Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228734 Renewal 08/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.123(a)The label, for Novolog Flex Pen prescribed to Individual #2, was completly illegible due to be cracked, peeling and ripped and cannot be used for following medication administration procedures.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by pharmacy.A new legible label for the Novolog Flex Pan was obtained from individual's residential provider on 8/4/2023. 08/17/2023 Implemented
2380.181(f)Individual #1's assessment was completed on 12/22/2022. There was not documentation as to when the assessment was provided to the plan team; therefore, compliance could not be measured.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The assessment results letter has been amended to include the date the assessment was copied and sent out to the team. Program Specialists have been trained on this change to the results letter on 8/16/2023. A copy of the assessment results letter with this change and training verification will be included with this plan of correction. 08/17/2023 Implemented
SIN-00209339 Renewal 08/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Individual #1's physical examination completed 11/1/21, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank.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.Individual #1 will have a newly completed physical exam with her annual physical date in November by her residential provider. All sections will be reviewed at that time for completeness and correctness. The individual is within 3 months of her annual date and due to insurance reasons a new physical can not be completed until that date. Documentation of correct and complete physical exam will be forwarded 11/30/2022 Implemented
2380.111(c)(10)Individual #1's physical examination completed 11/1/21 and Individual #4's physical examination completed 6/22/22, 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.Individual #1 will have a newly completed physical exam with her annual physical date in November by her residential provider. All sections will be reviewed at that time for completeness and correctness. The individual is within 3 months of her annual date and due to insurance reasons a new physical can not be completed until that date. Individual #4 will have his current physical taken to his doctor's office by his residential provider and have the doctor review the incomplete sections and complete them, since this physical was only completed two months ago. 11/30/2022 Implemented
2380.21(u)Individuals #1, #2, #3 and #4 were no informed of the individual rights under Chapter 2380 regulations.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.The Individual Rights form that is reviewed annually with the individuals at the ATF following the 2380 regulations was updated by Director and compliance officer on 8/10/2022. This for was reviewed with individuals #2, #3, and #4 by the program specialist on 8/10/2022., documentation of the review was obtained. Individual #1 had the updated form reviewed with her on 8/15/2022 by the program specialist as that is her regular attendance day, documentation was obtained. The program specialist also completed training for all ATF staff on the updated individual rights form on 8/10/2022, documentation was obtained. All documentation will be forwarded. 08/31/2022 Implemented
2380.36(b)Direct Service Worker #1 had training in general fire safety 7/21/2020 and then again on 3/15/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Direct Service Worker #1had training by a fire safety expert on 7/7/2022. Documentation of the training will be forwarded. 08/31/2022 Implemented
2380.39(c)(3)Direct Service Worker #2 did not receive training in Individual Rights during training year 7/1/21 through 6/30/22.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Direct Service Worker #2 had training completed on the newly updated individual rights form on 8/10/2022. Documentation of this training will be forwarded. 08/31/2022 Implemented
SIN-00133812 Renewal 04/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1, date of admission 1/22/18 did not have an initial assessment. Individual #2, date of admission 1/19/18 did not have initial assessment.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 assessment was completed on April 30, 2018. Moving forward, the program specialist will use a chart with due dates to ensure the completion of an assessment within 60 calendar days, The Program Administrator will review this chart monthly for compliance. [Within 15 days of receipt of the plan of correction, the CEO or designated management staff person shall educate the program specialist(s) of the responsibilities of the position as per 2380.33(1)-(19). Documentation of the training shall be kept. Documentation of the aforementioned monthly reviews of tracking chart shall be kept. (AS 5/11/18)] 04/30/2018 Implemented
SIN-00095685 Renewal 06/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Direct Service Worker #1, date of hire 4/24/15, was not provided orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility. The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.The pre-service and orientation forms for Direct Service Worker #1 have been located as they were misfiled. The Adult Training Facility Director was on vacation during the licensing inspection and he had filed them in his file cabinet when filling in for the Program Specialist in Aptil and May 2015, completing the final document needed for Worker #1 within thirty days of her hire date 04/24/2015.. Effective June 22, 2016, the Program Specialist will complete Pre-service and Orientation forms for all new hires and forward them to the Program Manager for verification of completion and timeliness. The Program Manager will train new employees if the Program Specialist is unavailable. A checklist will be maintained by the Program Manager to ensure the forms are completed within the required timeframe.. The Program Manager will create a file for storage of these documents and will mark the folder "Complete" when all documents are accounted for. Training files will be reviewed by the Program Manager within three months of our license expiration with the completion of an inspection scoresheet to verify accuracy in accordance with 2380.36 and reviewed again within two weeks of the licensing inspection to verify all documents are accounted for. The Program Director will review all licensing inspection scoresheets and approve plans for bringing areas of non-compliance into compliance with the regulations. All three Adult Training Facility management personnel will be trained on this procedure by the Executive Director on Wednesday, June 22, 2016, and will sign a Training Verification form to verify they understand the process to remain in compliance with the regulation requirement.. Once the training has been completed, copies of the Pre-service and Orientation forms for Direct Service Worker #1, along with training verification of this new process will be forwarded to substantiate the Plan of Correction. 06/22/2016 Implemented
SIN-00074472 Renewal 05/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(1)Individual #1's assessment, dated 10-09-14, did not include the strengths and needs of the individual. Individual #2's assessment, dated 7-15-14, did not include the strengths and needs of the individual. Individual #3's assessment, dated 3-13-15, did not include the strengths and needs of the individual. Individual #4's assessment, dated 8-29-14, did not include the strengths and needs of the individual.The assessment must include the following information: Functional strengths, needs and preferences of the individual.The assessment document will be changed to include functional strengths, needs, and preferences of each individual. This form will be used beginning 07/01/2015. All staff will be trained on the use of the assessment and verification will be forwarded. A copy of the assessment and an example of its use will be forwarded for proof of completion.[CEO or designees will immediately update the assessments for Individuals' #1, #2, #3 to include strengths and needs. All Individuals assessments will be reviewed and strengths and needs of the individuals will be added to the assessments if needed. (AS 6/23/15)] 06/30/2015 Implemented
2380.186(a)The most recent three month ISP review completed for Individual #2 had an ending date of 5-19-15. The previous review had an ending date of 2-02-15.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 Director and the Program Specialist will create and use a chart to track due dates for ISP three month reviews to make sure the review is completed for each individual within the required time frame. The chart will be updated monthly as ISP's occur. A copy of this chart will be forwarded as proof of completion. 06/30/2015 Implemented
SIN-00192362 Renewal 09/02/2021 Compliant - Finalized
SIN-00176966 Renewal 10/02/2020 Compliant - Finalized
SIN-00154261 Renewal 04/25/2019 Compliant - Finalized
SIN-00114498 Renewal 05/25/2017 Compliant - Finalized
SIN-00092566 Renewal 06/03/2016 Compliant - Finalized
SIN-00056560 Renewal 06/02/2014 Compliant - Finalized
SIN-00044081 Renewal 01/16/2013 Compliant - Finalized