Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224453 Renewal 05/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(r)Individual # 1 -7 was not informed of exercising his/her rights so that another client's rights are not violated.A client's rights shall be exercised so that another client's rights are not violated.The Executive Director revised the "Individual Rights, Complaint/Grievance Procedure Acknowledgment Form: to include the following statement: "An individuals rights may not be exercised so that they violate the rights of another individual." The revised form with be reviewed with all individuals receiving services under 55 PA Code Chapter 2390. It will be the responsibility of the individual's assigned Program Specialist to review the revised form with all individuals by June 30, 2023. 06/30/2023 Implemented
2390.21(s)Individual #1 -7 was not informed of the right of receiving assistance from the facility to negotiate choices in accordance with the facility procedures to resolve differences and make choices.The facility shall assist the affected clients to negotiate choices in accordance with the facility's procedures for the clients to resolve differences and make choices.The Executive Director revised the "Individual Rights, Complaint/Grievance Procedure Acknowledgment Form" to include the following statement: "Your OSI Program Specialist will assist you and work with you and others involved, as applicable, to resolve the concern or assist you in negotiating choices within OSI's policies and procedures." The revised form with be reviewed with all individuals receiving services under 55 PA Code Chapter 2390. It will be the responsibility of the individual's assigned Program Specialist to review the revised form with all individuals by June 30, 2023. 06/30/2023 Implemented
2390.40(a)The Orientation training for staff # 4 did not include length of training for Person Centered Planning, the prevention, detection and reporting of abuse, Client rights and Recognizing and Reporting Incidents.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.The HR/Administrative Assistant revised the "Employee Orientation Checklist" to meet the requirement: "Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept." Individual training topics required by 55 PA Code Chapter 2390 have been separated by line. Columns for start, stop, total time, and date has been added to the document. A formula has been added to total time for all orientation training topics. (Please see attachment #2) 06/05/2023 Implemented
2390.49(c)(6)Staff # 1 did not receive training in the implementation of each individual plan of supported individuals.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 Client Services Manager developed a form to track annual training hours for training on the implementation of the ISP: "ISP Implementation Staff Training Sheet." (please see attachment #3) The Client Services Manager will meet with DSPs and supervisory staff to train them on the purpose and use of the "ISP Implementation Staff Training Sheet" on July 13, 2023. Due to all ISPs being updated in July for fiscal year 2023-24, implementation of this new training sheet will coincide with these updates. 07/13/2023 Implemented
SIN-00202013 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.63There was no light outside of the wood pen area egress nor the cutting area egressRooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents.OSI will install motion sensor flood lights over the wood pen and cutting area egresses. The electrician's estimate was received 4/4/22. Lights are to be installed by June 1, 2022. 06/01/2022 Implemented
2390.82(a)Emergency Evacuation Procedures don't indicate the means of Transportation.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.Means of transportation has been added to OSI's Emergency Evacuation Procedures. OSI will utilize the company's fleet of vehicles for any emergency transportation needs. 04/04/2022 Implemented
2390.85(a)-2The 01/26/22 fire drill did not indicate the hypothetical location of the fire. The space was left blank.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.The Safety Committee Chairperson has been retrained on completing all sections of the fire drill form for each drill, including the hypothetical location of the fire. 03/29/2022 Implemented
2390.21(b)For all of the clients reviewed in this sample, they signed documentation saying that they received, read, and understand their civil rights, however their individual rights were not written out or included on the signed documentation found in the individual's chart.The facility shall educate, assist and provide the accommodation necessary for the client to understand the client's rights.The individual rights have been added to the form that is signed by clients indicating that they have received, read, and understand their rights. OSI calls this the "Individual Rights & Grievance Form." 03/29/2022 Implemented
2390.49(c)(3)At the time of the inspection, there was no documentation that demonstrated that Staff #1-4 had annual training on client rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Staff responsible for developing the annual training schedule for staff will follow the "OSI Training Plan" that includes training on individual rights. 03/31/2022 Implemented
