Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244073 Renewal 05/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Documentation indicates that Individual #5 had a Tuberculin skin test completed on 3/9/21 then again on 4/1/23. This exceeds the two-year time frame and grace period.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.For Physical Examination Procedures following will be implemented for program participants. 1) 3 months prior to the due date, the individual will receive a letter stating the date the completed physical form/TB test with results (DATE) is due. They will be informed that they will not be allowed to attend if the physical form is not received. A blank Physical Form will be included. 2) On the date the Physical form is due, a reminder letter will be sent with the same information in number 1. They will also be informed they will not be able to attend after the 15-day grace period if the competed physical exam/ TB test with results (DATE needed) is not received. A blank Physical form will be included. 3) If necessary, at the beginning of the 15-day grace period, the provider will be notified the last day the individual can attend until the requested information/forms is received. 05/27/2024 Implemented
2380.173(1)(v)Individual #1 began attendance on 9/14/23. The picture in his record was dated 8/26/19. Pictures must be current.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Every Adult Training component now has cameras to take photos. Managers can now take photos on a regular basis. They will use the Electronic Recordkeeping System, Awards, to access the individuals Face Sheet. Click update face sheet photo, then choose file. Then select downloaded photo from computer. 05/28/2024 Implemented
SIN-00224736 Renewal 05/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Tuberculin skin testing with negative results every 2 years. Individual #1 had a Tuberculin skin testing with negative results on 11/22/19 and their next one occurred on 1/28/22. This exceeds the requirement.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.May 10, 2023 - At Prospectus Berco the Health Care Coordinator (HCC) notifies program participants, their families and or providers of their need to have physicals and TB test done in accordance with the licensing regulations. THE HCC receives and reviews all Physical examinations including TB tests after they have been completed to ensure that all required information is accurate and timely. May 10, 2023 - The Associate Director will receive copies of all Physical examinations including TB tests, for Chapter 2380 program participants. They will perform a second review that all information is accurate and within time frame to remain in compliance with applicable regulations. May 10, 2023 - Effective immediately the Director will review the dates of each program participant's TB test to remind the HCC and Associate Director of the due dates. No other violations were noted with TB tests. 05/31/2023 Implemented
SIN-00165233 Renewal 12/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(13)(i)Progress and growth over the last 365 days was not noted anywhere in the assessment in the area of Health in Individuals 1's, 2's, 3's, 4's, or 5's.filesThe assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Donna Trexler, Adult Training Director developed an addendum to the current assessment for individuals¿ 1,2,3,4 and 5. The addendum included the information on ¿Progress and Growth: Describe the progress and growth over the past 365 days in the areas of health, motor and communication skills, personal adjustment, and socialization (Include current level in each area):¿ This specific citation related to the area of Health. This document was completed and signed by Program Specialists Eileen Slovik and Heather Grasso. The addendum will then be attached to the current assessment by the Program Specialist. Completed documentation for individuals¿ 1, 2, 3, 4, and 5 will be attached to this Plan of Correction. Attached to this POC is the revised assessment which has been changed to include the above listed quotation. The new assessment will address this citation moving forward. The new assessment has been provided to Program Specialists on December 27, 2019, and will be utilized immediately. 12/30/2019 Implemented
2380.181(e)(13)(ii)Progress and growth over the last 365 days was not noted anywhere in the assessment in the area of Motor / Communication skills in Individuals 1's, 2's, 3's, 4's, or 5's.files.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.Donna Trexler, Adult Training Director developed an addendum to the current assessment for individuals¿ 1,2,3,4 and 5. The addendum included the information on ¿Progress and Growth: Describe the progress and growth over the past 365 days in the areas of health, motor and communication skills, personal adjustment, and socialization (Include current level in each area):¿ This specific citation related to the area of Motor/Communication Skills. This document was completed and signed by Program Specialists Eileen Slovik and Heather Grasso. The addendum will then be attached to the current assessment by the Program Specialist. Completed documentation for individuals¿ 1, 2, 3, 4, and 5 will be attached to this Plan of Correction. Attached to this POC is the revised assessment which has been changed to include the above listed quotation. The new assessment will address this citation moving forward. The new assessment has been provided to Program Specialists on December 27, 2019, and will be utilized immediately. 12/30/2019 Implemented
