Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238782 Renewal 02/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(b)-1There are no monthly fire alarm checks completed in June or July 2023.An employe trained in the operation of the equipment shall check the fire alarm monthly. Monthly Reminder added to Executive Director's Outlook Calendar and added visual test date box added to our monthly Safety, Health, and Wellness Checklist. 03/12/2024 Implemented
2390.87Training documented on 6/8/2023 for Staff #1 & Staff #2 is titled "Staff Meeting and Fire Extinguisher Training". This training does not identify if staff were trained in general fire safety.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.Training Documentation will revert to the previous method of cataloging ALL employees training hours instead of just printing the required ODP Training Certificates. (See Supporting Documentation Email.) 03/12/2024 Implemented
2390.104(3)The cover sheet for individual #3 dated 4/19/22 does not have a signature for consent for medical treatment.Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Written consent from the client, parent or guardian for emergency medical treatment.All Cover Sheets have been updated to include this required information. 03/12/2024 Implemented
2390.124(3)Individual #1's record does not indicate the name and telephone number of a physician or source of health care.Each client's record must include the following information: The name and telephone number of a physician or source of health care.All Cover Sheets have been updated to include this required information. 03/12/2024 Implemented
2390.124(4)Individual #1's record does not have written consent from the client, parent, or guardian for emergency medical treatment. The form was last signed on 10\24\2022 by the individual's mother, who is now deceased, and a new form has not been updated.Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment.All Cover Sheets have been updated to include this required information. 03/12/2024 Implemented
2390.40(a)Staff #1 completed training titled, "Review of Annual ODP Training Requirements" on 2/20/2023. The record of this training does include the length of training.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Training Documentation will revert to the previous method of cataloging ALL employees training hours instead of just printing the required ODP Training Certificates. (See Supporting Documentation Email.) 03/12/2024 Implemented
2390.40(a)Staff #2 completed training titled, "Review of Annual ODP Training Requirements" on 2/20/2023. The record of this training does not include the length of training.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Training Documentation will revert to the previous method of cataloging ALL employees training hours instead of just printing the required ODP Training Certificates. (See Supporting Documentation Email.) 03/12/2024 Implemented
2390.153(a)(3)The ISP signature sheet for Individual #3 dated 11/1/23 does not include documentation that a DSP contributed to the development of the plan. While staff indicated that DSP's were included in the assessment process, there is no documentation of this.The individual plan shall be developed by an interdisciplinary team, including the following: The client's direct care staff persons. Senior Program Specialist added a section to the assessment document to include "Additional Contributors" Signature Pages that allows DSPs to sign off on their contributions to ISP development. (See Supporting Documentation Email.) 03/12/2024 Implemented
2390.153(a)(3)Individual #2's ISP annual meeting held on Mach 23, 2022 did not include a direct service worker who works directly with the client or provide documentation that the direct service worker provided feedback.The individual plan shall be developed by an interdisciplinary team, including the following: The client's direct care staff persons. Senior Program Specialist added a section to the assessment document to include "Additional Contributors" Signature Pages that allows DSPs to sign off on their contributions to ISP development. (See Supporting Documentation Email.) 03/12/2024 Implemented
2390.153(a)(3)There was no documentation showing that a direct service worker contributed to individual #1's ISP plan meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The client's direct care staff persons. Senior Program Specialist added a section to the assessment document to include "Additional Contributors" Signature Pages that allows DSPs to sign off on their contributions to ISP development. (See Supporting Documentation Email.) 03/12/2024 Implemented
SIN-00219758 Renewal 02/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(a)The ODC Safety Policy Evacuation Plan lists 1048 N. Plum Street Lancaster as the Emergency Shelter Location. This building is currently empty as the previous tenant is no longer conducting business at that address. An Emergency Shelter is a physical location that provides shelter from the elements, and the provider does not have access to this building. The Evacuation Plan needs to be updated with a new Emergency Shelter Location.Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.The Evacuation Procedures Document was updated to the following: Evacuation Procedures For actual emergencies including natural disaster emergencies STAFF RESPONSIBILITIES Evacuate all staff and employees using the closest and safest evacuation route. Call `911. Close all doors turn off lights. Check bathrooms. Obtain all prescription medications from the First Aid Room; obtain the Emergency Safety Protocol Books and Attendance Clipboard. Assemble all staff and employees on the paved area in front of the storage shed (alternate location on grass by the fence across the driveway from the warehouse). Supervisors are responsible in aiding the evacuation of folks in their work areas. Account for all staff and employees. If necessary, remove all staff and employees to designated shelter. We will walk to: SHELTER: Weber Advertising 533 Janet Ave. (717) 299-1277 Transportation from the shelter shall be coordinated by the Executive Director and/or PSs. 1) Families/Providers will be notified to pick up their son/daughter/resident at shelter. 2) Public transportation system and residential facilities will be notified of need for transportation, pick up location and changes in transportation schedule. PARTICIPANT RESPONSIBILITIES 1) Remain with the group and follow all staff instructions. 2) Do not leave the group unless you are officially dismissed by ODC staff. 03/01/2023 Implemented
2390.21(b)Individual # 2 has not participated in client rights training for more than 2 years.The facility shall educate, assist and provide the accommodation necessary for the client to understand the client's rights.The Program Participant Orientation Checklist has been updated to the following: Employee Orientation Checklist Occupational Development Center Name ________________________________________ Date________________________ __________ Explanation of the admissions process. __________ Explanation of the organization, job assignments and job expectations. __________ Completion of the I-9, W-4, LCTCB and Local Tax forms __________ Resources for OVR Section 511 form __________ Worker¿s Compensation, Workers Comp Rights and Duties and Annually Signed Client Rights Forms __________ Discuss timeframe for Initial Assessment meeting __________ Present Participant Handbook. Encourage reading and review contents. Explain the following: a. attendance days, daily work hours b. absence and late policy, when and whom to call, consequences c. sick leave, holidays, vacation policy d. weather closings e. use of cafeteria, break and lunch schedule f. pay frequency /method of pay g. CPS/SGE h. telephone use policy/smoking areas i. disciplinary policy, rules/regulations, rights, grievance policy __________ Explain safety rules: a. reporting of all accidents to staff b. dispensing of medications c. general safety rules, evacuation procedures, fire drills, fire safety training upon admission and annually thereafter ___________ Explanation of Programming: a. quarterly reviews b. ISPs ___________ Tour of facility a. office area b. cafeteria, rest rooms, first aid room c. work areas ¿ introduction to staff d. point out exits, van pick up/drop off area e. smoking area f. introduction to supervisor/workstation This is to verify that the above items have been discussed and that I have received a copy of the Program Participant Handbook, Workers Comp Information, Rights & Duties Information, Client Rights, Section 511 Resources, Grievance Policy, Holiday Schedule and Weather/Closing Information. __________________________________________ _________________________ Employee Signature Date 03/28/2023 Implemented
