Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00203080 Renewal 03/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The walkway leading toward the exterior door nearest the cafeteria has a railing whose front-facing post is heavily dented toward its middle, and the handicap access door-opening button on it was non-operative. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.In 2015, a decision was made for better security and work automation to deactivate the automated door-opening button and install an ID access entry system on TWE's posterior doors. The previously deactivated button and pole has been removed on 4/19/2022. The monthly environmental checklist will go into effect May 2022; TWE supervisors were trained by the director on the added checkpoints on 4/19/22. 04/19/2022 Implemented
2390.124(8)It cannot be determined that the agency retained a copy of Individual#2's 2021 ISP meeting invitation letter, as it was not provided.Individual plan documents as required by this chapter.The Residential Care Coordinator will receive a counseling statement and will be retrained by Assistant Director of Residential Care Coordination regarding sending out meeting invitations letters 30 days in advance and notifying the Records department by 5/2/2022. The Residential Care Coordinator was trained by the Assistant Director of Residential Care Coordination on 4/15/2022. 05/02/2022 Implemented
2390.151(f)It cannot be determined if the 10/1/21 assessment was sent to individual#1's guardian/sister at least 30 days prior to the 1/6/22 ISP meeting, as verification was not provided.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Woods Records department will mail Individual #1's assessment to her team members by 4/22/2022. The Assistant Director of Care Coordination (Adult Day) was trained by the Adult Day Services Director on 4/18/2022 on how to proceed moving forward to verify that the 30 day due dates for assessment distribution are followed. Assistant Director of Care Coordination (Adult Day) will review this expectation with all Adult Day Care Coordinators on 4/20/2022. 04/22/2022 Implemented
2390.155(5)There are inconsistencies in what type of restrictive procedure is to be used for individual#1 as the 1/6/22 ISP states that a 2-5 person face up on the ground restraint should be used if the individual is displaying self-injurious behaviors. The most recent behavior support plan does not mention any restraint and only suggests seclusion and use of a Ukeru mat which the staff should hold while the individual punches it. The most recent quarterly ISP reviews states that no restraints should be used as this practice was terminated from the behavior support plan in 2019. There is no mention of any of this in the 10/1/21 assessment.The individual plan, including revisions, must include the following: Risks to the client's health, safety or well-being, behaviors likely to result in immediate physical harm to the client or others and risk mitigation strategies, if applicable.Residential Care Coordinator will be submitting a critical revision for the Individual Support Plan that addresses all inconsistencies with the current non-restrictive Behavioral Support Plan. The responsible residential care coordinator will also be retrained in expectations for reviewing and completing Individual Support Plans by the Residential Assistant Director of Care Coordination by 5/30/2022. Assistant Director of Care Coordination (Adult Day) will review this expectation with all Care Coordinators on 4/20/2022. 05/30/2022 Implemented
SIN-00165575 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The changing room has 3 electrical outlets within close reach of individuals. These outlets have no safety caps. Group 7 has a metal table located at the corner wall with a sharp edge. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Presently, there is no one enrolled in the TWE program requiring the use of the changing table, but as an added safety measure, safety caps have been placed on all outlets in this room. All metal edges were covered with duct tape providing a smooth surface. The monthly environmental checklist completed by TWE management was updated to include furniture. A quarterly environmental taking a closer look at all group furniture and completed by each group instructor was created. The Director of Vocational Services is responsible to confirm both environmental checks are completed. 11/13/2019 Implemented
2390.62The production office has its floor in need of extensive cleaning The front individual's men's bathroom had an unsecured toilet plunger. The women's bathroom has a toilet plunger unsecured in one stall.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas."Woods central housekeeping was contacted to strip and wax the floor. It looks brand new. The production office was added to the supervisor's monthly environmental checklist. Plunger was secured in the custodial closet and housekeeping trained on plunger storage expectation. An item to ensure proper storage was also added to both the custodial task/checklist and the supervisor's monthly environmental checklist. The Vocational Supervisor is to ensure that the custodial task/checklist has been completed. The Director of Vocational Services will ensure the monthly check is completed. " 11/11/2019 Implemented