2380.181(e)(13)(iii)Progress and growth over the last 365 days was not noted anywhere in the assessment in the area of Personal Adjustment in Individuals 1's, 2's, 3's, 4's, or 5's.filesThe 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.Donna Trexler, Adult Training Director developed an addendum to the current assessment for individuals¿ 1,2,3,4 and 5. The addendum included the information on ¿Progress and Growth: Describe the progress and growth over the past 365 days in the areas of health, motor and communication skills, personal adjustment, and socialization (Include current level in each area):¿ This specific citation related to the area of personal adjustment. This document was completed and signed by Program Specialists Eileen Slovik and Heather Grasso. The addendum will then be attached to the current assessment by the Program Specialist. Completed documentation for individuals¿ 1, 2, 3, 4, and 5 will be attached to this Plan of Correction. Attached to this POC is the revised assessment which has been changed to include the above listed quotation. The new assessment will address this citation moving forward. The new assessment has been provided to Program Specialists on December 27, 2019, and will be utilized immediately. 12/30/2019 Implemented
2380.181(e)(13)(iv)Progress and growth over the last 365 days was not noted anywhere in the assessment in the area of Socialization in Individuals 1's, 2's, 3's, 4's, or 5's.files.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.Donna Trexler, Adult Training Director developed an addendum to the current assessment for individuals¿ 1,2,3,4 and 5. The addendum included the information on ¿Progress and Growth: Describe the progress and growth over the past 365 days in the areas of health, motor and communication skills, personal adjustment, and socialization (Include current level in each area):¿ This specific citation related to the area of socialization. This document was completed and signed by Program Specialists Eileen Slovik and Heather Grasso. The addendum will then be attached to the current assessment by the Program Specialist. Completed documentation for individuals¿ 1, 2, 3, 4, and 5 will be attached to this Plan of Correction. Attached to this POC is the revised assessment which has been changed to include the above listed quotation. The new assessment will address this citation moving forward. The new assessment has been provided to Program Specialists on December 27, 2019, and will be utilized immediately. 12/27/2019 Implemented
SIN-00144674 Renewal 12/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #4's most recent physical examination is dated 5/23/18 and the previous physical examination occurred on 5/05/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #4 attended program approximately 2 hours on 5-21-18, the day after he was not to be in attendance. Staff did not immediately recognize that he was not to be in attendance on this date if a physical was not obtained. His residential provider was notified, but pick-up did not occur for 2 hours. Reminder letters were sent to Individual #4¿s residential provider on 5/2/18 and again on 5/16/18. This plan of correction will be to ensure staff are aware when a program participant can¿t attend program due to an expired physical. A manager or the Health Care Coordinator will call the residential provider the day before the grace period has expired to ensure the individual does not come to program unless they have a current completed physical. Training in this procedure will be provided by Donna Trexler no later than 1/4/19. 01/04/2019 Implemented