SIN-00146235 Renewal 11/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(a)The stairwell in Area #4, leading to the basement, does not have an audible alarm, and no alarm can be heard from inside the stairwell.There shall be an operable fire alarm that is audible throughout the facility.Attachment 4 12-4-18 Alarm installed and tested by ATA Alarm and communications Alarms will be "tested" by staff person assigned by Safety Committee going through the building to make sure audible throughout on a monthly basis. Documented on OSI Fire Drill-Alarm Test Spreadsheet. Monitored by Safety Committee Chairman. 12/04/2018 Implemented
2390.124(12)Individual #6 physical attached to the 7/13/2018 Assessment only included allergies to penicillin and walnuts. Individual #6 identification sheet and Individual Support Plan (ISP) indicate allergies to penicillin, walnuts and bee stings.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Attachment #3 12-12-18 Program Specialist retrained on content discrepancy in the ISP. Highlighted on ¿tickler¿ which is used as a guide for completing assessment. Review in June of 2019 Monitored by Program Specialist cross checking files 12/12/2018 Implemented
2390.151(e)(4)Individual #7 11/1/18 assessment did not include the supervision needs at the facility or in the community with staff. The assessment must include the following information: The client's need for supervision.Attachment #1 12-12-18 Program Specialist retrained on including clients need for supervision in the assessment. Highlighted on ¿tickler¿ which is used as a guide for completing assessment. Review in June of 2019 Monitored by Program Specialist cross checking files 12/12/2018 Implemented
2390.151(e)(5)Individual #7 11/1/18 Assessment doesn't include the ability to self-administer medications. The Assessment only indicated a preference to have parents administer medications if necessary and that the individual does not currently take medications. The assessment must include the following information: The client's ability to self-administer medications.Attachment #2 12-12-18 Program Specialist retrained on including ability to self administer medication in the assessment. Highlighted on ¿tickler¿ which is used as a guide for completing assessment. Review in June of 2019 Monitored by Program Specialist cross checking files 12/12/2018 Implemented
2390.156(a)Individual #6 ISP review completed on 08/16/18 was late; It was reviewing the months of May, June and July 2018 and should have been completed no later than 08/15/18. Individual #6 ISP review completed on 05/22/18 was late; it was reviewing the months of February, March and April 2018 and should have been completed no later than 05/15/18. Individual #6 ISP review completed on 02/22/18 was late; it was reviewing the period from November and December 2017 and January 2018and should have been completed no later than 02/15/18. Individual #6 ISP review completed on 11/21/17 was late; it was reviewing the period from August, September, October and November, which is more than a 3 month period. The ISP review should have been completed by no later than 11/15/17 and only reviewed the period from 8/1/17-11/30/17. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.12-12-18 Program Specialist retrained on completing 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. Annual review update date will be used to schedule all reviews. Highlighted on ¿tickler¿ which is used as a guide for completing reviews. Review in June of 2019 Monitored by Program Specialist cross checking files 12/12/2018 Implemented
SIN-00124935 Renewal 12/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(18)Individual #7 has grand mal seizures at his/her work place. The program specialist and Individual #7's supervisor were the only two staff to be trained on his/her Individual Support Plan (ISP) and seizure information contained in his/her ISP on 6/12/17. There was no documentation in his/her record to indicated that his/her job coaches working with him/her on a daily basis were trained in Individual #7's ISP and seizure information.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each client.The job coaches who work with #7t have been trained on his Grand Mal Seizures as specified in the ISP. When he has a seizure the program specialist or rehab manager will be notified. The program specialist or rehab manager will contact #7 parent. His parent will determine if he needs to go home. 01/19/2018 Implemented
2390.82(b)The facility had a fire inspection of the building by the local fire authority on 2/2/16 but did not notify the local fire department of the address of the facility and the number and disabilities of the clients served until 3/9/17; outside of the annual time frame.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.Although our agency did notify the local fire department or other fire safety authority in writing of address of the facility and the number and disabilities of the clients served, it was not done annually. We have now designated two staff persons, the Safety Committee Chairman and the Executive Director, who have placed recurring reminders on their calendars annually at least 30 days prior to the due date of the required letter to the fire department to ensure that this is done annually going forward. 12/14/2017 Implemented
2390.83(b)-1The fire alarm of the facility was not checked in March 2017. The facility indicated that a verbal fire drill was held on 3/28/17 but the fire alarm system was not checked for operation.An employe trained in the operation of the equipment shall check the fire alarm monthly. The Safety Committee Chairman has been designated to monitor monthly fire alarm checks. He will sign off on the Monthly Fire Drill Form. The Safety Committee Chairman and the Executive Director have placed recurring monthly reminders on their calendars at the beginning of the month to test the fire alarm. 01/19/2018 Implemented