2390.67Group 10 has a yellow chair with loose joints. Room 9 has another yellow chair with loose joints. Group 6 has a wooden chair with protruding chair fastener. Another wooden chair has loose joints. Group 11 has A blue chair which lacks hand grips. The chair arms are wrapped in cellophane.Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions.All chairs were discarded and an order was placed for new chairs. The monthly environmental checklist completed by TWE management was updated to include furniture and a quarterly environmental completed by each group instructor was created and implemented. The Director of Vocational Services is responsible to ensure quarterly environmental checks are completed. 11/11/2019 Implemented
2390.81Group 6 has a double exit door. The left door mechanism does not readily open the door. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.Woods' maintenance came out to evaluate immediately. The left door requires a stronger push, but it does open with limited force. A new door was installed. A line item was added to the Supervisor's monthly environmental to ensure proper functioning of all doors. The Director of Vocational Services is responsible to ensure monthly environmental checks are completed. 12/02/2019 Implemented
2390.40(b)Staff member's #'s1-4 were not trained on individual#1's behavioral support plan dated 9/18/18 as on 10/24/19.The facility shall keep a training record for each person trained."Clinicians will train current staff working with individual #1 on her BSP by 1/7/20. Vocational Care Coordinators and Clinical staff will provide BSP and ISP trainings within 14 days of the ISP meeting and BMRC meeting. In addition, BSPs and ISPs are available in EHR for review by any staff who is newly assigned to work with an individual. If an individual transfers to another location and/or day program, the clinicians will go to the new location within 14 days of transfer. Vocational Care Coordinators are responsible to ensure their assigned staff receive all required training. This includes ISP/BSP training that is provided by clinicians and care coordinators. Previously tracking of this training has been difficult due to measures taken to ensure the confidentiality of individuals. The tracking system has been revised and enhanced with the addition of a confidential log of who has been trained by the clinicians and vocational care coordinators that the manager will be able to reference when monitoring, planning and scheduling staff training. " 01/07/2020 Implemented
2390.156During inspection the program specialist Staff #1 stated that individual#1's plan did not include a behavioral support plan. It was found that this was not the case and that a BSP was written and to be implemented as of 9/18/18 and then again on 3/21/19. Therefore, the plan could not be implemented as the program specialist was unaware of its existence and for the fact that it was not included on the assessment which was completed after the BSP was developed.The facility shall implement the individual plan, including revisions."As noted in 40(b), the necessary team members were not properly trained by the plan's author resulting in a lack of information. Training on the BSP will occur by 1/7/20 and the BSP training procedures have been updated to ensure better communication and training consistency. Vocational Care Coordinators are responsible to ensure their assigned staff receive all required training. This includes ISP/BSP training that is provided by clinicians and care coordinators. Please note, while the care coordinator was not trained on the plan, she was routinely collecting behavior data, which she then forwarded to the clinician to be reported on monthly. " 01/07/2020 Implemented
SIN-00119855 Renewal 08/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.124(12)There was a content discrepancy between the current assessment dated 5/15/2017 for Individual #4 and the individual's current ISP dated 6/30/2018. The current ISP states that the individual has a restrictive behavior plan; the current assessment states that the individual has a non-restrictive behavior plan and SEESP for psychotropic medication.Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.The SC has updated the ISP and a copy was provided to records. (See attachment #5) The regulation, including the importance of reviewing the ISP for accuracy was reviewed with the Vocational Program Specialist by TWE Manager on 9/29/17. (See attachment #2) Going forward the VPS will review the ISP for the most current accurate information. If he/she does not have a copy of the ISP, he/she will notify the TWE Manager who will follow up to see that one is obtained. 09/29/2017 Implemented
2390.151(e)(4)Individual #1's assessment dated 3/03/201 did not document the individual's need for supervision.The assessment must include the following information: The client's need for supervision.An addendum to Individual #1's assessment was completed on 9/29/17 to address her need for supervision. (See attachments #1) The regulation was reviewed with the Vocational Program Specialist by TWE Manager on 9/29/17. (See attachment #2)[A Program Designee will be responsible to review assessments for accuracy and completeness to ensure ongoing compliance with this regulation. JG 10/23/17] 09/29/2017 Implemented