2390.21(u)Individual #1 signed the rights form 4/22/21 and then not again until 9/15/22. Individual #2 does not have a current signed rights form. Information provided indicates the last form was signed more than 2 years ago. Individual #4 signed the rights form 5/24/21 and then not again until 9/15/22.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.The Program Participant Orientation Checklist has been updated to the following: Employee Orientation Checklist Occupational Development Center Name ________________________________________ Date________________________ __________ Explanation of the admissions process. __________ Explanation of the organization, job assignments and job expectations. __________ Completion of the I-9, W-4, LCTCB and Local Tax forms __________ Resources for OVR Section 511 form __________ Worker¿s Compensation, Workers Comp Rights and Duties and Annually Signed Client Rights Forms __________ Discuss timeframe for Initial Assessment meeting __________ Present Participant Handbook. Encourage reading and review contents. Explain the following: a. attendance days, daily work hours b. absence and late policy, when and whom to call, consequences c. sick leave, holidays, vacation policy d. weather closings e. use of cafeteria, break and lunch schedule f. pay frequency /method of pay g. CPS/SGE h. telephone use policy/smoking areas i. disciplinary policy, rules/regulations, rights, grievance policy __________ Explain safety rules: a. reporting of all accidents to staff b. dispensing of medications c. general safety rules, evacuation procedures, fire drills, fire safety training upon admission and annually thereafter ___________ Explanation of Programming: a. quarterly reviews b. ISPs ___________ Tour of facility a. office area b. cafeteria, rest rooms, first aid room c. work areas ¿ introduction to staff d. point out exits, van pick up/drop off area e. smoking area f. introduction to supervisor/workstation This is to verify that the above items have been discussed and that I have received a copy of the Program Participant Handbook, Workers Comp Information, Rights & Duties Information, Client Rights, Section 511 Resources, Grievance Policy, Holiday Schedule and Weather/Closing Information. __________________________________________ _________________________ Employee Signature Date 03/28/2023 Implemented
2390.21(v)At the time of the inspection, there wasn't a current copy of a signed statement acknowledging the receipt of the information on client rights available for individual #2.The facility shall keep a copy of the statement signed by the client or the client's court-appointed legal guardian, acknowledging receipt of the information on client rights.The Program Participant Orientation Checklist has been updated to the following: Employee Orientation Checklist Occupational Development Center Name ________________________________________ Date________________________ __________ Explanation of the admissions process. __________ Explanation of the organization, job assignments and job expectations. __________ Completion of the I-9, W-4, LCTCB and Local Tax forms __________ Resources for OVR Section 511 form __________ Worker¿s Compensation, Workers Comp Rights and Duties and Annually Signed Client Rights Forms __________ Discuss timeframe for Initial Assessment meeting __________ Present Participant Handbook. Encourage reading and review contents. Explain the following: a. attendance days, daily work hours b. absence and late policy, when and whom to call, consequences c. sick leave, holidays, vacation policy d. weather closings e. use of cafeteria, break and lunch schedule f. pay frequency /method of pay g. CPS/SGE h. telephone use policy/smoking areas i. disciplinary policy, rules/regulations, rights, grievance policy __________ Explain safety rules: a. reporting of all accidents to staff b. dispensing of medications c. general safety rules, evacuation procedures, fire drills, fire safety training upon admission and annually thereafter ___________ Explanation of Programming: a. quarterly reviews b. ISPs ___________ Tour of facility a. office area b. cafeteria, rest rooms, first aid room c. work areas ¿ introduction to staff d. point out exits, van pick up/drop off area e. smoking area f. introduction to supervisor/workstation This is to verify that the above items have been discussed and that I have received a copy of the Program Participant Handbook, Workers Comp Information, Rights & Duties Information, Client Rights, Section 511 Resources, Grievance Policy, Holiday Schedule and Weather/Closing Information. __________________________________________ _________________________ Employee Signature Date 03/28/2023 Implemented
2390.49(c)(4)At the time of the inspection, training records for staff #1 do not document that the required training; recognizing and reporting incidents, was completed.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The ODC introduced a new policy during our 2/20/23 In-service training to address the Annual ODP Training Requirements. OCCUPATIONAL DEVELOPMENT CENTER POLICY: Required Annual Training for ODC Staff Members Source Document(s): 55 Pa Code Chapter 6100.143 ODP Announcement 21-034, ¿ODP Regulation Update: Orientation and Annual Training Question and Answer Document and Annual Training Clarifications¿ ODP Announcement 21-060, ¿Guidance for 24-Hour Annual Training Requirements in Training Years 2021 and 2022 _________________________________________________________________ SCOPE: All ODC Employees POLICY: In accordance with the ODP 6100 Regulations, all ODC Direct Support Professionals (DSPs) will complete 24 hours of training annually in areas listed below. Management, program, administrative, fiscal, dietary, housekeeping, maintenance and ancillary staff persons will complete 12 hours of training annually in the 6 areas listed below. Required Training Areas: ¿ (1)¿The application of person-centered practices, community integration, individual choice and assisting individuals to develop and maintain relationships. ¿ ¿ (2)¿The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§¿10225.101¿10225.5102), the Child Protective Services Law (23 Pa.C.S. §§¿6301¿6386), the Adult Protective Services Act (35 P.S. §§¿10210.101¿10210.704) and applicable protective services regulations. ¿ ¿ (3)¿Individual rights. ¿ ¿ (4)¿Recognizing and reporting incidents. ¿ ¿ (5)¿The safe and appropriate use of behavior supports if the person works directly with an individual. ¿ ¿ (6)¿Implementation of the individual plan if the person provides an HCBS or base-funding service. The required trainings menu can be accessed at: https://www.myodp.org/mod/page/view.php?id=24073 ODC Staff Members will be required to submit their required amount of training certificates to their direct supervisor by June 30th of the calendar year. Failure to complete these required training courses annually can result in disciplinary action up to and including termination. SIGNED: ________________________________ Executive Director Effective Date: Reviewed/Revised: 02/20/2023 Implemented
