| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.59 | Emergency numbers were not displayed or posted in staff member's 1&2's office. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone. | We have hung the Emergency phone list in the two offices that did not have them visible. We have reviewed all other work areas to insure that they also are visible |
04/05/2022
| Implemented |
| 2390.60(b) | The First Aid area did not contain a bed or cot. | The first aid area shall have a bed or cot, a blanket and a first aid kit. | We have purchased a cot and it is in the nurse's office and available to use. |
01/05/2022
| Implemented |
| 2390.60(d) | The first aid kit provided during inspection did not contain scissors. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors. | WE have made sure that all first aid kits include the above list and if they are used will be replaced promtly. |
01/05/2022
| Implemented |
| 2390.67 | Safe conditions were not practice; poisons material was stored with food in cabinet Hallway #1 and there was a bottle with liquid material in it which was not in its original labeled container. | Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions. | We have mandated that no cleaning (poison products) are keep in the same area as our drinks products and that all cleaning or poisonous are label with MSDS labeling at all times and kept in a locked area. |
01/05/2022
| Implemented |
| 2390.67 | Safety conditions where not practiced there was a bottle with liquid material with a handwritten label and Hand Sanitizer, the bottle did not have its original label | Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions. | All poisonous material was removed from the Hallway closet #1. We have removed all unmarked bottles of liquid material that did not
have their original labeling on it. These bottles have been discarded and only those bottled with original labels are being used |
11/30/2021
| Implemented |
| 2390.71(a) | Men's Bathroom #1, #2, #3 and Women's bathroom #2 and #3 was not ventilated by an operable windows or mechanical ventilation. | Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation. | We had to call in a plumber (bill attached). For bathrooms in work areas, needed to reset 3 timers and re-install timer trippers that were removed. For front office bathrooms, reset timers and found bad fan motor above men's room drop ceiling. Timothy Off Heating & Air Conditioning replace fan. |
01/05/2022
| Implemented |
| 2390.84(a) | The warehouse contained only one Fire Extinguisher and the area was greater than 1,500 square feet of indoor floor space, additional fire extinguishers are needed. | There shall be at least one fire extinguisher with a minimum 10ABC rating for each floor including the basement. If there is more than 1,500 square feet of indoor floor area on any floor including the basement, there shall be an additional fire extinguisher with a minimum 10ABC rating for each additional 1,500 square feet of indoor floor area. | We purchased additional Fire extinguishers from Keystone Fire Protection and have mounted them in the warehouse. |
06/16/2022
| Implemented |
| 2390.84(g) | Fire extinguisher(s) located in the maintenance workshop was not inspected annually, last inspection was completed 11/2020. | Fire extinguishers shall be inspected and approved annually by the local fire department or other fire safety authority. The date of the inspection shall be on the extinguisher. | We had Keystone Fire Protection come in and inspected the fire extinguisher in January 2022. |
01/05/2022
| Implemented |
| 2390.84(g) | Fire extinguisher(s) located in the Mechanical Room and the Electric Room was not inspected annually, last inspection for both was completed 01/2020. | Fire extinguishers shall be inspected and approved annually by the local fire department or other fire safety authority. The date of the inspection shall be on the extinguisher. | We had Keystone Fire Protection come in and inspect the two fire extinguishers. |
01/05/2022
| Implemented |
| 2390.87 | Individuals#1-#5 were not instructed and/or reinstructed annually in general Fire Safety, no written/signed document record was provided.
Agency documentation does not contain content of the fire safety training individual#6 received on 1/6/20.
Agency documentation does not contain content of the fire safety training individual#7 received on 6/17/21.
