Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240146 Renewal 02/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual #1, date of hire 09/20/15, was informed and explained client rights and the process to report a rights violation on 01/04/22 and then again on 01/24/24. Individual #1 signed a copy of client rights which was reportedly completed in 2023. However, the signed copy of client rights did not include a date; therefore, compliance could not be measured. [Repeat Violation, 03/23/23]The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Chapter 23.90 21 (U) Individual rights shall be read to every client by their program specialist and will be signed and dated on the day that it was read. All Individual rights documentation will be checked for completeness before being filed in their in personal binders. 03/05/2024 Implemented
2390.152(d)Individual #2's assessment, dated 10/23/23, was not signed by the Program Specialist.The client and persons designated by the client shall be involved and supported in the initial development and revisions of the individual plan.Chapter 2390 152 (D). All Individuals assessments or any documentation needed to be signed by the individual will be done so on the day that the document is presented to the individual. Along with proper date (s). 03/05/2024 Implemented
SIN-00221456 Renewal 03/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #3 completed fire safety training on 3/3/21 and then again 7/13/22. [Repeated Violation---4/27/22]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.All program specialists have received training in the requirements of Chapter 2390.87. Individual received fire safety training on 7/13/22. All individuals will receive fire training in June 2023. Annual training will take place thereafter, with documentation maintained. 03/28/2023 Implemented
2390.124(5)Individual #4 admission date is 9/12/22. Their record indicated their most recent physical examination had been completed on 2/15/22. However, Individual #4's record did not contain a copy of the 2/15/22 physical examination therefore, compliance could not be measured.Each client's record must include the following information: Physical examinations.All program specialists have received training requirements of Chapter 2390.124. Individuals #4 physical form was completed on 2/15/22. Individuals physical form was retrieved and will be placed in his casefile. Documentation will be submitted upon request .All individuals are required to have a physical before being admitted into the program. 03/28/2023 Implemented
2390.151(a)Individual #4's admission date is 9/12/22, and their initial assessment was completed on 1/9/23. [Repeated Violation---4/27/22]Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.All program specialist have been trained in the requirements for chapter 2390.151 (a). 03/29/2023 Implemented
2390.151(e)(2)Individual #4's 1/9/23 assessment did not address their dislikes. This section of the assessment stated, "unknown."The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.All program specialists will receive training in the requirements for the chapter 2390.151 (e). Individual #4 "dislikes" section of the assessment was updated and corrected, Documentation of change will be provided upon request. 03/29/2023 Implemented
2390.151(e)(8)Individual #1's 12/13/22 assessment did not explain their ability to evacuate in the event of a fire. [Repeated Violation---4/27/22] The assessment must include the following information: The client's ability to evacuate in the event of a fire.All program specialist have received training on Chapter 2390.151 (e) (8). Individual #1 assessment has been updated to include the necessary changes. Document will be submitted upon request. 03/29/2023 Implemented
2390.21(u)Individual #1's admission date is 1/3/22, was not informed or explained individual rights. Individual #2's admission date is 10/4/21, was informed and explained client rights on 10/20/21 and then again 2/22/23. [Repeated Violation---4/27/22]The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.All program specialists have been received training in Chapter 2390.21 (u). Individual #1 and #2 going forward will be monitored to make sure that individual rights are explained annually and signed by client. 03/29/2023 Implemented
2390.151(f)Individual #2's assessment completed 6/21/22 was not sent to individual plan team members for the annual review meeting held on 8/10/22. Individual #3's assessment completed 1/31/23 was sent to their individual plan team members on 2/1/23 for an annual review meeting held on 3/2/23.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.All program specialist have received training on Chapter 2390.151 (f). Individuals assessments going forward will be completed in the time allotment that is required. 03/29/2023 Implemented
