/30/2022 Implemented
2390.87Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety. Staff #1 received fire safety training on 3/29/21 and then not again until 6/2/22. Staff #2 received fire safety on 11/16/2020 and then again on 4/6/22. Staff #3 received fire safety training on 11/4/2020 and then again on 5/5/22. This exceeds the requirement. Individual #4 received fire safety on 6/1/21 and then not again until 7/22. This exceeds the requirement.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The Program Manager will ensure all employees will have annual fire safety training upon hire and annually thereafter and ensure the training falls in the calendar year, not fiscal training year. 01/01/2023 Implemented
2390.104(4)Individual #1's record did not contain medical information pertinent to diagnosis and treatment in case of emergency.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.All individuals will have their emergency forms updated to include any support needed to be offered for an emergency pertaining to ones diagnosis. 01/02/2023 Implemented
2390.21(u)The facility shall inform and explain client rights and the process to report a rights violation to the client, and persons designated by the client, upon admission to the facility and annually thereafter. Individual #1, Individual #2, and Individual #4's Clients rights did not have a date on them. There is no way to know when they were signed by the individuals.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.All individuals will receive their client rights training upon admission to the program and annually thereafter. 01/02/2023 Implemented
SIN-00158471 Renewal 07/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)None of the six individual files reviewed have current assessments. Individual #1 was admitted on 01-07-19 and he has no current assessment. Individual #2's last assessment is from 12-15-17. Individual #3's last assessment is from 01-09-18. Individual #4's last assessment is from 11-09-17. Individual #5's assessment is from 01-08-18. Individual #6 was admitted on 01-03-19 and he has no current assessment.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.For the six individuals that were identified having missing assessments have been completed. An audit was performed on the remaining books and all assessments have been completed.. The Program Specialists will be responsible for filling out a new assessment for all newly hired employees by the first 60 days of employment and then continue to assess annually thereafter. To prevent future missing assessments, the Program Director will be responsible for completing quarterly quality assurance checks. The Vocational assessment piece will be added to the QA checklist form used for all book audits throughout the year. 08/16/2019 Implemented
SIN-00135557 Renewal 07/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(a)The fire alarm was not audible in the warehouse area off the main work floor.There shall be an operable fire alarm that is audible throughout the facility.The facility added an alarm with audio and strobe light to the area off of the main work floor. Responsible party- Director of Operations 07/12/2018 Implemented
2390.153(5)Individual #1 and Individual #2 are currently taking medication prescribed to treat the symptoms of a diagnosed psychiatric illness an there is no protocol to address the social, emotional and environmental needs of the client.A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Individuals #1 and #2 have the Social, Emotional, and Environmental plan added to their files as of 7/20/18. The Program Specialists will create a list of individuals that are prescribed psychotropic medications. The list will be reviewed quarterly by the Program Specialists and the Director of Operations to ensure all SEE plans are on file. The facility implemented a social, emotional, and environmental plan for ALL individuals that are prescribed psychotropic medications. The facility made proper notification to each individuals Supports Coordinators for this information to be added in the individuals current ISP. Responsible party- Program Specialist and Director of Operations 07/23/2018 Implemented
2390.156(a)The most recent review of the ISP in the record for Individual #3 was dated 12/11/17. 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.At the time of licensing inspection individual #3 was missing a quarterly ISP from the file. The meeting was held on March 27th, 2018 and has since been placed in individual #3's file and is currently up to date as of 7/5/18. To prevent future ISP meetings from being missed and or late, the facility will establish a schedule that will highlight all clients' quarterly ISP reviews to be held in the quarter. The schedule will include the clients' name, date to be held, and Program Specialist assigned to the client. The Program Specialist and the Director of Operations will review the schedule quarterly. Responsible party- Program Specialist and Director of Operations. 07/24/2018 Implemented