2390.49(c)(5)At the time of the inspection, the training records for staff #1 do not document that the required training; the safe and appropriate use of behavior supports, was completed.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 a client.The ODC introduced a new policy during our 2/20/23 In-service training to address the Annual ODP Training Requirements. OCCUPATIONAL DEVELOPMENT CENTER POLICY: Required Annual Training for ODC Staff Members Source Document(s): 55 Pa Code Chapter 6100.143 ODP Announcement 21-034, ¿ODP Regulation Update: Orientation and Annual Training Question and Answer Document and Annual Training Clarifications¿ ODP Announcement 21-060, ¿Guidance for 24-Hour Annual Training Requirements in Training Years 2021 and 2022 _________________________________________________________________ SCOPE: All ODC Employees POLICY: In accordance with the ODP 6100 Regulations, all ODC Direct Support Professionals (DSPs) will complete 24 hours of training annually in areas listed below. Management, program, administrative, fiscal, dietary, housekeeping, maintenance and ancillary staff persons will complete 12 hours of training annually in the 6 areas listed below. Required Training Areas: ¿ (1)¿The application of person-centered practices, community integration, individual choice and assisting individuals to develop and maintain relationships. ¿ ¿ (2)¿The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§¿10225.101¿10225.5102), the Child Protective Services Law (23 Pa.C.S. §§¿6301¿6386), the Adult Protective Services Act (35 P.S. §§¿10210.101¿10210.704) and applicable protective services regulations. ¿ ¿ (3)¿Individual rights. ¿ ¿ (4)¿Recognizing and reporting incidents. ¿ ¿ (5)¿The safe and appropriate use of behavior supports if the person works directly with an individual. ¿ ¿ (6)¿Implementation of the individual plan if the person provides an HCBS or base-funding service. The required trainings menu can be accessed at: https://www.myodp.org/mod/page/view.php?id=24073 ODC Staff Members will be required to submit their required amount of training certificates to their direct supervisor by June 30th of the calendar year. Failure to complete these required training courses annually can result in disciplinary action up to and including termination. SIGNED: ________________________________ Executive Director Effective Date: Reviewed/Revised: 02/20/2023 Implemented
2390.49(c)(6)At the time of the inspection, the training records for staff #1 do not document that the required training; Implementation of the individual plan, was completed.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with a client.The ODC introduced a new policy during our 2/20/23 In-service training to address the Annual ODP Training Requirements. OCCUPATIONAL DEVELOPMENT CENTER POLICY: Required Annual Training for ODC Staff Members Source Document(s): 55 Pa Code Chapter 6100.143 ODP Announcement 21-034, ¿ODP Regulation Update: Orientation and Annual Training Question and Answer Document and Annual Training Clarifications¿ ODP Announcement 21-060, ¿Guidance for 24-Hour Annual Training Requirements in Training Years 2021 and 2022 _________________________________________________________________ SCOPE: All ODC Employees POLICY: In accordance with the ODP 6100 Regulations, all ODC Direct Support Professionals (DSPs) will complete 24 hours of training annually in areas listed below. Management, program, administrative, fiscal, dietary, housekeeping, maintenance and ancillary staff persons will complete 12 hours of training annually in the 6 areas listed below. Required Training Areas: ¿ (1)¿The application of person-centered practices, community integration, individual choice and assisting individuals to develop and maintain relationships. ¿ ¿ (2)¿The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§¿10225.101¿10225.5102), the Child Protective Services Law (23 Pa.C.S. §§¿6301¿6386), the Adult Protective Services Act (35 P.S. §§¿10210.101¿10210.704) and applicable protective services regulations. ¿ ¿ (3)¿Individual rights. ¿ ¿ (4)¿Recognizing and reporting incidents. ¿ ¿ (5)¿The safe and appropriate use of behavior supports if the person works directly with an individual. ¿ ¿ (6)¿Implementation of the individual plan if the person provides an HCBS or base-funding service. The required trainings menu can be accessed at: https://www.myodp.org/mod/page/view.php?id=24073 ODC Staff Members will be required to submit their required amount of training certificates to their direct supervisor by June 30th of the calendar year. Failure to complete these required training courses annually can result in disciplinary action up to and including termination. SIGNED: ________________________________ Executive Director Effective Date: Reviewed/Revised: 02/20/2023 Implemented
SIN-00183688 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(d)At the time of the inspection, the First Aid Kit did not include tweezers.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors.The Safety, Health and Wellness Checklist was updated to include First Aid Kit Contents. See attached Checklist. 03/31/2021 Implemented
2390.124(2)On Individual #1's emergency contact sheet, both emergency contacts listed for the individual did not include their address.Each client's record must include the following information: The name, address and telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency.Participant File Checklist has been updated to include "at least 2 persons are listed as contacts, must include their addresses and phone numbers." See attached Checklist in Supporting Documentation Email. 03/31/2021 Implemented
SIN-00169436 Renewal 01/16/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.58The telephone in the warehouse was not functioning.A facility shall have an operable, noncoin operated telephone.During Licensing Inspection, it was noticed that the phone in the warehouse area was not operational. The Executive Director (ED) called the Occupational Development Centers IT company, Central Pennsylvania Technologies, to come and troubleshoot the situation. It was determined that there was a malfunction with the phone itself. The ED replaced the phone in the warehouse area on 2/4/10 with another and that fixed the issue. To prevent further occurrences, ODC will add lights/electric/ AND phones¿ to our existing monthly safety health and wellness checklist. (See attached photo and updated SHW checklist in the Supporting Documentation Email.) This was completed on 2/10/20. 02/10/2020 Implemented
2390.82(a)The written emergency evacuation plan did not include the individual's and staff's responsibilities or the means of transportation to the emergency shelter location.Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.The Executive Director (ED) edited the Emergency Evacuation Plan (EEP) to include staff and participant responsibilities. The name, was also added to the EEP on 2/4/20. It is attached in the Supporting Documentation email. To prevent any further occurrences, the ED forwarded the edited document to the Office Manager to replace the old one in the Employee Handbook. The ED also emailed digital copies of the new document to the Senior Program Specialist, Production Manager, and Program Specialists with instructions to print and replace the posted EEPs around the building with the new edited version. This was completed on 2/10/20. It reads as the following: Evacuation Procedures For actual emergencies including natural disaster emergencies STAFF RESPONSIBILITIES Evacuate all staff and employees using the closest and safest evacuation route. Call `911 Close all doors turn off lights. Check bathrooms. Obtain all prescription medications from the First Aid Room; obtain the Emergency Safety Protocol Books and Attendance Clipboard. Assemble all staff and employees on the paved area in front of the storage shed (alternate location on grass by the fence across the driveway from the warehouse). Supervisors are responsible in aiding the evacuation of folks in their work areas. Account for all staff and employees. If necessary, remove all staff and employees to designated shelter. We will walk to: SHELTER: Transportation from the shelter shall be coordinated by the Executive Director and/or PSs. 1) Families/Providers will be notified to pick up their son/daughter/resident at shelter. 2) Public transportation system and residential facilities will be notified of need for transportation, pick up location and changes in transportation schedule. PARTICIPANT RESPONSIBILITIES 1) Remain with the group and follow all staff instructions. 2) Do not leave the group unless you are officially dismissed by ODC staff. 02/10/2020 Implemented