2380.181(f)Individual #1's assessment dated 6/09/18 was not sent to the supports coordinator and the team at least 30 days before the annual meeting which was held 6/19/18. Individual #2's assessment dated 11/01/18 was not sent to the supports coordinator and the team at least 30 days before the annual meeting which was held 11/27/18. Individual #3's assessment dated 6/01/18 was not sent to the supports coordinator and the team at least 30 days before the annual meeting which was held 6/11/18. (repeat violation 1/3/18)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).Individuals #1 and #2 were new program participants and the assessment was completed after they were in attendance for approximately 2 months. Individual #1¿s start date was 4/9/18 and Individual #2 started on 9/4/18. For new program participants, the plan of correction will be to complete the assessment within the first week of attendance and ensure that the Support Coordinator does not schedule a meeting prior to 30 days following the receipt of the completed assessment. This information will be shared through training of all managers no later than January 4, 2019, by Donna Trexler, Program Director. Individual #3¿s assessment was dated 3/12/18 and Individual #4 is the program participant with the assessment dated 6/1/18. The plan of correction will be to ensure the Support Coordinator does not reschedule a meeting earlier than previously scheduled to allow for receipt of the assessment in a timely manner. Managers will need to not allow a meeting be rescheduled earlier to allow this regulation to be met. Training in this POC will be done no later than 1/4/19 by Donna Trexler. All assessments are being completed during the 2nd quarterly meeting which allows for this regulation to be met. This Plan was put in to place following the 2017 licensing. 01/04/2019 Implemented
2380.183(5)Individual #3 is prescribed psychotropic medication to treat the symptoms of a diagnosed psychiatric illness and there was no protocol to address the social, emotional and environmental needs of the individual (SEEP).The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.On 12-11-2018, on the Day of Inspection, A SEEP was immediately written and reviewed with all staff working with individual #3. Training on this regulation will be completed for all managers responsible for writing SEEP's and the training the staff. This training will be completed by Donna Trexler, Program Director by 1/4/2019. Included in the training will be a review of procedures when a new medication is added to an individuals regimen as well as a review when new program participants come to the program to ensure all SEEP's are written in a timely manner. A review of all current program participants medications will be conducted to ensure all SEEP's are written and reviewed. This will be completed by 1/4/2019. Donna Trexler will review all results of this review. 01/04/2019 Implemented
SIN-00125308 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 had fire safety training on 6/10/2016. She didn't receive it again until 6/30/2017, which exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Fire safety training for direct service workers and program specialists will be completed bi-annually to ensure all are trained in a timely manner to meet the requirements of this regulation. A written record of this fire safety training will be held biannually. Donna Trexler, Program Director is responsible to ensure training is being held. Fire safety training was held on January 26, 2018 and a written record was completed. The next fire safety training will be held in July, 2018. All staff will be trained in regulation 2380.36 (f) and the expectations of staffs¿ role in ensuring compliance. The training will be completed and shared with all staff no later than February 2, 2018, by Donna Trexler. Training records will be added to ¿Training Manager¿ immediately upon completion of training. 02/02/2018 Implemented
2380.53(a)Hand sanitizer was found unlocked on a cart in program room 3.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All staff will be trained in regulation 2380.53 (a) and the expectations of staffs¿ role in ensuring compliance. The training will be completed and shared with all staff no later than February 2, 2018, by Donna Trexler. Training records will be added to ¿Training Manager¿ immediately upon completion of training. Visual cues will be placed in all components as a constant reminder to staff that poisonous materials must remain locked (inaccessible to individuals) when not in use. All visual cues will be available no later than February 2, 2018. 02/02/2018 Implemented
2380.53(c)Mouthwash, with a label instructing to call poison control if ingested, was found stored with food items including 2 boxes of cereal in a cabinet in program room 3's office.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.All staff will be trained in regulation 2380.53 (c) and the expectations of staffs¿ role in ensuring compliance. The training will be completed and shared with all staff no later than February 2, 2018, by Donna Trexler. Training records will be added to ¿Training Manager¿ immediately upon completion of training. Visual cues will be placed in all components as a constant reminder to staff that poisonous materials must be kept separate from food, food preparation surfaces and dining surfaces. All visual cues will be available no later than February 2, 2018. Donna Trexler is responsible for completion of this plan of correction and it will be completed no later than February 2, 2018. 02/02/2018 Implemented