SIN-00204156 Renewal 04/27/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87The most recent fire safety training for Individual #5 was completed 8/06/2020.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.All Program Specialists have received training in the requirements of Chapter 2390.87. Individual #5 received fire safety training on 4/27/22. Supporting documentation will be sent to the Human Services Licensing Representative under separate cover. All individuals will receive fire safety training in June 2022. Annual training will take place thereafter, with documentation maintained. 06/30/2022 Implemented
2390.151(a)Individual #6, date of admission 10/01/2021, had an initial assessment completed 12/01/2021.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.All Program Specialists have received training in the requirements for Chapter 2390.151 (a). Supporting documentation will be sent to the Human Services Licensing Representative under separate cover. 05/31/2022 Implemented
2390.151(e)(6)Individual #6's assessment completed 12/01/2021, did not the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. 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.All Program Specialists have received training in the requirements for Chapter 2390.151 (e) (6). On 4/29/22, Information from the residential program regarding Individual #6's safety around poisonous materials was obtained. Also, an assessment was made here at the workshop as well. Documentation for this will be sent to the Human Services Licensing Representative under separate cover. 05/31/2022 Implemented
2390.151(e)(8)Individual #2's assessment completed 6/01/2021, did not include the individual's 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.All Program Specialists have received training in the requirements for Chapter 2390.151 (e) (8). Individual #2 has been in this facility for many years and we have never had any issues with her ability to evacuate the facility in the event of a fire. This information has now been added to her assessment. Supporting documentation will be sent to the Human Services Licensing Representative under separate cover. 05/31/2022 Implemented
2390.21(u)The agency's current Individual Rights Policy did not include the following rights:21b the facility shall educate, assist and provide the accommodation necessary for the client to understand the client's rights., 21c A client may not be reprimanded, punished or retaliated against for exercising the client's rights., 21d A court's written order that restricts a client's rights shall be followed., 21f A client who has a court-appointed legal guardian, or who has a court order restricting the client's rights, shall be involved in decision-making in accordance with the court order., and 21g A client has the right to designate persons to assist in decision-making and exercising rights on behalf of the client. Individual #1 and Individual #5 were informed of the individual right's policy on 4/04/2022. Individual #2 was informed of the Individual Right's Policy on 1/04/2022. Individual #3 was informed on the individual right's policy on 1/03/2022. Individual #4 was informed on the individual right's policy on 2/23/2022. Individual #6 was informed on the individual right's policy on 10/01/2021.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.All Program Specialists have received training in the requirements for Chapter 2390.21(u). A new Individual Rights policy has been developed and will be reviewed with all individuals by 5/13/22. Documentation of the new policy and the Program Specialist training will be sent to the Human Services Licensing Representative under separate cover. 05/31/2022 Implemented
SIN-00168682 Renewal 01/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #2 had an assessment completed on 5-4-18 and then again on 5-21-19.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.All Program Specialist will be retrained for compliance with the relevant regulation. Program Specialists have marked their calendars with the due dates for each assessment and will complete them within the required time frame of one year. The Program Director will keep a spreadsheet of each individual's assessment due date and will monitor for compliance with the required time frames. Supporting documentation of completion with this plan of correction will be sent to the regional Human Services Licensing Supervisor. [At least quarterly for 1 year, the program director shall monitor the aforementioned spread sheets and a 25% sample of completed assessments to ensure timely completion. Documentation of aforementioned monitoring by the program director shall be kept. (DPOC by AES, HSLS on 1/17/20)] 01/16/2020 Implemented
2390.151(f)The program specialist provided Individual #1's assessment, completed 7-23-19, to the plan team members on 8-8-19 for an annual ISP meeting on 8-28-19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.All Program Specialist will be retrained for compliance with the relevant regulation. Program Specialists have marked their calendars with the due dates for each assessment and will send them to the team at their completion, and at least 30 days ahead of the ISP meeting. The Program Director will keep a spreadsheet of each individual's assessment due date and will monitor for compliance with the required time frames. Supporting documentation of completion with this plan of correction will be sent to the regional Human Services Licensing Supervisor. [At least quarterly for 1 year, the program director shall monitor the aforementioned spread sheets and a 25% sample of correspondence documentation to ensure the program specialist has provided all individuals current assessments to the plan team members, timely. Documentation of aforementioned monitoring by the program director shall be kept. (DPOC by AES, HSLS on 1/17/20)] 01/16/2020 Implemented