2390.151(e)(5)Individual #2's assessment dated 8/04/2017 did not indicate the individual's ability to self-administer medication.The assessment must include the following information: The client's ability to self-administer medications.An addendum to Individual #2's assessment was completed on 9/29/17 addressing his abilities to self-medicate. (See attachments #3) The regulation was reviewed with the Vocational Program Specialist by TWE Manager on 9/29/17. (See attachment #2)[A Program Designee will be responsible to review assessments for accuracy and completeness to ensure ongoing compliance with this regulation. JG 10/23/17] 09/29/2017 Implemented
2390.151(e)(6)Individual #3's assessment dated 9/30/16 did not indicate the individual's knowledge of poisons.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.An addendum to Individual #3's assessment was completed on 9/29/17 addressing his abilities with poisons/chemicals. (See attachments #4) The regulation was reviewed with the Vocational Program Specialist by TWE Manager on 9/29/17. (See attachment #2)[A Program Designee will be responsible to review assessments for accuracy and completeness to ensure ongoing compliance with this regulation. JG 10/23/17] 09/29/2017 Implemented
SIN-00099807 Renewal 07/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.22(d)The governing body's previous meeting was held on 09/10/2015 and the most recent meeting was held on 01/26/2016.The governing body shall meet at least quarterly.Due to an unexpected change in the Woods Resources CEO, the December 2015 governing body meeting was not held until January 2016. Going forward, all efforts will be made to maintain quarterly meetings as required by the regulations. 01/26/2016 Implemented
2390.22(e)The governing body did not review TWE financial reports.The governing body shall review and approve quarterly and annual financial reports.The Executive Administrative Secretary, who takes and maintains the minutes from the governing body's meetings, was notified by the Vice President of Programs, Woods Services to include specific programs' financial report, not just general, going forward. This includes the TWE program. 01/19/2017 Implemented
2390.40(b)There was no documentation the CEO completed 24 hours of vocational or human services training within the 06/01/2015-05/31/2016 training year. Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually.The CEO completed 79.00 hours of training credits during the training year June 2015 through May 2016. However, this information was not supplied to our training department to be entered onto his training record. The training department entered the information into our system and it is now reflected on his training record. (see attachment) Going forward the CEO will be reminded of the importance of handing in any training credits earned during the training year to our training department to ensure compliance with the regulations. 05/31/2016 Implemented
2390.62There was feces and urine found in the third and fourth toilet bowl of the men's room located on the main floor.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Note: The third and fourth toilet did not contain feces. However, in one toilet there was urine and the other as a resident exited, it was noted that he did not flush his urine. During the walk thru inspection, the third and fourth toilets were flushed by Katie Wescott, Manager, TWE. The urine went down accordingly and the toilet was not clogged. Staff will continue to monitor the bathrooms for cleanliness and repair when present and report any issues to the necessary department staff. 07/14/2016 Implemented
2390.124(4)Individual # 3's record did not document an emergency medical consent form. Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment.Individual #3's parents were sent letters requesting they date and sign the consent for emergency medical in February 2015, a second request on March 10, 2015, and a third request on April 1, 2015 to which Woods did not receive anything back. When individual #3's mother visited on 8/12/16, she signed the consent. (see attachments) Records Services has the following procedure: 1. Consents are mailed in January. 2. Approximately 30-45 days later, a list is compiled of those not returned to Records. A second set of consents is prepared and mailed. They are sent out under the cover of a "second request" letter. 3. Approximately 30-45 days after the second is mailed, a list is compiled of those not returned to Records and is sent out to the Program Specialists. 08/12/2016 Implemented
2390.151(e)(13(ii)Individual # 2's annual assessment dated 12/15/2015 did not document progress and growth in the area of communication.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.Although the Vocational Program Specialists go into specific detail in regards to an individual's current functioning, they were retrained by the TWE manager to specifically address and state whether skills have been maintained, regressed or improved. (see attachment) 09/14/2016 Implemented
2390.151(e)(13)(iii)Individual # 2's annual assessment dated 12/15/2015 did not document progress and growth in the area of personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Although Vocational Program Specialists go into specific detail in regards to an individual's current functioning, they were retrained by the TWE manager o specifically address and state whether skills have been maintained, regressed, or improved. (see attachment) 09/14/2016 Implemented