2380.62Emergency numbers were not posted on or near the new telephone in program room 4.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.Telephone numbers of the nearest hospital, police department, fire department, and poison control center were posted on the phone in component #4 on January 3, 2018, the date of inspection. This was completed by Tina Fisher, instructor, immediately upon recognition of deficiency. As phones are replaced within the program Donna Trexler, Program Director will ensure emergency phone numbers are placed on the new phone immediately. Duplicate listings of emergency phone numbers will be printed and hung on the walls by the phones as an alternate and duplicate reference. This task will be completed by Jenny Miller, administrative assistant and hung by program staff no later than February 2, 2018. All staff will be trained in regulation 2380.62 and the expectations of staffs¿ role in ensuring compliance. The training will be completed and shared with all staff no later than February 2, 2018, by Donna Trexler. Training records will be added to ¿Training Manager¿ immediately upon completion of training. 02/02/2018 Implemented
2380.91(a)Individual #1, Individual #3, Individual #4, and Individual #5 all had fire safety training on 6/10/2016. They didn't receive fire safety training again until 6/30/2017, which exceeds the annual requirement. Individual #2 had fire safety training on 6/13/2016. She didn't receive it again until 7/3/2017, which exceeds the annual requirement.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Fire safety training for individuals will be completed bi-annually to ensure individuals are trained in a timely manner to meet the requirements of this regulation. A written record of this fire safety training will be held biannually. Donna Trexler, Program Director is responsible to ensure training is being held. Fire safety training was held on January 26, 2018 and a written record was completed. The next fire safety training will be held in July 2018. All staff will be trained in regulation 2380.91 and the expectations of staffs¿ role in ensuring compliance. The training will be completed and shared with all staff no later than February 2, 2018, by Donna Trexler. Training records will be added to ¿Training Manager¿ immediately upon completion of training. 02/02/2018 Implemented
2380.181(f)The annual assessment completed on 2/3/2017 for Individual #1 was not provided to the team 30 days prior to the ISP meeting held on 2/13/2017. The annual assessment completed on 3/9/2017 for Individual #2 was not provided to the team 30 days prior to the ISP meeting held on 3/21/2017. The annual assessment completed on 3/17/2017 for Individual #3 was not provided to the team 30 days prior to the ISP meeting held on 3/30/2017. The annual assessment completed on 3/14/2017 for Individual #5 was not provided to the team 30 days prior to the ISP meeting held on 3/30/2017.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).The following new procedure will be implemented beginning February 1, 2018. The program specialist will submit the assessment to the SC at the time of the second quarterly. This will allow for ample time (at least 30 calendar days) prior to the ISP meeting. Jenny Miller (Adult Training Administrative Assistant) will be responsible to send the document to the SC and other plan team members. Jenny will also document the date information was sent to the SC and other plan team members. Awareness of this regulation was made to staff immediately following inspection. Formal training will be completed by February 2, 2018. All staff will be trained in regulation 2380.181 (f) and the expectations of staffs¿ role in ensuring compliance. The training will be completed and shared with all staff no later than February 2, 2018, by Donna Trexler. Training records will be added to ¿Training Manager¿ immediately upon completion of training. 02/02/2018 Implemented
SIN-00108686 Renewal 01/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(e)Staff 1 (instructor/direct care staff) completed fire safety training on 10/26/2015. Staff 1 did not receive fire safety training in 2016. Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.A new orientation form for employees who transfer from a Prospectus Berco residential program to our day program has been developed. The Director of the program has reviewed all staff records and everyone is now up to date, including staff 1. 03/16/2017 Implemented
2380.111(c)(1) Individual 2s physical exam dated 8/5/2016 was left blank in the area of medical history. Individual 5s physical dated 10/7/2016 was left blank in the area of medical history.The physical examination shall include: A review of previous medical history.The Medical History section on individual 2 and individual 5s physical exam forms have been completed by the day services Health Care Coordinator. Individual 2 was corrected on 3/16/17 and individual 5 was completed on 1/25/17. Managers are in the process of reviewing all files to ensure compliance in this area. The correction date for this process is 3/31/17. 03/16/2017 Implemented
