Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225135 Renewal 07/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(ii)Individual #1's Individual Record did not include information relating to the presence or absence of identifying marks on the individual. A document titled "PERSONAL DATA/FACE SHEET" contained an item to record identifying marks, if any; the space next to this item on the form was blank. It could not be determined whether Individual #1 lacks identifying marks or whether this area was left blank unintentionally. If an individual lacks identifying marks, the form should state so clearly.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The provider immediately corrected the violation by adding an identifying mark ¿beauty mark on left cheek¿ on the individuals facesheet. Correction made on 8/3/23. 08/03/2023 Implemented
2380.181(e)(10)Individual #3's Individual Assessment, dated 11/03/2022, did not contain a Lifetime Medical History. Although a document titled "Lifetime Medical History/Updates" was located in the Individual Record near the Assessment, this document contained only medical information from the year preceding the Assessment. A Lifetime Medical History should contain all known and relevant medical information occurring across the individual's lifespan. Individual #2's Individual Assessment, dated 05/01/2023, did not contain a Lifetime Medical History.The assessment must include the following information: A lifetime medical history.-The provider immediately corrected the violation by compiling information from the individual¿s family and ISP from Current Health Status, General Health, and Know and Do section. Correction made 8/3/23. 08/04/2023 Implemented
SIN-00207195 Renewal 07/27/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(b)There was no blanket in the first aid area.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.1. The provider immediately corrected the violation by placing a blanket from the Program Specialist office onto the first-aid bed. Correction made prior to licensing representatives leaving the ATF on 7/27/22. 08/01/2022 Implemented
2380.111(a)Individual #1 had a late annual physical examination. The Individual's previous physical occurred on 2/17/2021, and the current on 3/11/2022.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.1. Program Specialists added all physical due dates, as well as, immunizations to the outlook calendar shared by all of Day Program Management. All Program Specialist caseloads has been added as of 8/19/22. 2. Once physical form is received by a member of Day Program Management, it will be reviewed and initialed by the Program Specialist, as well as, the Operations Director. Starting 8/23/22. 08/23/2022 Implemented
2380.181(e)(10)The initial assessment completed on 4/11/2022 for Individual #2 did not contain a lifetime medical history. The annual assessment completed on 12/02/2021 for Individual #3 did not contain a lifetime medical history. The annual assessment completed on 3/14/2022 for Individual #4 did not contain a lifetime medical history.The assessment must include the following information: A lifetime medical history.1. The provider began reaching out to support teams regarding medical history for individuals #2, #3, #4, as well as the remainder of the program participants. This provider created a form to send out to all the individuals, families, and other providers, for additional lifetime medical information. Program Specialists for individuals #2, #3, and #4 will complete the lifetime medical history and attach to the skills assessment by 9/9/22 09/09/2022 Implemented
2380.186The facility shall implement the individual plan, including any revisions. There are individuals who attend the program who have restrictions regarding sharps -- sharps need to be locked or inaccessible in their presence. At the time of the inspection, 3 butter knives were found unlocked and accessible in a drawer in the small kitchen/dining area located off the second program area. Several sharp, pronged "BBQ-style" forks were found in a drawer in the larger kitchen/dining area located off the main program area.The facility shall implement the individual plan, including any revisions.The provider immediately corrected the violation by removing the sharp objects, including knives and BBQ forks, with the assistance of the licensing representatives. All sharp objects removed were placed into a locked area of the main kitchen area. This will continue to be utilized as the area in which the sharp objects are to be kept. Correction made prior to licensing representatives leaving the ATF on 7/27/22. 08/01/2022 Implemented
SIN-00170283 Renewal 01/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2's and Individual #3's annual physicals were late. Individual #1 had one on 02-27-18, then not again until 04-29-19. Individual #2 had one 11-12-18, then not again until 12-19-19.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.1) A list of all consumers TB dates/DPT dates/Physical due dates was made immediately and stored on the share drive where all day program management can access it to reference the people on their caseload and update as needed. 2) New consumers information will be added to the master list upon agreement to provide services. Information will be checked prior to their start date to ensure that the dates are within the appropriate timeframes for them to begin receiving services. 3) Reminders will be added on management outlook calendars upon receipt of documentation (physical with immunization dates) to be able to adhere to upcoming due dates and the respective reminder dates. 4) Reminders for upcoming TB/DPT/Physical due dates will be sent to families/providers a minimum of 45 days and then additionally 30 days prior to the date that they will be due/expire. 01/30/2020 Implemented
2380.111(c)(5)Individual #1's TB test was late. He had the test completed on 10-03-17 then not again until 10-21-19, which is outside of the 15-day grace period windowThe physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.1) A list of all consumers TB dates/DPT dates/Physical due dates was made immediately and stored on the share drive where all day program management can access it to reference the people on their caseload and update as needed. 2) New consumers information will be added to the master list upon agreement to provide services. Information will be checked prior to their start date to ensure that the dates are within the appropriate timeframes for them to begin receiving services. 3) Reminders will be added on management outlook calendars upon receipt of documentation (physical with immunization dates) to be able to adhere to upcoming due dates and the respective reminder dates. 4) Reminders for upcoming TB/DPT/Physical due dates will be sent to families/providers a minimum of 45 days and then additionally 30 days prior to the date that they will be due/expire. 01/30/2020 Implemented
SIN-00150504 Renewal 02/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)There were 2 failed fire drills in February. On 2/6/2019 and 2/7/2019, Individual #4 refused to evacuate during both fire drills.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Operations Director and Day Program Specialist met with Individual #4 to discuss the importance of exiting the building during a fire drill. Fire safety materials were reviewed with individual #4. one time monthly program specialist will conduct a mock fire drill for individual #4 and document his progress. 03/14/2019 Implemented
2380.111(c)(1)This section was blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: A review of previous medical history.A review of previous medical history has been completed on individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books 04/03/2019 Implemented