SIN-00108423 Renewal 01/30/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #4 was instructed in fire safety on 6-10-15 and again on 7-15-16. Individual #5 was instructed in fire safety on 6-10-15 and again on 6-28-16. Individual #7 was instructed in fire safety on 6-10-15 and again on 6-28-16.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.Individuals will be trained every 11 months in fire safety including use of fire extinguishers. Currently most individuals are due for annual training by June 10, 2017. They will all receive training by May 31, 2017. This will be completed by the Program Specialists, under the supervision of the Program Director. Documentation of such training will be kept in each individual¿s casefile, as well as a master file for the Program Director. Individual files will be inspected for continued compliance during the annual internal program licensing conducted by Program Specialists. In the event that an individual is on leave of absence at the time of the retraining, they will be retrained upon their return to work and documentation of their leave will be kept in their file. [At least quarterly for 1 year, the Program Director shall review the aforementioned master file and a 25% sample of fire safety training documentation to ensure all individuals are instructed upon initial admission/employment and reinstructed annually as required. (AS 2/28/17)] 02/25/2017 Implemented
2390.151(e)(12)Individual #3's assessment, completed 4-6-16 did not include recommendations for specific areas of vocational training. The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.The missing information has been added to the assessment. This was completed on 2/20/17. Documentation of compliance will be sent to the regional office under separate cover. Program Specialists will conduct an internal licensing file inspection for continued compliance. Such inspections are ongoing throughout the year. The Program Director will receive monthly reports on the results of internal licensing. [Within 30 days of receipt of the plan of correction the program specialist(s) shall review all individuals' assessment to ensure all required information is included and shall immediately update with missing information. Aforementioned file inspections shall continue at least quarterly. (AS 2/28/17)] 02/25/2017 Implemented
2390.151(f)The program specialist provided Individual #8's assessment, dated 5-6-16 to the supports coordinator and plan team members on 5-6-16 for the ISP meeting on 6-1-16.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).The Program Specialists will insure that assessments are sent to the SC at least 30 calendar days in advance of the ISP meeting. Program Specialists will conduct an internal licensing file inspection for continued compliance. Such inspections are ongoing throughout the year. The Program Director will receive monthly reports on the results of the internal licensing. [The program director shall develop and implement a tracking system and train program specialist(s) as to the system to ensure the program specialist(s) provides the assessments to the plan team members at least 30 days prior to the ISP meeting. Aforementioned file inspections shall be completed at least quarterly. (AS 2/28/17)] 02/25/2017 Implemented
2390.156(d)The program specialist did not provide the ISP Reviews, dated 11-4-16, 8-5-16, 5-5-16 and 2-4-16, for Individual #1 to all plan team members including the family. The program specialist did not provide the ISP Reviews, dated 12-8-16, 9-8-16, 6-8-16 and 3-8-16, for Individual #2 to all plan team members including the family. The program specialist did not provide the ISP Reviews, dated 11-29-16, 8-29-16, 5-30-16 and 2-29-16, for Individual #3 to all plan team members including the family. The program specialist did not provide the ISP Reviews, dated 11-25-16, 8-25-16, 5-25-16 and 2-25-16, for Individual #5 to all plan team members including the family. The program specialist did not provide the ISP Reviews, dated 11-20-16, 8-20-16, 5-20-16 and 2-20-16, for Individual #6 to all plan team members including the family. The program specialist did not provide the ISP Reviews, dated 11-12-16, 8-12-16, 5-12-16 and 2-12-16, for Individual #7 to all plan team members including the family. 