2380.111(c)(4)Individual 4s physical exam conducted on 7/5/2016 indicates that the doctor did not complete a vision or hearing screening. The physical examination shall include: Vision and hearing screening, as recommended by the physician.This section on the physical exam form was completed by the doctor with a comment of ¿not done¿. Individual 4 wears hearing aids. 01/19/2017 Implemented
2380.111(c)(7)Physical exams for 3 individuals reviewed did not contain regulated information regarding the individuals' health maintenance needs, medication regimen or the need for blood work. Individual 1s physical dated 3/16/2016 was left in the area of health maintenance needs. Individual 2s physical dated 8/15/2016 was left blank in the area of blood work requirements. Individual 3s physical dated 2/4/2016 was left blank in the areas of access of health maintenance needs, medical regimen, and blood work requirements. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Individual 1 ¿ a letter indicating areas to be completed will be sent to the residential provider on 3/16/17 along with a copy of the physical exam form, with an expected correction date of 4/16/17. Individual 2 ¿ a letter indicating areas to be completed will be sent to the family on 3/16/17 along with a copy of the physical exam form, with an expected correction date of 4/16/17. Individual 3 ¿ a new physical exam form has been received (dated 2/10/17) and the area of health maintenance has been completed. Managers are in the process of reviewing all files to ensure compliance in this area. The correction date for this process is 3/31/17. 03/16/2017 Implemented
2380.111(c)(8) Individual 7s physical exam dated 3/15/2016 states 'no' as a response to physical limitations. However, individual 7 is dependent upon a wheelchair. The physical examination shall include: Physical limitations of the individual.Individual #7 is deceased. However, incoming physical exam forms moving forward will be reviewed to ensure the information is consistent with the assessment and the actual condition of the program participant. 01/23/2017 Implemented
2380.111(c)(10) Physical exams for 2 individuals reviewed did not contain regulated information regarding information pertinent to diagnosis in case of emergency. Individual 1s physical dated 3/16/2016 was blank in this area. Individual 2s physical dated 8/15/2016 was left blank in this area.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical exam form has been revised to separate medical history, and medical information pertinent to diagnosis and treatment in case of emergency. 1¿s PE has been updated/corrected to include information pertinent to diagnosis in case of emergency. A letter will be sent to 2s family so correction can be made. The letter will be sent 3/16/17 with an expected return date of 4/16/17. Managers are in the process of reviewing all files to ensure compliance in this area. The correction date for this process is 3/31/17. 04/16/2017 Implemented
2380.111(c)(11)Physical exams for 2 individuals reviewed did not contain regulated information regarding the individuals' diet. Individual 1' physical dated 3/16/2016 was left in the area of special dietary instructions. Individual 7s physical dated 3/15/2016 responds to the question of special dietary instructions as 'no'. However, according to the individual's ISP, he requires physical assistance in eating; he can utilize a spoon with physical prompts; is given pureed/chopped food due to dysphigia; and if he refuses to eat or his appetite is less (0% - 50% of food eaten) nutrients are to be administered through his peg tube. The annual assessment dated 10/12/2016 states that individual 7 uses a bottle to drink and is on a pureed diet with physical assistance. The physical examination shall include: Special instructions for an individual's diet.Individual #7 is deceased. However, incoming physical exam forms moving forward will be reviewed to ensure the information is consistent with the assessment and the actual condition of the program participant. They will also be reviewed for completeness. Letters will be sent with a copy of the exam form requesting necessary information with an expected return date. For individual #1 a letter was sent to the provider on 3/16/17 with a return date of 4/16/17. 04/17/2017 Implemented
2380.132(9)In the room titled 'the apartment' a deep freezer containing food was unplugged. The freezer contained a strong, sour odor coming from a large 3-gallon container of spoiled vanilla ice cream which had approximately 1 to 2 inches of chunky liquid.If the facility provides or arranges for meals for individuals, the following requirements apply: Cold food shall be kept at or below 45°F. Hot food shall be kept at or above 140°F. Frozen food shall be kept at or below 0°F.The freezer in the apartment is not currently being used. However, moving forward when in use for special events, the freezer will be checked daily by either the director or one of the associate directors to make sure it is at or below 0 degrees. This will be monitored and documented on the Temperature Record Chart. 01/19/2017 Implemented