Agency documentation does not contain content of the fire safety training individual#8 received on 1/7/20. | 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. | Although individual #5 did receive fire and safety training in 2020 and 2021, the attendance of individual #5 was not appropriable documented by the trainer. This trainer was removed from that position, effective 12/31/2021/ The chairperson of the safety committee will begin fire and safety training when Handi-Crafters reopened un January 2022 |
01/05/2022
| Implemented |
| 2390.101 | It could not be determined if Individual#5 has or has had any Communicable diseases as this portion was omitted on the Annual Physical Examination form dated 6/7/21. | Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician. | The program specialists for individual #5 will contact the individual's mother to have the physician address the question regarding any communicable diseases. Copy be sent. |
01/24/2022
| Implemented |
| 2390.112(b)-1 | Individual#11's file did not contain a signed copy of written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures from their orientation as it was not provided. | Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client. | This information was included in the client file and provided on 11/30/2021 and 12/1/2021 as requested. Please see email. |
12/01/2021
| Implemented |
| 2390.124(4) | Written consent for Individuals #4 , and #5 was not provided at time of inspection. | Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment. | Consent form was, in fact, in the client file. Copy to be emailed. |
11/30/2020
| Implemented |
| 2390.124(5) | It cannot be determined that individual#10's file contains a record of physical examinations as one was not provided at time of inspection | Each client's record must include the following information: Physical examinations. | We had requested a record of physical examinations as of June 17, 2021. As of this date we still have not received the information requested. |
11/12/2021
| Implemented |
| 2390.127 | Individual #8's files did not contain a signed consent for the release of information. | Written consent of the client, or guardian, if the client is adjudicated incompetent, is required for the release of information, including photographs, to persons not otherwise authorized by statute to receive it. | The signed consent form was included in the client file but has been submitted again. |
11/30/2021
| Implemented |
| 2390.151(a) | It could not be determined if Individual#2's assessment was completed annually. Current assessment was completed 11/19/21. No documentation was provided of when previous assessment was completed.
It could not determine if Individual#4's assessment was completed annually. Current assessment was completed 11/11/21. No documentation was provided of when previous assessment was completed.
It could not determine if Individual#5's assessment was completed annually. Current assessment was completed 05/27/21. No documentation was provided of when previous assessment was completed | 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 most current assessment was prepared on 10/21/21. The previous assessment was prepared on 10/21/2019, as noted in the 10/12/21 assessment. Individual was absent from 3/20/20 until 10/5/2021 due to the pandemic. Therefore, no assessment was prepared in 2020. |
11/30/2021
| Implemented |
| 2390.151(e)(10) | Individual#6's lifetime medical history was not in the record and it was not provided at inspection. | The assessment must include the following information: A lifetime medical history. | During that period of the pandemic interrupted client services and attendance resulting in a delay of
completion, however, this has not been the rule. |
11/30/2020
| Implemented |
| 2390.151(e)(11) | It cannot be determined that the agency has a copy of individual#10's psychological evaluation on file. The individual's assessment lists an evaluation having been completed in September 3, 2010, but it was not provided during the inspection. | The assessment must include the following information: Psychological evaluations, if applicable. | The psychological evaluation was in the individual's file. |
11/30/2020
| Implemented |
| 2390.159(1) | Individua#6's file did not contain a vocational evaluation and it was not provided. | If the facility provides vocational evaluation, the following apply: (1) The vocational evaluator shall perform the evaluations. | The individual start at Handi-Crafters in 1988. We can not locate the vocational evaluation preformed at that time. |
12/01/2020
| Implemented |
| 2390.159(3)(ii) | Individual#11's vocational assessment does not contain information on the individual's employment objectives. | If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The employment objectives for the client. | We have replaced the Vocational Evaluator who has not included all aspects of the written report as required by regulations and Handi-Crafters policy. The replacement will be appropriately trained and monitored by the program specialists. |
11/30/2021
| Implemented |
| 2390.159(3)(iv) | Individual#9's vocational evaluation does not contain clear information on the individual's level of personal and social adjustment. | If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's level of personal and social adjustment. | The vocational evaluation for this individual was prepared in November 2013. The subsequent evaluators have been trained to include all required areas, including personal and social adjustment. The attached vocational evaluation summary was implemented on 1/9/2018 and has been adhered to since. |