2390.151(e)(13(iv)Individual # 2's annual assessment dated 12/15/2015 did not document progress and growth in the area of socialization 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.Although the Vocational Program Specialists go into specific detail in regards to an individual's current functioning, they were retrained by the TWE manager to specifically address and state whether skills have been maintained, regressed or improved. (see attachment) 09/14/2016 Implemented
2390.155(a)Individual # 3¿s three month ISP review documentation dated 06/01/2015-08/31/2015 was not implemented by the ISP start dated on 06/13/2015. Individual # 6¿s three month ISP review documentation dated 10/01/2015-12/31/2015 was not implemented by the ISP start dated on 11/01/2015. Individual # 9¿s three month ISP review documentation dated 09/01/2015-11/30/2015 was not implemented by the ISP start dated on 11/21/2015. Individual # 10¿s three month ISP review documentation dated 12/01/2015-02/29/2016 was not implemented by the ISP start dated on 02/23/2016. The ISP shall be implemented by the ISP's start date.In order to be more efficient, Woods implemented a system on 4/1/14 whereby 3 Month reviews occur according to the calendar year as opposed to the ISP start date. Our system allows us to better track and consistently adhere to the required 3 month time frame between reviews, regardless of changing or postponed ISP dates. Although our 3 month reviews do not start on the ISP start date, there is always a review covering, documenting, and referencing an ISP start date. 155(a) states the ISP shall by implemented by the ISP's start date and that does take place in our system. Our individuals are reviewed uniformly every 3 months. On the reviews that occur during the month of the ISP start date, the ISP date and new outcomes are clearly referenced and defined in the 3 month review narrative section. To ensure that the review documents ISP implementation by the ISP start date (per reg 155), the review covering the month when the ISP takes place shows two charts: one referencing the previous outcomes and one referencing the exact ISP start date with the new outcomes created at the ISP and to be implemented on the ISP start date. Prior to changing our system, our new procedure was reviewed with Ms. Sandra Wooters. Holly Wolbransky, Director, Woods Services, had several communications thru email and over the telephone with Ms. Wooters for approval (see attachment) While Ms. Wooters did acknowledge that we "were probably doing more than required", she did not have an issue with the new system as long as it had "date to date coverage", which Woods does. 07/11/2016 Implemented
2390.156(a)Individual # 1's three month ISP review documentation dated 07/01/2015-09/30/2015 was completed on 10/19/2015. Individual # 1's three month ISP review documentation dated 10/01/2015-12/31/2015 was completed on 01/20/2016. Individual # 1's three month ISP review documentation dated 01/01/2016-03/30/2016 was completed on 04/19/2016. Individual # 2's three month ISP review documentation dated 07/01/2015-09/30/2015 was completed on 10/19/2015. Individual # 3's three month ISP review documentation dated 03/01/2015-05/31/2015 was completed on 06/21/2015. Individual # 3's three month ISP review documentation dated 09/01/2015-11/30/2015 was completed on 12/23/2015. Individual # 3's three month ISP review documentation dated 12/01/2015-02/29/2016 was completed on 03/23/2016. Individual # 4's most recent three month ISP review documentation reported on the period from 12/01/2015-02/29/2016. Individual # 8's three month ISP review documentation dated 11/01/2015-01/31/2016 was completed on 02/17/2016. Individual # 8's three month ISP review documentation dated 02/01/2016-04/30/2016 was completed on 05/17/2016. 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.TWE manager changed 3 month review due dates and retrained Vocational Program Specialists (VPS) to ensure timely collection and distribution of reviews. (see attachment) For Individual #3, the ISP review dated 3/1/15-5/31/15 was completed on 6/11/15, not 6/21/15. The ISP review dated 9/1/15-11/30/15 was completed on 12/10/15 and not 12/23/15. These were completed within the required regulation requirement. The dates reflected were the residential assessment dates of completion and not the vocational assessments. (see attachments) For Individual #4, it is unclear what the citation is as it seems like an incomplete statement. 09/14/2016 Implemented
SIN-00077083 Renewal 04/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Staff #1's most recent fire safety training was completed on 10/11/13.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.Staff #1 will be trained on 04/22/2015 in Fire Safety. Please see attachment A. Effective 6/1/15, (the start of our new training year) fire Safety will be completed by each TWE employee within 364 days of the last fire safety training to remain in compliance with this regulation. The TWE management team is responsible for monitoring training to ensure we remain in compliance with this regulation. The management team will develop a tracking record of all staff training to ensure that the fire safety and other required trainings are completed annually. 06/01/2015 Implemented