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.Copies of the reviews have been sent to all team members. This was completed by 2/24/17. Documentation of compliance will be sent to the regional office under separate cover. Program Specialists will conduct an internal licensing file inspection for continued compliance. Such inspections are ongoing throughout the year. The Program Director will receive monthly reports on the results of internal licensing. Declination forms will be signed by team members who are not interested in receiving this information, and such forms will be kept in each individual¿s file. Individuals who are their own guardian will be given the option of including or excluding team members from receiving reviews. Documentation of any exclusions will be kept in the individual¿s file. [Prior to providing ISP reviews to the plan team members, the Program specialist shall review individuals' record including ISPs, invitation letters and declinations documentation to ensure plan team members are provided the ISP review documentation as required. Documentation of the correspondence shall be kept. Aforementioned file inspections shall be completed at least quarterly. (AS 2/28/17)] 02/25/2017 Implemented
SIN-00088257 Renewal 12/30/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.34(c)Production Manager #1 did have the educational qualifications for the production manager position.A production manager shall meet one of the following groups of qualifications: (1) Possess a bachelor's degree or above from an accredited college or university in Business or Engineering.(2) Possess an associate's degree or its equivalent from an accredited college or university in Business or Engineering; and 2 years work experience in industrial work. (3) Possess a high school diploma or a general education development certificate; and 4 years work experience in industrial work, which includes at least 2 years supervisory experience.Academic credentials for Production Manager #1 listed have been obtained and are now included in his personnel file. Copies of these credentials will be emailed to the region under separate cover. The Human Resource office for The Arc of Butler County has made proof of academic credentials a part of the required paperwork needed during the hiring process for all staff. [CEO will review the next 3 hires to ensure qualifications are obtained and maintained in the staff records. Documentation of reviews shall be kept. (AS 3/7/16)] 02/15/2016 Implemented
2390.35(d)Floor Supervisors #2, #3 and #4 do not have the educational qualifications for the floor supervisor position.A floor supervisor shall meet one of the following qualifications: (1) Possess 30 credit hours from an accredited college or university.(2) Possess a high school diploma or a general education development certificate, and 1 year work experience in industry or rehabilitation.Academic credentials for Floor Supervisors #2, #3, and #4 listed have been obtained and are now included in their personnel file. Copies of these credentials will be emailed to the region under separate cover. The Human Resource office for The Arc of Butler County has made proof of academic credentials a part of the required paperwork needed during the hiring process for all staff.[CEO will review the next 3 hires to ensure qualifications are obtained and maintained in the staff records. Documentation of reviews shall be kept. (AS 3/7/16)] 02/15/2016 Implemented
2390.59Telephone numbers for the nearest ambulance were not posted on or by the telephones in the program areas.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneThe telephone number for the local ambulance service has been added to the list of emergency numbers and posted by each telephone. This was completed on 1/8/16. Photo documentation will be sent to the regional office under separate cover. Going forward, phones will be checked by the Production Manager for complete emergency number lists during each monthly safety inspection.[Documentation of monthly checks shall be kept. (AS 3/7/16)] 12/30/2016 Implemented
2390.82(b)The two most recent fire safety inspections were 7/31/14 and 11/19/15.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.The Program Director will insure that the facility is inspected by a fire safety authority within 11 months of the previous inspection. In the event that the local fire safety authority is unable to meet that schedule, the Program Director shall furnish the address of the facility and the number and disabilities of the clients served to the local fire department. Documentation of such shall be kept on file. 10/18/2016 Implemented