2390.87Individual #1 is profoundly Deaf and does utilize some American Sign Language (ASL). Individual #1 had a Communication Assessment Reports and Recommendations completed on 7/18/18 that stated Individual #1 would benefit from the use of a visual gestural video and/or photo dictionary, being taught ASL, and being provided a communication specialist that has received training in ASL and all visual communication devices. There is no evidence that the fire safety training provided on 4/4/19 or 5/28/19 was completed in the appropriate mode of communication.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.Individual #1 received Fire Safety Training in American Sign Language from his Enhanced Communication Staff, on 1/30/20. Individual #1 was able to provide his signature that he received the training. A PDF of the training containing his signature is attached to the Supporting Documentation Email as, ASL Fire Safety Training. A video segment of the training was also attached to the Supporting Documentation Email. Individual #1 can be seen engaging with the trainer about the presentation. To prevent further occurrences the Senior Program Specialist (SPS) will review any recommendations contained in the individuals Communication Assessment Reports (CAR) and ISPs during the intake process and share that information with all ODC staff members. Enhanced Communication staff will add any visual supports needed to the participants work area and inform less fluent ASL staff members of the participants preferred methods of communication and communication needs. An ODP approved enhanced communication staff member will conduct the yearly fire safety training to appropriate individuals in ASL and have participants sign and date the training sheet for documentation purposes. 01/30/2020 Implemented
2390.111(a)Individual #1 record does not include evidence of a completed preadmission interview.A client shall have a preadmission interview.The Senior Program Specialist will take notes documenting any pre-admission activity for all potential Program Participants. To prevent any further occurrences, the Executive Director reviewed the Senior Program Specialist Job Description with the SPS. Specifically the following sections: e) Completes the intake, admission, orientation, and assessment procedures for new employees as outlined in the 2390 regulations. f) Ensures that employee records are maintained as required by the 2390 regulations. This was reviewed on 2/10/20. Note: Individual #1s lack of pre-admission notation was considered an anomaly as he was previously an ODC Program Participant years ago. He needed to retire for health reasons and his original documentation was purged. He was readmitted to the program after he chose to return last year. It is highly likely that the pre-admission such as the notes made by the Senior Program Specialist for (See Supporting Documentation Email) was contained in Individual #1s original documentation years ago. 02/10/2020 Implemented
2390.112(b)-1Individual #1 was not given information about work benefits.Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client.The Executive Director (ED) edited the Program Participant Handbook to include the following specific language on 2/4/20 and emailed the edited document to the Senior Program Specialist (SPS) to distribute to Program Participants. To prevent future occurrences, the SPS has replaced the old handbook with the new edited version in the ODC Intake materials for Program Participants. Wages Program Participants are eligible to earn wages immediately upon entering the program. Wages are paid by check every other Friday. Program Participants will be paid piece-rate for the work that they complete, for skills development activities and for work transition periods. Piece-rates are based on commensurate rates for similar tasks in the local industry. There are no health benefits or retirement plans offered by the ODC to Program Participants, however Participants are covered by the ODCs Workers Compensation Insurance if they are injured during their work hours at the ODC. Panel information is posted in the main hallway. Program Participants will not accrue wages for time spent in a meeting, away from the building for an appointment or refusing to work. If a program participants paycheck is lost or stolen, it should be reported immediately to the Office Manager. Vacation All program participants who have been employed for one full year from the date of their admission are eligible for the same number of paid vacation days as the number of days they are scheduled to work on a weekly basis. Vacations must be arranged with a minimum of one week advance notice to the participants Program Specialist in order to ensure payment. Paid vacation time must be used during the year earned and is not accrued or compensated when not used. Vacation pay is determined by using the average hourly rate for the most recent full quarter worked. 02/04/2020 Implemented
2390.151(a)Individual #1, #2 and #6 initial Assessment was not completed within 60 days of Date of Admission.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.The Senior Program Specialist (SPS) edited the Employee Orientation document to include a check box for Discuss Timeframe for Initial Assessment Date. This edit was completed as of 2/4/20. The new Orientation Checklist will be completed by the SPS during a new program participants intake. The SPS will then assign a Program Specialist (PS) once the Program Participant¿s orientation is complete and inform them of the date the initial assessment is due. The assigned PS will complete the initial assessment by the date listed on the Orientation Checklist. The PS will distribute the initial assessment to all team members within 60 days and add the new yearly rotation to the Annual Assessment Tracking Chart. To prevent further occurrences, the Senior Program Specialist will be responsible for reviewing the completed initial assessments and their addition to the Annual Assessment Tracking Chart and that they are sent to team members as scheduled. 02/04/2020 Implemented
2390.151(d)Individual #1 and #2 Annual Assessment not signed and dated by the program specialist.The program specialist shall sign and date the assessment.The Senior Program Specialist (SPS) revamped our assessment document to include a REQUIRED SIGNATURE line on the front page of the document. As per the Licensing Inspectors suggestions, she also included all pertinent PA Code numbers in each section of the new assessment document. The new assessment documents will be completed and signed by the Program Specialists (PS) by assigned caseload and sent to team members 30 days before the ISP meeting. PSs will sign and date the assessment documents annually. Please see the completed new assessment form in the supporting documentation email titled DE Assessment. To prevent further occurrences, the new assessments will be completed as per the new Annual Assessment Tracking Chart (Please see POC answer for violation 55 PA Code Chapter 2390.151(f) and the supporting documentation for that training that occurred on 2/4/20) The Senior Program Specialist will be responsible for reviewing the completed assessments of the Program Specialists to ensure that they include signature and date and that they are sent to team members as scheduled. 02/04/2020 Implemented