2390.156(c)(1)Individual #1 did not have monthly documentation, since the implimentation of the ISP dated 5/30/14. Individual #2 did not have monthly documentation, since the implimentation of the ISP dated 10/1/14. Individual #3 did not have monthly documentation, since the implimentation of the ISP dated 11/1/14. Individual #4 did not have monthly documentation, since the implimentation of the ISP dated 2/6/15. Individual #5 did not have monthly documentation, following the implimentation of the ISP dated 2/11/15. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.During this current survey and in previous years Woods is in compliance with this regulation as interpreted in the 2390 regulations. During this current licensing survey the information was maintained and addressed in the Vocational three month reviews. Vocational three month reviews include monthly data toward an individual's goals for the previous three months as well as a narrative broken up into three paragraphs, one paragraph for each month, which addresses participation and progress during the prior three months toward ISP outcomes (please see attachment B) Since this is no longer acceptable by BHSL and their interpretive of the regulation has been amended, going forward, the vocational program specialists will complete and submit monthly documentation to the TWE manager who will ensure they are completed, signed and dated the vocational program specialists. TWE Manager will send the monthlies to the Records department by the 15th of the month to be filed within the individual's record. 06/01/2015 Implemented
SIN-00058534 Renewal 03/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)The assessment for individual #1, completed 6/19/13, was not sent to the sc until 7/16/13 for the ISP meeting 7/18/13. The assesment for individual # 2, completed 10/27/13, was not sent to the sc until 11/22.13 for the ISP meeting held 12/4/13. The assessment for individual #3, completed 12/12/13, was not sent to the sc until 3/7/14 for the ISP meeting held on 3/14/14. The assessment for individual # 4, completed 2/20/14, was not sent to the sc 3/12/14 for the ISP meeting scheduled for 3.24/14.(f) 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 regulatory requirements have been reviewed with Program Specialists by their supervisor to enhance compliance with Woods' Program Planning Guidelines so that regulatory deadlines can be met. Please see the Program Specialist Meeting Minutes dated 3/18/2014. Additionally, Effective 3/31/2014, workloads in the Records Services Dept have been reassigned. Two staff are now processing all ISP-related documents to comply with Regulatory timelines so that documents are mailed and received by Supports Coordinators, as well as Team members, at least 30 calendar days prior to an ISP meeting. 03/31/2014 Implemented
2390.156(b)The ISP 3month review for individual # 5, for the period 5/13-7/13, was signed by the program specialist but not dated.(b) The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.This was discussed at the most recent Program Specialist meeting on 3/18/2014. Program Specialists were instructed they and the individual must sign and date the reviews. Please see the Program Specialist Meeting Minutes dated 3/18/2014. 03/18/2014 Implemented
SIN-00045973 Renewal 03/07/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(a)The facilities emergency evacuation procedure did not include a means of transportation or an emergency shelter locaton.(a) Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.The Woods Enterprise is located on Woods campus where our individuals reside. The emergency shelter location, if needed, would be their residence. Woods also has its own transportation department on campus which would be used to transport in an emergency. Please see updated document sent in email. 04/23/2013 Implemented
2390.85(b)-1The facilities fire drills were held at similar times of the day. The drills held in the afternoon were all between 1:08pm and 1:38pm; on 2/13/12, 4/19/12, 6/13/12, 8/15/12, 10/22/12 and 12/19/12.(b) Fire drills shall be held at different times of the day.Woods has a Corporate Fire Drill schedule which notes day program fire drills should rotate between the morning and afternoon at various times and locations. The dates indicated on this citation are for our afternoon drills. Individual¿s departure time from program is 2:15pm. Memo sent to fire drill conductors to address this concern immediately. Please see document sent in email. 04/23/2013 Implemented
2390.156(c)(1)A reviewed record did not include monthly documentation on a client's participation and progress.(c ) The ISP review must include the following: (1) A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.Individual PM's 3 month review did contain participation and progress; however, it was not in her file in our Records Department at the time of the survey. All Vocational Program Specialist received training on reg 2390.156.c. Please see document sent in email. 04/22/2013 Implemented
SIN-00222598 Renewal 03/28/2023 Compliant - Finalized
SIN-00141304 Renewal 09/05/2018 Compliant - Finalized