2390.87Floor Supervisor #3's most recent trainings in general fire safety and in the use of fire extinguishers were 10/6/14 and 11/11/15. Floor Supervisor # 5's most recent trainings in general fire safety and in the use of fire extinguishers was 6/9/14. Individual #1 most recent training in general fire safety and in the use of fire extinguishers was 6/9/14. Individual #2 was admitted on 4/13/15 and had training in general fire safety and in the use of fire extinguishers on 2/12/15.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.: Floor Supervisor #3 has been trained in general fire safety. Documentation of such training will be emailed to the region under separate cover. Floor Supervisor #5 is no longer employed with this agency. Individual #1 has been trained in general fire safety. Documentation of such training will be emailed to the region under separate cover. Individual #2 is no longer receiving services through this agency. All staff and clients will be trained on general fire safety and use of fire extinguishers upon initial employment or admission and annually thereafter. The Program Specialists will schedule such training and maintain documentation in each individual¿s file. The files will be reviewed at internal program licensing for continued compliance. The Program Director shall be responsible for insuring that all staff receive initial fire safety training and annual training thereafter and will keep documentation of such training on file. 05/31/2016 Implemented
2390.111(a)Individual #3, admitted on 1/7/15 and did not have a preadmission interview.A client shall have a preadmission interview.The Program Specialist will insure that all individuals will have a preadmission interview. Program Specialists within the workshop will conduct an internal licensing exercise and inspect each other¿s files for immediate and continued compliance with this regulation. This internal inspection will be done monthly, with at least 10% of files being reviewed each month. The Program Director will receive monthly reports detailing the results of the internal licensing inspections. 12/30/2016 Implemented
2390.111(b)-1Individual #3, admitted 1/7/15 was not notified in writing of acceptance for services.Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. The Program Specialist will insure that all individuals will be notified in writing of acceptance for services. Program Specialists within the workshop will conduct an internal licensing exercise and inspect each other¿s files for immediate and continued compliance with this regulation. This internal inspection will be done monthly, with at least 10% of files being reviewed each month. The Program Director will receive monthly reports detailing the results of the internal licensing inspections. 12/30/2016 Implemented
2390.112(a)-1Individual #3, admitted on 1/7/15 was not oriented to the facility and to the services offered. Upon admission, a client shall be oriented to the facility and to the services offered. The Program Specialist will insure that all individuals will be oriented to the facility and services offered upon admission. Program Specialists within the workshop will conduct an internal licensing exercise and inspect each other¿s files for immediate and continued compliance with this regulation. This internal inspection will be done monthly, with at least 10% of files being reviewed each month. The Program Director will receive monthly reports detailing the results of the internal licensing inspections. 12/30/2016 Implemented
2390.124(5)The record for Individual #4, admitted on 2/4/13 did not include a physical examination.Each client's record must include the following information: Physical examinations.A copy of Individual #4¿s physical cannot be obtained at this time. The supports coordinator stated that because he is Base funded, no physical exam is required for their records. Documentation of this will be emailed to the region under separate cover. Individual #4¿smother was contacted and she has no record of any physical exam on hand, however, she will try to get a copy of his most recent physical from his doctor. If she provides a copy to us, it will be emailed to the region under separate cover. Going forward, Program Specialists within the workshop will conduct an internal licensing exercise and inspect each other¿s files for immediate and continued compliance with this regulation. This internal inspection will be done monthly, with at least 10% of files being reviewed each month. The Program Director will receive monthly reports detailing the results of the internal licensing inspections.[Immediately, CEO or designated staff persons will review all individuals' records for required information including physical examinations and missing information will immediately be obtained. Documentation of all reviews shall be kept and reviewed by the Program Director at least monthly to ensure accurate completion and required information is in all individuals' records. (AS 3/7/16)] 02/19/2016 Implemented
2390.124(11)(iv)Individual #2's record did not include notices that the plan team members team members may decline the ISP review documentation.Each client's record must include the following information: Documentation of ISP reviews and ISP revisions under §  2390.156 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation.: Individual #2 is no longer receiving services at this facility. Going forward, Program Specialists within the workshop will conduct an internal licensing exercise and inspect each other¿s files for immediate and continued compliance with this regulation. This internal inspection will be done monthly, with at least 10% of files being reviewed each month. The Program Director will receive monthly reports detailing the results of the internal licensing inspections.[Immediately, CEO or designated staff persons will review all individuals' records for required information including notices that the plan team member may decline the ISP review documentation and missing information will immediately be obtained. Documentation of all reviews shall be kept and reviewed by the Program Director at least monthly to ensure accurate completion and required information including notices that the plan team member may decline the ISP review documentation is in all individuals' records. (AS 3/7/16)] 12/30/2016 Implemented