2390.151(e)(10)Individual #7 Lifetime Medical History was not completed or sent with the 12/30/19 Assessment.The assessment must include the following information: A lifetime medical history.The Senior Program Specialist (SPS) revamped our assessment document to include a section for Lifetime Medical History. As per the Licensing Inspectors suggestions, she also included all pertinent PA Code numbers in each section of the new assessment document. The new assessment documents will be completed by the Program Specialists (PS) by assigned caseload and sent to team members 30 days before the ISP meeting. The Lifetime Medical section of the assessment will be updated as new information is reported by supports coordinators, family members, or the individual. PSs will request updates each year while completing the Lifetime Medical section of the assessment. Please see the completed new assessment form in the supporting documentation email titled DE Assessment. The SPS included the section for 2390.151(10) A Lifetime Medical History on 1/30/2020 on page 6 of this document. To prevent further occurrences, the new assessments will be completed as per the new Annual Assessment Tracking Chart (Please see POC answer for violation 55 PA Code Chapter 2390.151(f) and the supporting documentation for that training that occurred on 2/4/20) The Senior Program Specialist will be responsible for reviewing the completed assessments of the Program Specialists to ensure that they include a Lifetime Medical History and that they are sent to team members as scheduled. 02/04/2020 Implemented
2390.151(f)Individual #2, #3, and #4 Annual Assessment was not sent to ISP team 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Our Senior Program Specialist (SPS) created a new spreadsheet to track the dates of when our assessment documents need to be sent out to team members. The spreadsheet contains 4 columns that must be completed by the PS according to the Program Participants on their caseload. The first three columns were completed by 1/29/20. The PSs entered their participants: Annual ISP renewal date, the month when their annual ISP meeting usually occurs (this can fluctuate due to Supports Coordinators preferred scheduling methods) and the target date for the assessment to be sent to the team members. (Completed 1/29/20) And finally, The 4th column is the date that the PS actually sends the Assessment to team members. The SPS will monitor this column on a bi-weekly basis to prevent any further occurrences. The SPS, the Program Specialists (PSs) and the Executive Director (ED) participated in a training on 1/30/20 on how to locate the spreadsheet, complete the required data entry, and review everyones responsibilities in maintaining the document. (Please see attachment Annual Assessment Chart Training Documents.¿ in the supporting documentation email ) The attached training has also been added to the New Program Specialist Training Documentation Checklist. Our Annual Licensing Inspection occurred on 1/16-1/17/20, and the new tracking sheet has just been put into action. We will send an updated spreadsheet to Licensing on March 6, 2020 to show the updates that have been made to individuals that are scheduled to have meetings in February. 03/06/2020 Implemented
SIN-00146064 Renewal 12/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.22(c)New Board members did not complete Conflict of Interest disclosure form.A member of the governing body shall fully disclose conditions that may create a conflict of interest.Next Board Meeting Scheduled for 1/22/19. Conflict of Interest Forms to be signed by all existing Board members and then renewed as needed as new Board members are identified. Pdf to be sent on 1/23/19 01/23/2019 Implemented
2390.23Agency does not have contract rate setting policy as per regulation.The facility shall establish sound and ethical bidding, contracting and selling practices to reflect reasonable costs consistent with the economical and efficient operations of the facility.This policy was in existence, but overlooked during the inspection. See attached pdf of ethical bidding and selling practices. 01/15/2019 Implemented
2390.81Area 4 exit door not able to be opened without extreme force. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.See attached video of Area 4 Door. 01/15/2019 Implemented
2390.123Area 3 had individual goal books which were kept unlocked. Small work room also had goal books unlocked.Information in the client records shall be kept confidential. Client records shall be kept locked when unattended.All Goal books will be kept in the locked Program Specialists Office until current goals are uploaded into our new digital tracking system. Area laptops are password protected 01/15/2019 Implemented
2390.124(4)Individual #6 most current release of information form dated 6/30/2009 does not include consent for emergency medical treatment.Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment.See attached pdf of signed release form. 01/15/2019 Implemented
2390.124(10)Repeat 10/11/2017. The current ISP was not in individual #1 record. It was asked at the entrance to have all updated ISPs for review.Each client's record must include the following information: A copy of the current ISP.See Attached Program Specialists Handbook and 2390 Review Training Dated 1/15/19. Program Specialist will compare HCSIS ISP versions with hardcopies during each quarterly review and print new ISPs as necessary. 01/15/2019 Implemented
2390.124(12)Repeat 10/11/2017. Individual #1 3/30/2018 physical states he needs assistance cutting up his food. This is not in his current ISP or assessment. Individual #5 physical 8/23/2017 states he has a seizure disorder. This is not a diagnosis in his ISP or assessment. Individual #5 assessment 8/10/2018 states he needs to cut his food into small pieces. This is not mentioned in his ISP. The same assessment states he requires assistance in the bathroom; this is not mentioned in his ISP. Individual #6 current ISP states no known allergies but most current physical dated 8/4/2017 has listed "Phenobarbital" in section titled "Allergies & Contraindicated Medications". Most current assessment dated 4/17/18 also states no allergies.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Individual #1 3/30/2018 physical states he needs assistance cutting up his food. (Please see attached email to SC requesting language continuity.) Individual #5 physical 8/23/2017 states he has a seizure disorder. (It is our belief that the inspector misread the physical and saw the "possible conditions for the physician to note in the section of the form. The doctor notes Doran's speech impediment later in the document but does not list seizure disorder as an existing condition. (Please see attached physical for Individual #5.) Individual #5 assessment 8/10/2018 states he needs to cut his food into small pieces. (Please see updated assessment.). The same assessment states he requires assistance in the bathroom; this is not mentioned in his ISP. (Please see updated assessment.) Individual #6 current ISP states no known allergies but most current physical dated 8/4/2017 has listed "Phenobarbital" in section titled "Allergies & Contraindicated Medications". Most current assessment dated 4/17/18 also states no allergies. (Please see updated documents.) 01/15/2019 Implemented
2390.151(a)REPEAT 8/27/15 AND 10/13/2017. Individual #4 had annual assessment on 06/05/17 and not again until 07/31/18.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.See Attached ¿ Meeting Schedule Spread Sheet and Program Specialists Handbook and 2390 Review Training Dated 1/15/19. PS¿s retrained on Annual Assessment Requirements. 01/15/2019 Implemented