2390.87Staff #1's date of hire was 7/25/17 and he did not receive training in general fire safety and the use of fire extinguishers until 7/26/17.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.Staff who act as new staff orientation trainers have been retrained on the requirement to provide general fire safety and the use of the fire extinguisher on the first day of orientation (date of hire). In addition, staff who are responsible for this training have signed an acknowledgement form. 12/15/2017 Implemented
2390.111(b)-1Individual #1 had a preadmission interview completed on 11/22/16 and then orientation to the facility on 11/22/16. The acceptance notification letter in Individual #1's record did not contain a date that would indicate when he/she was given written notification of acceptance within 30 days of his/her preadmission interview.Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. Intake letter has been revised. Attachment #9 Executive Director will review and approve Letters of Acceptance 01/19/2018 Implemented
2390.124(12)REPEAT from 9/1/16 annual inspection: Documents in Individual #2's record contained varying diagnosis for him/her that did not match each other. His/her individual face sheet indicated, quotes, disabilities/conditions: ID, CP, edema, osteoporosis, hx: seizure d/o, hyperlipidemia, hypertension, obesity, chronic non-infectious diarrhea, bursitis, allergic rhinitis, anemia, obstructive sleep apnea. His/Her assessment indicated, quotes, dx of CP, severe ID, and seizure d/o. His/Her 11/9/17 physical indicated, quotes, dx of OSA, anemia, ID, obesity, osteoporosis, hx of seizure. His/Her Individual Support Plan (ISP) indicated dx: CP, seizure disorder, dependent edema, obesity, high cholesterol, hypertension, post menopausal osteoporosis, chronic non-infectious diarrhea, bursitis, hx of fractured left homerus, hx of fractured right wrist and allergic rhinitis.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Assessment Guide will be implemented effective 2/1/18 Reminder to review all content and make sure there are no discrepancies Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(4)Individual #3's 6/6/17 assessment did not indicated a length of time he/she could be unsupervised while attending the 2390 program or it's offsite. His/Her assessment indicated, in quotes, he/she is able to independently leave the OSI premises during his/her lunch breaks, end quotes. The assessment must include the following information: The client's need for supervision.Assessment Guide will be implemented effective 2/1/18 Reminder to include supervision and to specify amount of unsupervised time. Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(7)Individual #2's 9/29/17 assessment and Individual #4's 12/30/16 assessment did not include their knowledge of 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.Assessment Guide will be implemented effective 2/1/18 Reminder to specifically state knowledge of the danger of heat sources and ability to sense and move away Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(9)REPEAT from 9/1/16 annual inspection: Individuals #5-7's assessments did not include documentation of their functional and medical limitations.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.Assessment Guide will be implemented effective 2/1/18 Reminder to includeFunctional and Medial Limitatio ns Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(10)REPEAT from 9/1/16 renewal inspection: Individuals #2-8's assessments did not include a lifetime medical history that was completed at the time of the assessment. Their lifetime medical histories were not completed until their annual Individual Support Plan (ISP) meetings, which were held 30 days after the assessments were completed. Individuals #4 and #5's assessments did not have a lifetime medical history completed or attached to their assessments.The assessment must include the following information: A lifetime medical history.Master Lifetime Medical will be kept in the medical section of the file. All updates will be noted on the master Procedure reminder is on the Assessment Guide Program Specialist have received training on the Assessment Guide Attachment #5 01/18/2018 Implemented
2390.151(e)(13)(i)REPEAT from 9/1/16 renewal inspection: Individual #3's 6/6/17 assessment and Individual #7's 1/16/17 assessment did not include progress in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Assessment Guide will be implemented effective 2/1/18 Reminder to include progress over last 365 days in health. Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(13(ii)REPEAT from 9/1/16 renewal inspection: Individual #3's 6/6/17 assessment, Individual #4's 12/30/16 assessment, Individual #6's 5/19/17assessment, Individual #7's 1/16/17 assessment and Individual #8's 6/12/17 assessment did not include progress in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.Assessment Guide will be implemented effective 2/1/18 Reminder to include progress over last 365 days in motor skills. Reminder to include progress over last 365 days in communication skills skills. Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/17/2018 Implemented