2390.151(a)Individual #2, admitted on 4/13/15 does not have an initial assessment. Individual #3, admitted on 1/7/15 does not have an initial assessment. The most recent assessment for Individual #4 was completed on 8/26/14. The most recent assessment for Individual #6 was completed in 1/2/14. Individual #7, admitted on 11/18/14 does not have an initial assessment. The most recent assessment for Individual #8 was completed on 4/28/14. The most recent assessment for Individual #9 was completed on 8/8/14.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.: Individual #2 is no longer receiving services at this facility. Initial assessments for individual #3 and individual #7 have been completed and emailed to the region under separate cover on 2/19/16. Going forward, the Program Specialists will insure that each individual has an initial assessment within 60 calendar days after admission and an updated assessment annually thereafter. This will be monitored for compliance by the Program Director through use of a spread sheet containing each individual¿s admission date, 60-day assessment date, and dates for upcoming annual reassessments. Email notification reminders for each item will be set up for the Program Director to insure ongoing compliance with this regulation.[Individual #4's assessment was completed on 3/16/16. Individual #9's assessment was completed on 3/16/16. Individual #6's assessment was completed on 3/15/16. (AS 4/9/16)] 12/30/2016 Implemented
2390.156(a)The program specialist did not complete 3 month ISP review of the services and expected outcomes for Individual #7, admitted on 11/18/14. The most recent 3 month ISP review of the services and expected outcomes for Individual #9, admitted on 6/9/14 was completed by the program specialist on 7/14/15. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.The Program Director will insure the following: all 3 month ISP reviews shall be completed in a timely manner. This will be accomplished by creating a spreadsheet containing each individual¿s ISP date and their 3 month ISP review dates. Email notification reminders for upcoming reviews will be set up for the Program Director to insure ongoing compliance with this regulation. A copy of this spreadsheet will be emailed to the region under separate cover by 2/19/16.[Immediately, program director or designated staff will review all individuals' records to ensure all IPS reviews are completed and will complete needed ISP reviews. CEO or designated staff person will review a 25% sample of records at least quarterly to ensure ISP reviews are completed within the required timeframe. Documentation of reviews shall be kept. (AS 3/7/16)] 12/30/2016 Implemented
2390.156(d)Individual #1's 3 month ISP reviews dated 12/22/14, 3/22/15, 6/22/15 and 9/17/15 were not sent to the plan team. Individual # 4's 3 month review of the ISP dated 12/12/14 was sent to the SC on 2/9/15. Individual #6's 3 month reviews of the ISP dated 3/9/15, 6/9/15 and 9/9/15 were not sent to the plan team. Individual #8's 3 month reviews of the ISP dated 2/24/15, 5/24/15, 8/24/15 and 11/18/15 were not sent to the plan team. Individual #9's 3 month ISP review dated 1/2/15 was sent to the SC on 3/24/15.The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.: 3 month ISP reviews for Individuals #1, #6, and#8 have been sent to the plan team as of 2/11/16. Going forward, the Program Specialists will insure that each 3 month review is sent to the plan team in a timely manner. This will be monitored for compliance by the Program Director through use of a spread sheet containing each individual¿s admission date, 60-day assessment date, and dates for upcoming annual reassessments. Email notification reminders for each item will be set up for the Program Director to insure ongoing compliance with this regulation. [Immediately, program director or designated staff will review all individuals' records to ensure all IPS reviews have been provided to all team members as required and all ISP reviews that have not been sent will immediately be sent. Documentation of correspondence shall be kept. The program specialist will send ISP review documentation to all team members as required and within required timeframe. Documentation of correspondence shall be kept. Program director will review a 25% sample of correspondence at least monthly to ensure ISP reviews are sent to all team members within required timeframes. Program Director will update tracking system upon review. CEO will review tracking system at least quarterly to ensure completion and that ISP reviews are sent to all team members within required timeframes. Documentation of reviews shall be kept (AS 3/7/16)] 12/30/2016 Implemented