2390.151(e)(6)Individual #3 assessment dated 01/18/18 does not identify poison safety awareness. Individual #5 assessment 8/10/2018 does not state if he is poison safe. It is not clear. The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.See Attached ¿ Updated Annual Assessments including Poison Safety Awareness. 01/15/2019 Implemented
2390.151(e)(7)Individual #2 assessment dated 5/30/2018 states that "it is unlikely that she would come into direct contact with dangerous heat sources at work, but if so would be supervised", which does not address if the individual is able to understand the danger of heat sources or the ability of the individual to sense and move away from heat sources quickly. Individual #3 assessment dated 01/18/18 does not identify his ability to sense and move away from heat sources. Individual #5 current assessment does not state if he can sense and move away quickly from heat sources.The assessment must include the following information: The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.See Attached - Updated Annual Assessments to include Heat Sources awareness and ability to move away 01/15/2019 Implemented
2390.153(5)REPEAT 8/27/15 AND 10/11/2017. Individual #5 ISP 11/21/2018 states he has a mood disorder and takes the medication Venaflaxine ER 37.5mg. He does not have a SEEN plan in place.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.See attached correspondence with Residential Program and Updated SEEN Plan for Doran M. 01/15/2019 Implemented
2390.153(7)(ii)Repeat 10/11/2017. Individual #2 most current ISP dated 7/18/18 does not include information regarding potential to advance in vocational programming or into competitive community-integrated employment.The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.See attached correspondences with Supports Coordinator requesting to include information provided in Maria¿s Annual Assessment 01/15/2019 Implemented
2390.155(b)Repeat 10/11/2017. Individual #3 assessment does not indicate if he is poison safe. Simple green, ant and roach spray, and paint were unlocked in the small work area. Unmarked spray bottle with a liquid substance in it and 409 degreaser were also unlocked on a shelf in the work area next to the men's bathroom.The ISP shall be implemented as written.See attached Annual Assessment - Annual Assessment Document updated to included specific areas for Poison Awareness. Potentially hazardous materials are to be kept in the locked supply closet when not in use. 01/15/2019 Implemented
2390.156(a)REPEAT 10/13/16 AND 10/11/2017. Individual #3 had quarterly reviews on 10/31/18, 08/14/18, 05/31/18 and 01/26/18. Also, individual #5 ISP reviews 12/7/2018, 9/11/2018, and 5/31/2018 were late. Individual #6 ISP review dates were 11/30/18, 8/24/18, and 5/24/18. 2/2018 was not found. 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.See Attached in Supporting Documentation Email - Updated Meeting Schedule Spread Sheet and Program Participant Orientation Checklist. 01/15/2019 Implemented
2390.156(a)REPEAT 10/13/16 AND 10/11/2017. There were no ISP reviews completed for individual #1 over the review year. His DOA was 1/12/2018. 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.See Attached in Supporting Documentation Email - Updated Meeting Schedule Spread Sheet and Program Participant Orientation Checklist. 01/15/2019 Implemented
2390.156(b)Individual #6 ISP review dated 5/8/2018 was not signed and dated by staff or individual. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.See Attached in Supporting Documentation Email ¿ Program Specialists Handbook and 2390 Review Training Dated 1/15/19. PS¿s retrained on Quarterly Review Signature and Date Requirements. 01/15/2019 Implemented
2390.156(c)(2)REPEAT 8/27/15 AND 10/11/2017. Individual #3 ISP quarterly reviews do not include seizure protocol information (frequency). SEEN plan utilization not included on 1/18, 5/18, 8/18 reviews. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.See Attached in the Supporting Documentation Email - Quarterly Reviews updated to include Seizure Frequency/Protocol and SEEN Plan Utilization Info. Email requesting info from Residential Program 01/15/2019 Implemented
2390.156(d)Individual #3 and #5 ISP reviews over the annual review year were not sent out to his team members. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.See Attached in Supporting Documentation Email - Program Specialists Handbook and 2390 Review Training Dated 1/15/19. PS¿s retrained on annual review needing to be sent to all team members unless refused 01/15/2019 Implemented
SIN-00121506 Renewal 10/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(1)The program specialist failed to coordinate and complete assessments for individuals 1, 2, and 3. The program specialist shall be responsible for the following: Coordinating and completing assessments. The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.33(b)(6)The program specialist failed to review individual 1, 2, and 3 ISPs for accuracy. The program specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions for content accuracy.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.33(b)(9)The program specialist failed to supervise, monitor, and evaluate services provided to individual 1, 2, and 3. Outcomes and applicable plans per indiviuals ISP were not being provided. The program specialist shall be responsible for the following: Supervising, monitoring and evaluating services provided to the client.This infraction caused the creation of our new Spot Check/Binder Checklist. As we discussed during the on-site, the bulk of our citation this year were the result of one individual's work performance. We are confident that our new documentation will improve our oversight of the programming department in general and also continue to educate our staff members as they perform the random spot checks. 11/29/2017 Implemented
2390.124(6)Individuals 1, 2, and 3 a current assessment is not a part of their record. Each client's record must include the following information: Assessments as required under §  2390.151 (relating to assessment).The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.124(10)Individuals 1, 2, 3, 4, 5, and 6 a current ISP was not in their record. Each client's record must include the following information: A copy of the current ISP.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.124(12)Individual #1 ISP last updated 9/27/2017 states he has an allergy to Fusamax. His Fact Sheet states KNA. Individual #3 current ISP under health status states she has an Axis I diagnosis of depression. Under the psychosocial section it states she does not have a mental health diagnosis. Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.This issue has been reconciled. The program specialist updated the emergency contact/ fact sheet to include the allergy. Moving forward, the Binder Checklist (Section 1) is dedicated to the review of our individuals' emergency contact form information and its periodic review. Binder Checklist training and specific review of citations 2390.156(e), 2390.153(5), and 2390.124(12) to occur at the monthly staff meeting on 12/7/17. 12/07/2017 Implemented
2390.151(a)REPEAT. Individual #1 last assessment was completed 7/7/2014. His admission date is 1/13/1989. Individual # 2 had no assessment in his record. His admission date is 11/7/2007. Individual #3 had no assessment in her record. Her admission date is 6/27/1986. 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.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.151(e)(10)REPEAT. The medical history attached to individual #4 2/14/2017 assessment is not current. The medical history attached to individual #6 11/4/2016 assessment is blank. The assessment must include the following information: A lifetime medical history.See attached Medical History for individual 4 in the Supporting Documentation email. Binder Checklist will prevent any further incidents. ODC will document all attempts of trying to obtain Lifetime Medical History. 11/29/2017 Implemented