2390.151(e)(13)(iii)REPEAT from 9/1/16 renewal inspection: Individuals #4, #6 and #8's assessments did not include their progress in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Assessment Guide will be implemented effective 2/1/18 Reminder to include progress over last 365 days in personal adjustment. Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(13(iv)REPEAT from 9/1/16 renewal inspection: Individuals #2, #4, #6 and #8's assessments did not include their progress in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Assessment Guide will be implemented effective 2/1/18 Reminder to review all content and make sure there are no discrepancies Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(e)(13)(v)REPEAT from 9/1/16 renewal inspection: Individuals #4 and #6's assessments did not include their progress in vocational skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Assessment Guide will be implemented effective 2/1/18 Reminder to include progress over last 365 days in vocational skills. Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.151(f)REPEAT from 9/1/16 renewal inspection: Individual #4's 12/30/16 assessment was not sent to his/her residential team member or behavior support team member.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).Assessment Guide will be implemented effective 2/1/18 Reminder to Send copies to all team members 30 days prior to ISP meeting Program Specialist have been trained Coworker will review assessment Rehab Manager will randomly review assessments Attachment #5 01/18/2018 Implemented
2390.153(5)REPEAT from 9/1/16 renewal inspection: Individual #1's date of admission to the facility was 2/20/17. His/Her Individual Support Plan (ISP) did not have a protocol to address his/her social, emotional and environmental needs until after 4/19/17, when the protocol was created. Individual #4's ISP did not include a protocol to address his/her social, environmental and emotional needs while at OSI facility or work offsite. His/Her ISP only indicated a protocol for his/her residential program.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.Rehab Manager will be responsible for SEEN plans being discussed at the Intake Meeting and finalized by the individuals start date. SEEN Plan has been added to the Client Preadmission Form. Program Specialist will monitor and update as they become more familiar with the individual. This process will be implemented 2/1/18 and continue. Attachment #6 02/01/2018 Implemented
2390.155(b)Individual #7's Individual Support Plan (ISP) indicated that when he/she has a seizure while at the OSI program, his/her mother is to be notified. According to his/her record of incidents in his/her record, Individual #7 had a seizure(s) on 11/10/17, 10/18/17, 6/16/17, 5/31/17, 1/5/17 and 9/30/16. There was no documentation that indicated Individual #7's mother was made aware of the seizures.The ISP shall be implemented as written.The Incident/Illness/injury report has been revised to include notification to specific individuals and the date they are notified. All staff have received training on the revised report. Safety Committee will review reports on a Monthly basis. Attachment #7 01/18/2018 Implemented
2390.156(c)(1)REPEAT from 9/1/16 renewal inspection: Individual #4's Individual Support Plan (ISP) reviews did not include a review of his/her participation and progress towards his/her ISP outcome to learn and practice vocational and social skills. His/Her ISP reviews only measured his/her attendance and rate at which he was getting paid. Individual #6's Individual Support Plan (ISP) reviews did not include a review of his/her participation and progress towards his/her ISP outcome to learn new job tasks and increase his/her social skills. His/Her ISP reviews only measured his daily attendance and rate at which he was getting paid. 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.Rehab Manager will take the ODP training outcome Development Program Specialist will be retrained on progress on outcomes. Training will be done at the Rehab Team Meeting on Monday, January 22, 2018 Rehab Manager will randomly check Quarterly Progress reports. Rehab Manager will randomly attend Quarterly meetings 01/19/2018 Implemented
2390.156(c)(2)Individual #7's Individual Support Plan (ISP) reviews do not review his/her seizures that occur while at the program, or a review of his/her seizure protocol. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialist will be retrained on reviewing the ISP Training will be done at the Rehab Meeting on Monday, January 22, 2018 Rehab Manager will randomly check Quarterly Progress Reports Rehab Manager will randomly attend Quarterly meetings. 01/18/2018 Implemented
SIN-00095107 Renewal 09/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(1)Staff #1 and Staff #2 did not receive training on program specialist responsibilities. The program specialist shall be responsible for the following: Coordinating and completing assessments. (2) Providing the assessment as required under § 2390.151(f) (relating to assessment). (3) Participating in the development of the ISP, including annual updates and revisions of the ISP. (4) Attending the ISP meetings. (5) Fulfilling the role of plan lead, as applicable, under § § 2390.152 and 2390.156(f) and (g) (relating to development, annual update and revision to the ISP; and ISP review and revision). (6) Reviewing the ISP, annual updates and revisions for content accuracy. (7) Reporting content discrepancy to the SC or plan lead, as applicable, and plan team members. (8) Implementing the ISP as written. (9) Supervising, monitoring and evaluating services provided to the client. (10) Reviewing, signing and dating the monthly documentation of a