Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222289 Renewal 05/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)An unannounced fire drill was not conducted in the month of September 2022.An unannounced fire drill shall be held at least once a month.Provider will conduct an unannounced fire drill every month. Adult Day Director has made a schedule, that only the director has access to, with the scheduled date of each month's fire drill for the year and an alternate date if needed. 10/14/2022 Implemented
2380.113(c)(2)Staff #2's physical exam dated 12/11/22 did not include tuberculin skin testing with negative results.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Staff #2's tuberculin skin testing with negative results was completed on 12/13/2022. Documentation of satff 2's negative results was obtained on 5/16/2023 05/16/2023 Implemented
2380.173(1)(v)Individual #1 and Individual #2's individual records do not contain current, dated photographs.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Current dated photographs of individual #1 and #2 were taken and added to their files on 5/17/2023. All other individuals current dated photographs we taken and added to their files by 5/18/23 05/18/2023 Implemented
2380.39(c)(1)Staff # 1 and Staff #3 did not receive annual training in the application of community integration and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff #1 completed all required annual training (the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationship), on 5/18/23. Staff #3 completed all required annual training, (the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships), on 5/26/23 05/26/2023 Implemented
SIN-00208063 Renewal 06/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)There were approximately 16 clear, unlabeled bottles of a sanitizing or cleaning solution in the locked poisons closet. With the bottles, there was a single printed page stating that the product was "MediClean Germicidal Cleaner." Poisonous materials must be stored in their original, labeled containers.Poisonous materials shall be stored in their original, labeled containers.The 16 bottles were removed from the locked poison closet, emptied and discarded. 06/03/2022 Implemented
2380.87(b)Two Individuals currently attending the the facility's program are hearing-impaired and there were no strobes or other equipment in the bathrooms to alert the hearing-impaired in the event of a fire.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Two strobes were installed in the bathrooms to alert individuals with hearing impairments in the event of a fire 07/18/2022 Implemented
2380.89(c)The written fire drill record for the drill that occurred on 4/29/2022 did not record whether the fire alarm was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.The fire drill record for April 29, 2022 was corrected to reflect that the fire alarm was operable. 06/03/2022 Implemented
2380.181(e)(14)The annual assessment completed on 5/31/2022 for Individual #1 and the annual assessment completed on 9/15/2021 for Individual #2 did not document the Individuals' ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.The assessments for every active participant were updated to include the individual's ability to swim 06/21/2022 Implemented
2380.21(u)The facility informed Individual #1 and Individual #2, of their Individual Rights, however, the rights statement used by the facility has not been updated to reflect the Individual Rights in the current Chapter 2380 regulatory chapter.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The individual rights were updated to reflect the individual rights in the current chapter 2380 regulator chapter. The updated rights were sent to each individual/family member, signed and returned to the agency. 08/08/2022 Implemented
SIN-00181756 Initial review 01/22/2021 Compliant - Finalized