2380.173(1)(ii)The records of the following 2 individuals do not contain all of the personal information as required. Individuals 2 and 6 had eye color missing from thier personal information.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.¿Eye color¿ was added to face sheets for both individual 2 and individual 6. Managers are in the process of reviewing all files to ensure compliance in this area. The correction date for this process is 3/31/17. 03/13/2017 Implemented
2380.173(9)Individual 1s record contains content discrepancies regarding his abilities with poisons. In individual 1s annual assessment dated 6/29/2016 it states that the individual can safely avoid all poisonous materials with set-up and he can use cleaning supplies to help clean home. The same assessment states 'no' in the question of safely uses poisonous materials and 'no' to avoids poisonous materials. Individual 7s record contains discrepancies in the area of his special dietary needs. Individual 7s physical dated 3/15/2016 responds to the question of special dietary instructions as 'no'. However, the individual's ISP states that he requires physical assistance with eating, has pureed/chopped diet due to dysphagia and must be given 2 cans of ensure Plus via his peg tube daily if he refuses to eat or eats less than 50% of his food. Individual 7s assessment dated 10/12/2016 states that he uses a bottle to drink and requires physical assistance with a pureed diet.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Individual #7 is deceased. However, incoming physical exam forms moving forward will be reviewed to ensure the information is consistent with the assessment and the actual condition of the program participant. The Supports coordinator for individual #1 has corrected the ISP to reflect being unsafe around poisonous materials. An email has been sent to the SC to correct the spelling of the word 'unsafe' in the ISP under the Safety Precaution section of his ISP. This has been corrected. 03/13/2017 Implemented
2380.181(e)(5)Individual 3s annual assessment dated 5/24/2016 does not assess the individual's ability to self-administer medications but has noted that individual 3 does not take any medications at the day program. However individual 3 has a PRN of Lorazepam to be taken prior to appointments. The Lorazepam was noted as being administered on 3/4/3016 and on 11/2/2016. The assessment must include the following information: The individual¿s ability to self-administer medications.Associate Director completed an addendum to the annual assessment, which states: Individual #1 occasionally takes PRN medication prior to appointments. According to her ISP she requires full assistance with medication administration. She does not possess the necessary quantification, discrimination and time association skills necessary to self-medicate. Managers are in the process of reviewing all files to ensure compliance in this area. The correction date for this process is 3/31/17. 03/13/2017 Implemented
SIN-00053220 Renewal 08/23/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.124(a)Individual #1 had a medication lable which read Dantrolene 25mg. The medication log read Dantrolene 2mg. Individual #2 takes Ativan 0.5mg. The name and dosage of the medication was not written on the medication log.(a)  A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.On 8/23/13, date of inspection, staff (SS) corrected the medication log by adding the medication and dosage to the log for individual #2 and staff (MC) corrected the dosage of Dantrolene for individual #1. Medication logs will be reviewed on a monthly basis by the program specialists beginning September 2013. A medication administration review will be conducted at the next in-service day (Nov. 7, 2013) by our certified medication instructors. --Partial Implemented Adequate Progress CH 10/1/13 08/23/2013 Implemented
2380.181(e)(6)The assessment for Individual #3 did not include the ability to safely use or avoid poisonous materials. (e)  The assessment must include the following information: (6)  The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Associate Director (HG) completed an assessment of individual #3 in the area of safely utilizing poisonous materials on the date of inspection. Program specialists were reminded to complete and review documentation, including assessments, in a thorough manner. All documentation will be reviewed prior to filing. --partially Implemented Adequate Progress CH 10/10/13 08/23/2013 Implemented
SIN-00204473 Renewal 06/14/2022 Compliant - Finalized
SIN-00085885 Renewal 01/20/2016 Compliant - Finalized
SIN-00069749 Renewal 10/21/2014 Compliant - Finalized