client¿s participation and progress toward outcomes. (11) Reporting a change related to the client¿s needs to the SC or plan lead, as applicable, and plan team members. (12) Reviewing the ISP with the client as required under § 2390.156. (13) Documenting the review of the ISP as required under § 2390.156. (14) Providing documentation of the ISP review to the SC or plan lead, as applicable, and plan team members as required under § 2390.156(d). (15) Informing plan team members of the option to decline the ISP review documentation as required under § 2390.156(e). (16) Recommending a revision to a service or outcome in the ISP as provided under § 2390.156(c)(4). (17) Coordinating the services provided to a client. (18) Coordinating the training of direct service workers in the content of health and safety needs relevant to each client. (19) Developing and implementing provider services as required under § 2390.158 (relating toChecklist of regulation 2390.33 Program Specialist responsibilities reviewed and signed by Program Specialist and Program Specialist Manager. 10/21/2016 Implemented
2390.67Purell hand sanitizer and Spray Nine bottles were unlocked in the main program area. Flammable Liquid was unlocked in the basement work area, Sani-cloth disinfectant wipes were unlocked in the program area, and disinfectant was unlocked in the men's bathroom. Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.The Purell hand sanitizer has been removed from the program area. The Spray Nine bottles are kept in a locked container when not in use. When in use, the use of the bottles is supervised directly by staff. The Flammable Liquids cabinet has been locked, and will remain locked with access by staff only. Sani-cloth disinfectant wipes have been placed in a locked cabinet, which will only by accessed by staff as well. The disinfectant in the men's bathroom has been removed and disposed of. 10/21/2016 Implemented
2390.124(10)Individual #1's record did not contain a current copy of the Individual Support Plan.Each client's record must include the following information: A copy of the current ISP.Quarterly Checklist: Copy of current ISP See questions and attachment #13 10/21/2016 Implemented
2390.124(12)Individual #4's 4/22/16 assessment indicated he/she was safe and was not safe with poisonous materials. Indvidual #4's Individual Support Plan indicated he/she was safe with poisons. Individual #2's social, emotional, environmental needs plan indicated a behavior support plan was in place. Individual #2's Individual Support Plan (ISP) indicated there was not a behavior support plan in place. Individual #3's ISP indicated Clonazepam and Buproprion were treating depression. The social, emotional, environmental needs plan indicated medications were treating mood disorder, major depressive disorder, and rec nos. Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.Clarification of discrepancies will be discussed with team members at ISP meeting. Discrepancies will be corrected in so mentioned files 06/30/2017 Implemented
2390.151(c)Individual #5's 1/5/16 assessment did not include the basis of the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations.Assessment Checklist: Checklist to include assessment based on assessment instruments, interviews, progress notes and observations. Checklist reviewed by staff other than clients Program Specialist. See questions and attachment #4 10/21/2016 Implemented
2390.151(e)(6)Individual #6's 2/1/16 assessment and Individual #7's 4/19/16 assessment did not include knowledge of safety around poisons. 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.Assessment Checklist: Checklist to include knowledge of safety around poisonous materials. Checklist reviewed by staff other than clients Program Specialist. See questions and attachment #5 10/21/2016 Implemented
2390.151(e)(9)Individual #8's 3/12/16 assessment did not include information regarding his/her vegal nerve stimulator, seizures, or his/her inability to ambulate stairs. Individual #11's 8/16/16 assessment and Individual #5's 1/5/16 assessment did not include functional and medical limitations. The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.Assessment Checklist: Checklist to include functional and medical limitations . Checklist reviewed by staff other than clients Program Specialist. See Questions and attachment #6 10/21/2016 Implemented
2390.151(e)(10)Individual #10's 11/9/15 assessment and Individual #8's 3/24/16 assessment did not include an updated medical history. Individual #3's 4/29/16 assessment, Individual #6's 2/1/16 assessment, Individual #11's 8/16/16 assessment, Individual #7's 4/19/16 assessment, and Individual #5's 1/5/16 assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.Assessment Checklist: Checklist to include lifetime medical history (Attached) Assessment checklist to be reviewed by staff other than client's Program Specialist. Annual Checklist: Checklist to include Lifetime medical updated. Annual checklist will be reviewed by Rehab Manager 10/21/2016 Implemented
2390.151(e)(13)(i)Individual #8's 3/24/16 assessment, Individual #7's 4/19/16 assessment, and Individual #6's 2/1/16 assessment did not include progress over the past year in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Assessment Checklist: Checklist to include progress over the past year in health. Checklist to be reviewed by staff other then the clients Program Specialist. See questions and attachment #7 10/21/2016 Implemented