2390.153(5)REPEAT. Individual #2 and #3 SEEN plans do not describe how staff are to support them. 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.SEEN Plans have been updated to include a section called, Protocol for Support. On an individualized basis, the SEEN plan documents how to best assist the individual if they require their SEEN Plan to be activated. Review of the SEEN Plans are also included in the Binder Checklist and their use is to be documented in the monthly progress notes. See attached SEEN plans, binder checklist, and quarterly reports. Binder Checklist training and specific review of citations 2390.156(e), 2390.153(5), and 2390.124(12) to occur at the monthly staff meeting on 12/7/17. 12/07/2017 Implemented
2390.153(7)(i)REPEAT. Individual #1 last updated ISP 9/27/2017 does not state his potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges including their potential to advance in vocational programming and community integrated employment , Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.153(7)(ii)Individual #1 last updated ISP 9/27/2017 does not state his potential to advance in Competitive community integrated employment. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges including their potential to advance in vocational programming and community integrated employment , Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.154(b)Individual #2 only the program specialist and supports coordinator attended his 8/7/2017 annual review. At least three plan team members, in addition to the client, if the client chooses to attend, shall be present for the ISP, annual update and ISP revision meetings.An update has been made to the ODC Program Specialist Handbook to include that a PS should encourage the SC to reschedule the annual meeting until the appropriate amount of team members can be present. This is also reflected in the new Binder Check document. 11/29/2017 Implemented
2390.155(b)Individuals 1, 2, and 3 are currently working on an outcome to build work skills. Their ISP is not being implemented as written. The outcome states the team will know progress is beging made by provider reports and quarterly reviews. These documents have not been completed. The ISP shall be implemented as written.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.156(a)REPEAT. Individuals 1, 2, and 3 did not have any ISP reviews over this annual review period. 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.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.156(c)(1)Individuals 1, 2, and 3 there is no monthly documentation of participation and progress towards their outcomes over the annual review period. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.The ODC has put an improved oversight system in place that includes a Program Participant Binder Checklist that will work in conjunction with the annual and monthly scheduled meetings. The checklist includes: Correct and Regularly updated Emergency Contact Info, ISP Review, Annual Assessment Review, Signature Sheets for meetings and Meeting Attendance requirements, Review of SEEN plans and Staff Protocol on how to assist that individual, Month Progress note review for dates and details about the individual's work assignments, successes, and challenges, Quarterly review tracking, and checking if sign in sheets dates match that of the ISP date. Various staff members will be designated to ¿spot check¿ various program participant records and then report their findings to the Senior Program Specialist. If any discrepancies or lack of required information is found, the Senior Program Specialist will follow up with the Program Specialist for that individual and together, they will review the entire Binder Checklist for that particular record. The PS will rectify the errors or missing documentation and/or provide documentation of their attempts to obtain the information within 5 working days. If the documentation is not provided, the PS will be subject to the ODC¿s progressive discipline policy that could lead to disciplinary action up to and including termination. Please see attached documentation in the Supporting Documentation email. 11/29/2017 Implemented
2390.156(c)(2)REPEAT. Individual #6 ISP review 12/6/2016 only states staff needed to refer to her SEEN plan approximately 1X this quarter. No further information was provided. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.¿3/17/17, 5/30/17, and 8/24/17 ISP reviews (see supporting documentation email) show an updated format for Individual # 6 that includes a precise number of referrals to the SEEN plan instead of an approximate number. The 12/6/16 ISP review indicating `staff needed to refer to her SEEN plan approximately 1 time this quarter¿ was written on 11/11/16 before recommendations from the 2016 Plan of Corrective Action were finalized. The 2016 Plan of Corrective Action for ODC was finalized on 12/1/16 and indicated a need for precise instead of approximate documentation on SEEN plan referrals. All ISP reviews written after that date include adequate information.¿ 11/29/2017 Implemented
2390.156(e)Individuals 1, 2, and 3 team members did not receive the option to decline. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The option to decline is contained on the ODC sign in sheet for the individual's ISP meeting. The Binder Checklist also includes a section to check and see if the individual and the participants present at the meeting have been given the chance to decline the mailed documentation. Please see attached Checklist in the Supporting Documentation email. Binder Checklist training and specific review of citations 2390.156(e), 2390.153(5), and 2390.124(12) to occur at the monthly staff meeting on 12/7/17. 11/29/2017 Implemented
SIN-00102561 Renewal 10/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.53The bottom step of exit out of the building center hallway exit had 23 inch by 6 inch crack wit loose cement pieces in and around the crack. Outside walkways shall be free from ice, snow, leaves, equipment and other hazards.See paper copy. 11/08/2016 Implemented
2390.61The bottom of the door in area four had a 10 inch hole ine the door.  Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.See paper copy. 11/08/2016 Implemented
2390.151(e)(10)Individual #6's assessment dated 2/4/16 does not include a medical history. The assessment must include the following information: A lifetime medical history.Revise all Annual Assessments to - Indicate whether or not a Lifetime Medical History is on file for client. If so, scan and attach to Annual Assessment before emailing to team members Attach a hard copy for team members who receive by traditional mail. See attached Program Specialist training/sign in. PAGE 4 of updated assessment document. (DE Annual Assess) in validation materials email. 11/08/2016 Implemented
2390.151(e)(11)Indivdual #6's assessment dated 2/4/16 did not include a psychological evaluation. The assessment must include the following information: Psychological evaluations, if applicable.Indicate whether or not a psychological evaluation is on file for client. If so, scan and attach to Annual Assessment before emailing to team members. Attach a hard copy for team members who receive by traditional mail. See attached Program Specialist training/sign in. PAGE 4 of updated assessment document. (DE Annual Assess) 11/08/2016 Implemented
2390.153(7)(i)Individual #6 ISP dated 6/2/16 does not assess his potentional to advance in vocational programing. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.In the ODC Annual Assessment, a client¿s potential for success in competitive employment will be noted in a newly added section ¿ Employment/Volunteer Information. When the ISP is approved, the Program Specialist will confirm that this is included in the ISP somewhere, ideally under the Employment/Volunteer Information section of the ISP. If this information is not present, the PS will send an email requesting the addition to be made and file the print out of email in client¿s file. Upon correction, the PS will print out and attach to the hard copy in the client¿s file. Please see attached Program Specialist training and PAGE 8 of Updated Assessment in validation materials email. 11/08/2016 Implemented