SIN-00116044 Renewal 07/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Annual assessments for Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, and Individual #6 did not include the following areas: Likes, dislikes, interests; Communication; Personal adjustment; Personal needs activities; Supervision; Ability to sel-administer meds; Ability to safely use or avoid poisonous materials; Ability to sense and move away from heat sources quickly; Ability to evacuate in the event of a fire; Recommendations for training; Health; Motor skills; and Socialization.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.Development and use of a visual tool packet to serve as a guide to complete a Work Services Vocational Assessment for each consumer upon admission and annually thereafter. Program Specialist's received a guide and personal training on its use on August 2, 2017 from a partner 2390 provider. 08/02/2017 Implemented
2390.156(a)Individual #1 had ISP Reviews done on 9/19/16, 12/12/16, 4/4/17, and 6/14/17. The timeframe between 12/12/16-4/4/17 exceeds the 3 month requirement. 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.It is the policy of the Burnley Workshop to complete reviews based on the team input at a meeting. The Program Specialist did not complete the three month review until a meeting could be held due to the severe illness of individual #1's mother/guardian. The POC is a change in policy that the review will be completed every three months with the consumer only. 08/02/2017 Implemented
SIN-00095647 Renewal 09/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.101 Staff 1 was hired on 1/21/2016 without any documentation of her communicable disease status. Staff 2 was hired on 12/1/2006 without any documentation of his communicable disease status. Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician.An "Employee Physical Addendum" form for the examining physician to "certify that the employee is free of contagious disease" .is available. This form was not available at the time of hire for staff 2. All staff are required to have return to work slips signed by the physician whenever symptoms are evident. This statement must be on that form. The employee supervisor, company health care nurse and Director will do ongoing monitoring to collect this documentation. 10/11/2016 Implemented
SIN-00080025 Renewal 07/30/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The ceiling of the workshop has a spray foam insulation that has fallen off in several places. The foam insulation that remains on the ceiling is covered with a thick layer of dust and dirt.  Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Burnley Workshop understands that the foam insulation on the ceiling is an issue and has already contracted with engineers and roofing consultants to determine the best solution to the issue. The following items outline what has been done to date regarding the issue as well as the plan to correct the issue: Insulation material was tested by Cocciardi associates and the material was found to be 75% cellulose and 25% non-fibrous other materials. Sample was no detect for asbestos containing fibers. Hemmler & Camayd Architects/HAS Engineers were contracted to perform a structural analysis of the building to determine if a drop ceiling could be constructed over the workshop production area. Based on Hemmler & Camayd's analysis, the roof structure could not support the installation of a drop ceiling. Mark J. Sobeck Roof Consulting Inc. was contacted to discuss roof insulation options. The company was hired to perform roof consulting services which include: meet with proposed contractors, review proposals, prepare roof inspection report and make recommendations for repairs based upon proposals and preventative maintenance. The plan of correction to remove existing cellulose insulation and install new fiberglass insulation at underside of roof. One contractor bid has been submitted to remove cellulose insulation and install new fiberglass insulation at underside of roof. A second bid is expected by September 10th. Additional bids are expected. Review of bids is expected to occur in September/October. Contractor award is expected to occur by end of October. Once a contractor is selected, plans for permits will be submitted. Permit process time frame is unknown and could delay the project. Project is expected to take several months to complete. The plan is for work to be completed by June 30, 2016. This is a target date as there are many unknowns that could affect the completion of this project. Until project is fully complete, daily inspections of the ceiling will be performed by maintenance personnel to determine loose insulation. Any loose insulation will be removed immediately. 06/30/2016 Implemented
2390.111(b)-1Individual #1 had a preadmission interview on 5/1/2014, but was not notified of her acceptance into the program until 4/14/2015. No formal notification of placement was made until this letter on 4/14/15. Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. Of the three admissions viewed by the inspector, Program Specialist notified one new person verbally that they were accepted for admission upon approval of waiver funding. Program Specialist sent the letter of admission when a start date was in place therefore violating 2390.111(b)(1) Program Specialist's reviewed the regulations and the checklist system developed to ensure compliance on August 11, 2015 08/11/2015 Implemented
SIN-00231610 Renewal 11/20/2023 Compliant - Finalized
SIN-00192054 Renewal 11/02/2021 Compliant - Finalized
SIN-00062771 Renewal 04/17/2014 Compliant - Finalized
SIN-00050076 Renewal 04/23/2013 Compliant - Finalized