2390.151(e)(13(ii)Individual #2's 5/20/16 assessment, Individual #6's 2/1/16 assessment, Individual #7's 4/19/16 assessment, and Individual #11's 8/16/16 assessment did not include progress over the past year in motor and communicaiton skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.Assessment Checklist: Checklist to include progress over the past year in motor and communication skills. Checklist to be reviewed by staff other then the clients Program Specialist. See questions and attachment #8 10/21/2016 Implemented
2390.151(e)(13)(iii)Individual #6's 2/1/16 assessment and and Individual #11's 8/16/16 assessment did not include progress over the past year in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Assessment Checklist to include progress over the past year in personal adjustment. Checklist reviewed by staff other than clients Program Specialist. See questions and attachment #9 10/21/2016 Implemented
2390.151(e)(13(iv)Individual #9's 5/20/16 assessment and Individual #11's 8/16/16 assessment did not include progress over the past year in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Assessment Checklist to include progress over the past year in socialization. Checklist reviewed by staff other than clients Program Specialist. See questions and attachment #10 10/21/2016 Implemented
2390.151(e)(13)(v)Individual #6's 2/1/16 assessment and Individual #8's 3/24/16 assessment did not include progerss over the past year in vocational skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills.Assessment Checklist: Checklist to include progress over the past year in vocational skills. Checklist to be reviewed by staff other then the clients Program Specialist. See questions and attachment #11 10/21/2016 Implemented
2390.151(f)There was no documentation to show Individual #3¿s 4/29/16 assessment and Individual #6's 2/1/16 assessment was sent to plan team members. Individual #5's 1/5/16 assessment was sent on 1/5/16 for a 2/1/16 Individual Support Plan (ISP) meeting. Individual #7's assessment was completed on 4/19/16. The ISP meeting was held on 5/11/16. 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).Assessment Checklist: Checklist to include checking to confirm the assessment is sent 30 days prior to the scheduled meeting. Checklist to be reviewed by staff other then the clients Program Specialist. See questions and attachment #12 10/21/2016 Implemented
2390.152(d)(5)There was no documentation to show that Individual #5's Individual Support Plan (ISP) was sent to the plan team members. The plan lead shall develop, update and revise the ISP according to the following: Copies of the ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision), shall be provided as required under §  2390.157 (relating to copies).Copies to will be added to the ISP. Annual Meeting checklist: Checklist will include ISP sent to plan team members. Rehab Manger will review Annual Checklist. 10/21/2016 Implemented
2390.153(1)Individual #3¿s 05/29/16 Individual Support Plan (ISP) did not include services provided or outcomes chosen by Individual #3. Individual #5¿s ISP did not include the outcome action steps for the increased vocational skills outcome. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Services provided to the client and expected outcomes chosen by the client and client's plan team.ISP Checklist with areas relevant to the vocational environment including services provided to the client and expected outcomes chosen by the client and clients plan team. Checklist will be completed by the Program Specialist and reviewed by the Rehab Manager. Request for "relevant" to vocational program requested. (BHSL) 11/21/2016 Implemented
2390.153(3)Individual #3¿s 5/29/16 Individual Support Plan (ISP) and Individual #5¿s ISP did not include current status of the outcome or a method of evaluation used to determine progress. Individual #6¿s 3/7/16 ISP did not include a method of evaluation used to determine progress. Individual #4's ISP did not include a method of evaluation used to determine progress for the employment outcome. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.ISP checklist with areas relevant to the vocational environment including Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. Checklist will be completed by Program Specialist and reviewed by Rehab Manager. Request for "relevant" to vocational program requested. (BHSL) 11/21/2016 Implemented
2390.153(4)Individual #5¿s Individual Support Plan (ISP) does not include supervision needs. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence.ISP checklist with areas relevant to the vocational environment including supervision needs. Checklist will be completed by Program Specialist and reviewed by Rehab Manager. Request for "relevant" to vocational program requested. (BHSL) 11/21/2016 Implemented
2390.153(5)Individual #3¿s Individual Supprt Plan (ISP) and Individual #11's ISP did not include his/her social, emotional, environmental needs 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.ISP checklist with areas relevant to the vocational environment including social, emotion, environment needs plan. Checklist will be completed by Program Specialist and reviewed by Rehab Manager. Request for "relevant" to vocational program requested. (BHSL) 11/21/2016 Implemented
2390.153(7)(i)Individual #3¿s 05/29/16 Individual Support Plan (ISP) and Individual #5¿s ISP did not include 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.ISP checklist with areas relevant to the vocational environment including potential to advance in vocational programming. Checklist will be completed by Program Specialist and reviewed by Rehab Manager. Request for "relevant" to vocational program requested. (BHSL) 11/21/2016 Implemented