11/30/2021
| Implemented |
| 2390.159(3)(v) | Individual#9's vocational evaluation does not contain clear information on the individual's work attitude. | If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's work attitude. | the vocational evaluation for individual #3 was prepared in November 2013. Subsequent vocational evaluators have been trained to include all required areas, including work attitude. The attached vocational summary was implemented on 1/19/2018 and has been adhered to since that date. |
11/30/2021
| Implemented |
| 2390.159(3)(vi) | Individual#9's vocational evaluation does not contain clear information on the individual's fatigue level. | If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: The client's fatigue levels. | The vocational evaluation does include information regarding fatigue levels and has been submitted for review. |
11/30/2021
| Implemented |
| 2390.159(3)(viii) | Individual#10's vocational evaluation is incomplete on recommendations for specific areas of training or placement, as the document submitted, jumps from the recommendation section of the evaluation mid-sentence to a summary of the evaluation on the next submitted page. | If the facility provides vocational evaluation, the following apply: The written evaluation must include the following information: Recommendations for specific areas of training or placement. | The evaluation was reviewed and does include specific areas of training and has been submitted. |
11/30/2021
| Implemented |
| 2390.159(4)(i) | It cannot be determined that the results of individual#7's December 2019 vocational evaluation was shared with the individual nor any other parties, as the evaluation provided by the agency did not contain a signed statement from any of the aforementioned parties confirming receipt. | If the facility provides vocational evaluation, the following apply: The facility shall ensure the client and the client's parent, guardian or advocate, as applicable, are informed of the results of the evaluation. The client and the client's parent, guardian or advocate, as applicable, shall sign a statement acknowledging receipt of the evaluation results. | Attached is the invitation letter for the team meeting to review the vocational evaluation. |
11/30/2021
| Implemented |
| 2390.159(4)(i) | It cannot be determined that the results of individual#9's vocational evaluation was shared with the individual nor any other parties, if applicable (such as parents, guardians, or advocates), as the evaluation provided by the agency did not contain a signed statement from any of the aforementioned parties confirming receipt | If the facility provides vocational evaluation, the following apply: The facility shall ensure the client and the client's parent, guardian or advocate, as applicable, are informed of the results of the evaluation. The client and the client's parent, guardian or advocate, as applicable, shall sign a statement acknowledging receipt of the evaluation results. | We will moving forward have all parties that are required per regulation sign off that they have received this information. |
11/30/2021
| Implemented |
| 2390.21(u) | At inspection the agency had provided individual#9 nor a person designated by them with an annual explanation of their rights or the process to report a rights violation as documentation was not provided. The Client Rights form submitted by the agency did not include a signature page | 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. | The Civil Rights compliance form was presented and signed upon admission to Handi-Crafters. The form submitted did, in fact, include a signature. It is dated 1/29/2020. Document submitted |
11/30/2021
| Implemented |
| 2390.49(b)(1) | Staff member#3 completed 11.25 hours of training for the training year-12 hours annually is required | The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | Provider will ensure that the full 12 hours of training is completed by all staff as required |
11/30/2021
| Implemented |
| 2390.124(1) | Individual#6's file did not include a record of the place of birth. It was blank in the record provided.
Individual#8's file did not include a record of the place of birth. It was blank in the record provided. The agency later provided a revised copy of the form showing a place of birth listed. | Each client's record must include the following information: The name, sex, admission date, birthdate and place, Social Security number and dates of entry, transfer and discharge. | Place of birth should be included on all cover sheets prepared by vocational evauluator. Subsequent vocational evaluators at the time of have been trained to complete all parts of the cover sheets. |
01/28/2022
| Implemented |
| 2390.151(f) | The agency failed to provide the assessment for individual #1 to the plan team members at least 30 calendar days prior to the meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | Handi-Crafters was closed from the month of December 2020 and re-opended on2/3/2021 due to the pandemic. The ISP meeting was held on 1/3/2021 but Handi-Crafters was closed and not invited. Upon return the Program Specialists prepared the assessment in an attempt to back fill and stay in compliance |
11/30/2021
| Implemented |
| 2390.153(c) | The ISP invitation sign in sheet of who participated in the plan meeting for individual#3 was not provided at time of inspection. | The list of persons who participated in the individual plan meeting shall be kept. | The invitation for the latest ISP meeting dated December1, 2021 has been submitted. |
11/30/2021
| Implemented |