2390.156(a)Individual #6 ISP review's dated 9/7/16, 6/15/16, 3/4/16, and 12/14/15 did not include a review of his SEEN plan. 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.Developed a statistics gathering system for each client with a SEEN plan. A separate binder will be established for each area for the supervisor to document how and when a SEENs plan is used and the success or lack of success in response to each occurrence. Using this data, the Program Specialist will include a narrative in the client¿s quarterly review including frequency of behaviors, whether or not the support protocol was successful and whether or not the SEENs plan requires revision. The target date for implementation of the SEENs tracking system is Dec. 1, 2016. Please see staff sign in sheet from 11/3 meeting and new SEEN tracking documents in following validation materials email 12/01/2016 Implemented
SIN-00082997 Renewal 08/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #2's assessement was not within 60 calendar days of admission. Admission date was 1/5/15 and the assessment was not completed at time of inspection. 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.All new admissions will be receive a full assessment within the first 60 days of attendance. The assessment has been updated to include all regulatory requirements. The use of the 20 day and 30 day assessments will be discontinued. 09/21/2015 Implemented
2390.151(c)Individual #1 and #3's assessment did not in the basis of assessment. The assessment shall be based on assessment instruments, interviews, progress notes and observations.The ODC Assessment document has been edited to include the basis of assessment. 09/21/2015 Implemented
2390.151(e)(8)Individual #1 and Individual #3's assessment did not include the ability to evacuate in the even of a fire. The assessment must include the following information: The client's ability to evacuate in the event of a fire.The ODC Assessment Document has been edited to include the client's ability to evacuate in the event of a fire. 09/21/2015 Implemented
2390.151(e)(12)Individual #1's assessment did not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.The ODC Assessment Document has been edited to include a section for recommendations for the individual's vocational training and/or placement. 09/21/2015 Implemented
2390.153(5)Individual #3's ISP did not include a SEEN Plan. 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.Program Specialist for individual #3 contacted the Supports Coordinator on 9/16/15 requesting that the SEEN plan be added. The ISP has been updated. 09/16/2015 Implemented
2390.156(c)(2)Individual #1 and Individual #3's ISP reviews did not review protocol for psychatropic medications. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Individuals taking psychotropic medications Quarterly Review Sheets have been modified to include a section describing their SEEN plan and how often it is referenced on a monthly basis. 09/21/2015 Implemented
2390.156(d)Individual #3's ISP review on 4/13/15 was not sent out to SC until 6/1/15. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Program Specialist have added a WEEKLY reminder in Outlook to mail out any QR reports that occurred during that week 09/21/2015 Implemented
SIN-00044886 Renewal 12/17/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62The air vents in the bathroom and outside the bathroom were packed with dirt/dust.Fully Implimented CSS 3-29-13 Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Vents cleaned- photo provided 12/18/2012 Implemented
2390.124(5)Individual #1's record did not include a copy of a physical. Partially Implimented/Adequate progress CSS 3-29-13 Each client's record must include the following information: (5) Physical examinations.New requests for physical/lifetime medical info letters will be sent out to all program participants. 02/22/2013 Implemented
2390.124(11)(iv)Indivdual's #1,2,3,4 & 5 records did not include notices that the ISP team members may decline the ISP review documentation.Partially Implimented/Adequate Progress 3-29-13 CSS Each client's record must include the following information (11) Documentation of ISP reviews and ISP revisions under §  2390.156 (relating to ISP review and revision), including the following: (iv) Notices that the plan team member may decline the ISP review documentation.New accept/decline letters to be presented to all team members 02/22/2013 Implemented
2390.124(12)There is content discrepancy between the personal data sheet and ISP that stated different places of birth for Individual #3 (Lancaster/Ohio)Each client's record must include the following information: (12) Content discrepancy in the ISP, the annual update or revision under §  2390.156.Original Birthplace verified and edited 02/22/2013 Implemented
2390.151(a)Indivdual #4 did not have an updated annual assessment in the records. Partially implimented/adequate progress CSS 3-29-13 (a)  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.Annual assessment updated 02/22/2013 Implemented
2390.151(e)(3)(iii)The annual assessment for Individual #1 did not contain the level of performance and progress in personal adjustment. Partially Implimented/Adequate progress CSS 3-29-13 (e) The assessment must include the following information: (3) The client's current level of performance and progress in the following areas: (iii) Personal adjustment.Level of performance and personal adjustment added to the ODC comprehensive assessment tool 02/22/2013 Implemented
2390.151(e)(7)The annual assessment for Indivdual's #1,2,3,4 &5 did not include the understanding of the danger of heat sources. Partially Implimented/Adequate Progress CSS 3-29-13 (e) The assessment must include the following information: (7) The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Heat source awareness added to ODC comprehensive assessment tool 02/22/2013 Implemented
2390.151(e)(10)The Lifetime Medical History was not included in the assessment for Indivdual #1. Partially Implimented/Adequate Progress CSS 3-29-13 (e) The assessment must include the following information: (10) A lifetime medical history.New requests for physical/lifetime medical info letters will be sent out to all program participants. 02/22/2013 Implemented
2390.151(e)(13)(i)The annual assessment for Individual's #1,2,3 &5 did not include progress and growth in the areas of Health, Motor & Communication, Persoanl Adjustment, Socialization, Vocational Skills. Partially Implimented/Adequate Progress CSS 3-29-13 (e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health.Health, Motor, Communication, Personal Adjustment, Socialization, and voactional skills all added to ODC comprehensive assessment tool. 02/22/2013 Implemented
2390.151(f)There was no documentation that all team members were informed of the results of the assessment for Individual" 1,2,3,4, & 5. Partially Implimented/Adequate Progress CSS 3-29-13 (f) 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).New accept/decline letters to be presented to all team members and new section for team member initials/date on QRs. 02/22/2013 Implemented
2390.156(c)(2)The quarterly reviews did not review the behavior support plan for Individual #4. Partially Implimented 3-29-13 CSS (c ) The ISP review must include the following: (2) A review of each section of the ISP specific to the facility licensed under this chapter.Behavior plan section will be added as applicable to QRs of individuals with BSPs. 02/22/2013 Implemented
SIN-00200675 Renewal 02/22/2022 Compliant - Finalized
SIN-00065368 Renewal 08/21/2014 Compliant - Finalized