2390.153(7)(ii)Individual #3's, #5's, #6's, #10's, and #11's Individual Support Plan did not include potential to advance in competitive 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.ISP checklist with areas relevant to the vocational environment including potential to advance in community - integrated employment . Checklist will be completed by Program Specialist and reviewed by Rehab Manager. Request for "relevant" to vocational program requested. (BHSL) 11/21/2016 Implemented
2390.154(a)(1)(iii)A direct service worker was not present at Individual #3's, #7's, and #11's Individual Support Plan meeting. The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2390.156 (relating to ISP review and revision). A plan team must include as its members the following: A direct service worker who works with the client from each provider delivering a service to the client.Annual Meeting checklist: Included on checklist = Direct Service Worker present at ISP planning meeting. Rehab Manager to review checklist after completion by Program Specialist 10/21/2016 Implemented
2390.156(b)Individual #10¿s 3/09/16 Individual Support Plan (ISP) review was not signed and dated by the program specialist. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.Quarterly Meeting checklist: Included on checklist = ISP review signed and dated by Program Specialist. 10/21/2016 Implemented
2390.156(c)(1)Individual #5's 11/03/15, 02/01/16, 05/16/16, 08/15/16 Individual Support Plan (ISP) reviews did not include progress made towards the increasing vocational skills outcome. 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.Quarterly Review Check: Progress toward outcomes See questions with attachment #14 10/21/2016 Implemented
2390.156(d)Individual #11¿s 3/18/16 Individual Support Plan (ISP) review was not sent to his/her caseworker. 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.Quarterly Meeting checklist: Included on checklist = Date sent 10/21/2016 Implemented
SIN-00079319 Renewal 06/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(a)The evacuation procedures did not include individual responsibilties and means of transportation. 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.Individual responsibilities and means of transportation amended in evacuation procedure. Attachment #8 07/10/2015 Implemented
2390.87Staff #2's hire date was on 8/27/2014 and he was not trained in fire safety untill 8/29/2014. 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.Procedure has been established to ensure fire safety training occurs on the first day of hire. Attachment #10 07/23/2015 Implemented
2390.124(10)Individual #13's record did not contain a current copy of the ISP. Each client's record must include the following information: A copy of the current ISP.Attachment #7 06/24/2014 Implemented
2390.151(a)Individual #13's assessment was completed on 1/24/2014 and then again on 2/19/2015. Does not meet annual time frame.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.Attachment #9 Procedure implemented. 08/01/2015 Implemented
2390.151(e)(13)(i)Individual #11's asessment did not include progress over the last 365 calendar days and current level in health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Revision added to Initial Assessment to include progress and current level in the area of health. Attachment #5 07/20/2015 Implemented
2390.151(e)(13(ii)Individual #11's asessment did not include progress over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.Revision added to Initial Assessment to include progress and current level in the area of motor and communication skill. Attachment #5 07/20/2015 Implemented
2390.151(e)(13)(iii)Individual #10 and #11's asessment did not include progress over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Revision added to Initial Assessment to include progress and current level in the area of personal adjustment. Attachment #6 and Attachment#5 07/20/2015 Implemented
2390.151(e)(13(iv)Individual #11's asessment did not include progress over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Revision added to Initial Assessment to include progress and current level in the area of socialization. Attachment #5 07/20/2015 Implemented
2390.152(d)(2)Individaul #14's ISP was not completed within 90 days. It was not completed at time of licensing. The plan lead shall develop, update and revise the ISP according to the following: The initial ISP shall be developed within 90 calendar days after the client's admission date to the facility.Initial ISP completed. Attachment#4 06/25/2015 Implemented
2390.153(4)Individual #11's ISP completed on 11/7/2014 did not include supervision level in the content. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence.Request for revision to ISP to include supervision level sent to SAM Support's Coordinator Amanda Texter. Attachment #2 07/20/2015 Implemented
2390.153(5)Indvidual #11's ISP completed on 11/7/2014 did not a contain SEEN PLAN in the content. 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 plan implemented. Attachment #3 06/26/2015 Implemented
2390.153(7)(i)Individual #11's ISP did not include 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.Request for revision to ISP to include potential to advance in vocational programming sent to SAM Support's Coordinator Amanda Texter. Attachment #2 07/20/2015 Implemented