2380.111(c)(4)Hearing screening was blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Hearing screening has been completed on individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books. This physical examination includes Vision and hearing screening 04/03/2019 Implemented
2380.111(c)(7)All 3 of these areas were blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Assessment of the individuals health and maintenance needs, medication regimen and the need for blood work at recommended intervals have been completed on individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books 04/03/2019 Implemented
2380.111(c)(8)This section was blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: Physical limitations of the individual.Physical Limitations has been added to Individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books 04/03/2019 Implemented
2380.111(c)(9)This section was blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: Allergies or contraindicated medication.Allergies and contraindicated medications have been added to Individual#3 Physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books 04/03/2019 Implemented
2380.111(c)(10)This section was blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Medical information pertinent to diagnosis and treatment in case of an emergency has been completed on individual #3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books 04/03/2019 Implemented
2380.111(c)(11)This section was blank on Individual #3's physical exam dated 2/9/2019.The physical examination shall include: Special instructions for an individual's diet.Special Instructions for Individual's has been added to the physical. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books 04/03/2019 Implemented
2380.181(e)(13)(i)Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018.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.Day Program Operations Director has updated Individual #1, Individual #2, and Individual #3 skills assessments to include section "Progress during past year" . Director also updated section documentation of disability which includes current disability, diagnosis and medical limitations. ((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) 03/05/2019 Implemented
2380.181(e)(13)(ii)Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018.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.Progress and Growth section has been currently updated for Individual #1, Individual #2, and Individual #3. All motor and communication skills have been updated on skills assessments 03/08/2019 Implemented
2380.181(e)(13)(iii)Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018.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 has been updated to reflect the following section : Personal Adjustment. Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Personal Adjustment. ((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) 03/08/2019 Implemented
2380.181(e)(13)(iv)Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018.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 has been updated to reflect the following section : Socialization. Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Socialization.. ((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) 03/08/2019 Implemented
2380.181(e)(13)(v)Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Assessment has been updated to reflect the following section : Recreation Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Recreation. ((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) 03/08/2019 Implemented
2380.181(e)(13)(vi)Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Assessment has been updated to reflect the following section : Community Integration Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Community Integration. ((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) 03/08/2019 Implemented
SIN-00130471 Renewal 02/23/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1's most recent TB test occurred on 8/01/17, and the previous test was 6/08/15. Individual #2's most recent TB test occurred on 3/09/17, and the previous test was 2/16/15. Individual #3's most recent TB test occurred on 2/01/16.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.1. The provider will ensure all program participants are current with their tuberculin skin (TB) testing required every two years (or chest x-ray with results noted). 2. Immediately following the licensing visit exit interview on 2/23/2018, the provider¿s Program Coordinator communicated with her three Program Specialists the importance of ensuring all program participants have current physical examination forms reflecting current TB tests with results noted. 3. To prevent future recurrence of this issue, assigned Program Specialists will schedule tuberculin skin (TB) testing expiration dates as appointment reminders in Outlook to ensure timeframes are maintained. The TB test Outlook reminders will be created for a minimum of one month prior to the actual expiration date. In addition, letters noting soon-due physicals/TB testing will be sent to consumer families a minimum of one month prior to the actual expiration date. If expiration is nearing, Supports Coordinators will also be notified by assigned Program Specialists. 4. The assigned Program Specialist is responsible for ensuring compliance specific to 2380.111(c)(5) Tuberculin skin testing with negative results every two years; or, if the tuberculin skin test is positive, an initial chest x-ray with results noted. The Program Coordinator will oversee implementation of this POC and ensure ongoing compliance via monthly review of consumer records in addition to a routine review of Outlook meetings scheduled via shared calendar viewing. Any further issue of non-compliance during the review process will be remedied immediately through retraining and/or progressive disciplinary action steps. ((Individual #3 will immediately receive a TB test -CH 5/8/18)) 02/23/2018 Implemented
2380.181(f)The annual assessment for Individual #1 was completed on 5/04/17 and was not provided to the Supports Coordinator and team at least 30 days prior to the annual ISP meeting which was held on 5/04/17.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).1. The provider will ensure consumer assessments are completed and sent to support team members at least 30 calendar days prior to ISP meetings. Email communication will be printed and placed in consumer record as proof assessment was sent to Supports Coordinator in a timely manner. 2. Immediately following the licensing visit exit interview on 2/23/2018, the provider¿s Program Coordinator communicated with her three Program Specialists the importance of timely assessment completion and dissemination to the appropriate team members to best prepare for the development, annual update, and revision of consumer ISP¿s. 3. To prevent future recurrence of this issue, assigned Program Specialists will schedule assessments as appointment reminders in Outlook to ensure timeframes are maintained. 4. The assigned Program Specialist is responsible for ensuring compliance specific to 2380.181(f) The program specialist shall provide the assessment to the SC, 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. The Program Coordinator will oversee implementation of this POC and ensure ongoing compliance via monthly review of consumer records in addition to a routine review of Outlook meetings scheduled via shared calendar viewing. Any further issue of non-compliance during the review process will be remedied immediately through retraining and/or progressive disciplinary action steps. 02/23/2018 Implemented
SIN-00111071 Initial review 03/30/2017 Compliant - Finalized