SIN-00069439 Renewal 12/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(c)(1)Staff person #1, the program specialist, did not meet the qualifications of the position. A program specialist shall meet one of the following groups of qualifications: Possess a master's degree or above from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field. Possess a bachelor's degree from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field; and 1 year experience working directly with disabled persons.On 1/19/2015, a copy of the college diploma awarding a Bachelor of Science degree to staff person #1 was scanned and emailed to the Head Licensor. [All staff persons records will be reviewed to ensure they contain the required qualifications for the positions. (CHG 1/22/15)] 01/19/2015 Implemented
2390.151(a)Individual #1's two most recent assessments were dated 6/18/13 and 12/2/14. Individual #2's two most recent assessments were dated 3/22/13 and 7/23/14. 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.On 1/21/2015, the Program Specialists were trained on the requirements of 2390.151(a) by Mary Kay Dugan, Director of Vocational Services for The Arc of Butler County. [The Director or designee will audit a sample of individual records monthly to ensure required items including assessments are completed timely. (CHG 1/22/15)] 01/21/2015 Implemented
2390.151(f)Assessment results for the following individuals were not sent to plan team members at least 30 calendar days prior to an ISP meeting: #1, #2, #3, #4, #5, #6 and #7. 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).On 1/21/2015, the Program Specialists were trained on the requirements of 2390.151(f) by Mary Kay Dugan, Director of Vocational Services for The Arc of Butler County. [The director or designee will audit a sample of individual records monthly to ensure the required notifications were completed and documented. (CHG 1/22/15)] 01/21/2015 Implemented
SIN-00056562 Renewal 11/25/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.40(b)Staff Person #1 completed 12.5 hours of training in the training year 7/1/12 to 6/30/13.(b) Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually.For fiscal year 2013-2014, all staff in required positions will obtain a minimum of 24 hours of inservice training. Starting in 1/14, required staff will be scheduled for and complete one hour/week of approved training. Documentation will be completed on a weekly basis and submitted to the Director for review. Any deviations from this schedule will be addressed in a timely manner. This will continue through 6/30/14. The responsible party is Mary Kay Dugan, Director of Vocational Services. [Staff Person #1 will complete 35.5 hours in the training year beginning 7/1/13. (CHG 12/16/13)] 12/15/2013 Implemented
2390.124(5)The record for Individual #1, admitted 6/10/13, does not include a physical exam. Each client's record must include the following information: (5) Physical examinations.The physical exam record for this individual has been obtained. A copy will be emailed to the Licensor. Our record system for individuals will be overhauled by 2/28/14. This overhaul will include sections that coincide with the licensing regulations, which will insure that the necessary forms are included in the files. Each casefile will then be audited for compliance by 6/30/14. The responsible party is Mary Kay Dugan, Director of Vocational Services. 12/15/2013 Implemented
2390.151(a)The assessment for Individual #2, admitted 7/2/13, was not completed until 11/12/13. The most recent assessment for Individual #3 was completed on 10/4/11.(a)  Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The missing assessment has been completed and will be emailed to the Licensor. Going forward, as casefiles are audited, deadlines for required reviews will be relayed to the appropriate Program Specialist so that they are completed on time. The responsible party is Mary Kay Dugan, Director of Vocational Services. 12/15/2013 Implemented
2390.151(e)(11)The assessment for Individual #4, admitted 7/11/11, does not include a psychological evaluation. (e) The assessment must include the following information: (11) Psychological evaluations, if applicable.The psychological evaluation for this individual has been obtained and a copy will be emailed to the Licensor. Our records system for individuals will be overhauled by 2/28/14. This overhaul will include sections that coincide with the licensing regulations, which will insure that the necessary forms are included in the files. Each casefile will be audited for compliance by 6/30/14. The responsible party is Mary Kay Dugan, Director of Vocational Services. 12/15/2013 Implemented
SIN-00187541 Renewal 05/04/2021 Compliant - Finalized
SIN-00148283 Renewal 01/10/2019 Compliant - Finalized
SIN-00128202 Renewal 01/25/2018 Compliant - Finalized