2390.153(7)(ii)Individual #11's ISP did not include potential to advance in 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.Request for revision to ISP to include potential to advance in community integrated employment sent to SAM Support's Coordinator Amanda Texter. Attachment #2 07/20/2015 Implemented
2390.156(e)Individual #10's option to decline the ISP review documentation was not sent to the entire team. Individual #10's mother was not sent a copy. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Signature sheet with notification sent to mother. Attachment #1 07/21/2015 Implemented
SIN-00063432 Renewal 06/16/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)The assessment for Individual #1 was not completed in the regulatory timeframe. Individual #1 had an initial assessment completed on 4/21/2014. He began working at OSI on 1/29/2014. 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.Program Specialist will be trained on regulatory timeframes by 8-21-14. Rehab Manager will monitor timeliness of Assessment Completion consistent with regulations. This will be accomplished by charting due dates. 08/21/2014 Implemented
2390.151(e)(3)(ii)The assessment for Individual #1 and Individual #6 did not include the ability to receive, retain, and carry out instructions.The assessment must include the following information: The client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions.Revised Assessment to state ability to receive, retain and carry out instructions. PS will be trained on revision. PS will be responsible to include ability to receive, retain and carry out on the assessment annually. Monitored by file audit. 1 to be completed by 9-18-14. Attachment #1-6 correction. 08/29/2014 Implemented
2390.151(e)(8)The assessment for Individual #1 did not include his ability to evacuate in the event of a fire. The assessment must include the following information: The client's ability to evacuate in the event of a fire.Revised assessment to state ability to evacuate in the event of a fire. PS will be trained on revision. PS will be responsible for noting ability to evacuate on the assessment annually. Monitored by file audit. #1 will be completed by 9-18-14 08/29/2014 Implemented
2390.151(e)(10)The assessment for Individual #6 and Individual #9 did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.Lifetime Medical Form has been designed and distributed to all clients who do not have a Lifetime Medical Form by 10-18-14. Lifetime Medical Forms will be required prior to admission process. PS will be responsible for including Lifetime Medical in assessment annually. Monitored by file audit. Attachments #2-6 and attachment #2-9 for correction. 10/18/2014 Implemented
2390.152(d)(3)The ISP for Individual #1 and Individual #2 was not on the Department designated form located in HCSIS.The plan lead shall develop, update and revise the ISP according to the following: The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) And also on the Department's web site.MH client ISP's will be converted to Department designated form by 1-1-2015. New admissions will be on Department Designated form. #1 and #6 will be converted to HCSIS form by 9-18-14. PS will be trained on Department designated HCSIS form. 12/31/2014 Implemented
2390.153(3)The ISP for Individual #1 and Individual #2 did not include the current status per outcome and how to determine outcome progress toward the expected outcome. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.Client #1 and #2 information will be converted to department designated HCSIS ISP form which includes outcome and outcome progress by 9-18-14. 09/18/2014 Implemented
2390.153(5)The SEEN plan for Individual #1 was not in the ISP.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.Client #1 information will be converted to Department designated HCSIS ISP form which includes SEEN plan by 9-18-14. 09/18/2014 Implemented
2390.156(c)(1)The ISP reviews for Individual #3, #6, #7, #8, and #11 did not include progress from the past three months on the ISP outcomes. 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.Progress from the last three months has been added to the quarterly reviews. PS will be trained on revision of progress in the quarterly reviews. PS will be responsible for noting progress over the three months on ISP reviews on a quarterly basis. Monitored at file audit. Attachments #3 as follows: #3-3Sep #3-3Dec #3-3Mar #3-6Mar #3-7Sept #3-7Dec #3-7Mar #3-7Jun #3-8Jul #3-8Oct #3-8Jan #3-8Apr 08/29/2014 Implemented
2390.156(c)(2)The ISP reviews from July 2013 and October 2013 for Individual #9 did not review her SEEN plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.SEEN Plan was added to the ISP review in December of 2013. PS will be retrained on the revision of review of SEEN plan in ISP review. #9. Monitored by file audit. Attachment #4July and #4October for correction. 08/29/2014 Implemented
2390.157There was no documentation to show that Individual #1's ISP was sent to team members within 30 days of the ISP meeting. A copy of the ISP, ISP annual update and ISP revision, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, ISP annual update and ISP revision meetings.Documentation has been added to the Designated HCSIS ISP form to include the distribution of the ISP to team members w/i 30 days of the meeting. PS will be trained on revision. PS will be responsible for sending ISP to team w/i 30 days of meeting on an annual basis. 09/18/2014 Implemented
SIN-00185156 Renewal 03/23/2021 Compliant - Finalized
SIN-00164895 Renewal 12/17/2019 Compliant - Finalized