| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.62 | The first aid area was filthy as was the blanket covering the cot. The bathrooms had visible built up dirt on the toilets and floors. The kitchen area right within the work area had a refrigerator and microwave that were visibly dirty inside and out. | Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas. | Avenues in-house janitorial crew began working in the warehouse program on 4/13/18. The bathrooms, first aid area, refrigerator and microwave have been cleaned. The first aid area has been decluttered. A plastic sheet is covering the bed, and clean sheets are kept in plastic until needed. The janitorial crew will maintain these areas each week to ensure compliance. It should also be noted that the restrooms, office area, and sick area will be remodeled in the next 12-18 months. (attachment 10) |
04/13/2018
| Implemented |
| 2390.64 | The outside ramp at the far end of the facility had a ramp leading down from the door that staff stated was used as a fire exit. It is several feet off the ground and there is no handrail on either side of the ramp. | Stairways, outside steps, porches and ramps shall have well secured handrails. | We are currently meeting with contractors/welders to secure proposals to add a railing to the metal ramp. (Attachment 9) Once installation is complete, we will provide further documentation. The railing will be installed on the ramp no later than 5/18/18. |
05/18/2018
| Implemented |
| 2390.67 | During inspection, janitorial staff came in and put on a mask and started sweeping right where consumers were working creating a large cloud of dust and debris. Individuals did not have masks on nor was one offered. | Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions. | Due to the nature of the work that the program performs, a good amount of dust and dirt is produced. There are masks available in program at all times. To prevent the kicking up of dust during the work time, sweeping will be completed at the end of the day, When sweeping is being performed, staff will offer individuals masks to use, should they so choose. |
04/18/2018
| Implemented |
| 2390.74(d) | There is no wall mirror in either of the two bathrooms. | Each lavatory shall have a sink, wall mirror, soap, toilet paper and individual clean paper or cloth towels or air hand dryer. | Mirrors have been mounted in each restroom. (Attachment 8) |
04/13/2018
| Implemented |
| 2390.82(a) | There was only one evacuation diagram in the entire facility and it was posted in an out of the way area, nowhere near the work areas. | 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 evacuation diagram that was posted in program has been updated and moved to a more visible location next to the office door and AED. Evacuation diagrams have also been posted in the main work area and in the rear of program near the fire exit. (Attachment 7) |
04/18/2018
| Implemented |
| 2390.84(a) | The fire extinguisher (one of the three required) near the main entrance was expired. | 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. | Pfeifer Fire Protection Inc. serviced the expired extinguisher on 3/23/18, and it is now in working order. To ensure that equipment is maintained, we will continue with our annual service contract for inspection and maintenance. (Attachment 5) |
03/23/2018
| Implemented |
| 2390.84(d) | The fire extinguisher near the main entrance was not mounted on the wall, but sitting on the floor. | Fire extinguishers weighing under 45 pounds shall be mounted on the wall so that the extinguishers are visible to staff and clients. | Pfeifer Fire Protection Inc. serviced the expired extinguisher on 3/23/18, and it is now in working order and has been re-mounted on the wall. To ensure that equipment is maintained, we will continue with our annual service contract for inspection and maintenance. (Attachment 6) |
03/23/2018
| Implemented |
| 2390.87 | The annual fire safety training was late for all five individuals as well as staff member Staff #1. It was conducted 01-04-17, then not again until 03-14-18. | 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. | The warehouse staff and individuals will complete fire safety twice yearly in order to ensure compliance. The next scheduled fire safety training is 9/14/18. |
04/18/2018
| Implemented |
| 2390.102 | There is not a staff on site at all times clients are present who is certified in first aid techniques. The one staff who is certified sometimes goes out on the truck. | At least one staff person certified in first aid techniques within the past 3 years shall be present when clients are at the facility. There shall be written documentation of the certification. | There are two staff who work in the warehouse program. One staff is currently CPR/First Aid certified, and the second is not. The second staff is scheduled for CPR/First Aid training on 5/9/18. Due to the nature of the program, the staff typically alternate performing truck driver duties and program supervisory duties. When performing truck driver duties, staff are not left alone with any individuals. Staff who perform supervisory duties supervise the individuals in program. In order to maintain compliance, the staff who is not yet CPR/First Aid certified is completing truck aid duties until he receives his certification, ensuring that he is not alone with individuals. The staff who is CPR/First Aid certified will remain in program supervising the individuals. |
05/09/2018
| Implemented |
| 2390.124(1) | The places of birth and genders of all individuals reviewed were not in the files. | 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. | Program Specialist added places of birth and genders to the annual update/special considerations forms for individuals 1-5. (Attachment 2) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |
| 2390.124(8)(ii) | No invitation to Individual #1's ISP meeting was found in the file. | Each client's record must include the following information: A copy of the invitation to: The annual update meeting. | Program specialist had a copy of ISP invite, but it had not been placed in individual #1's file at the time of licensing. The letter has been placed in the file. (Attachment 3) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
03/30/2018
| Implemented |
| 2390.124(12) | -- Individual #3's ISP talks about him being in a sexual offender treatment program (and there are notes within his HAB file from awhile back that states he has personal boundary issues), but that is not addressed anywhere in his current assessment. | Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under § 2390.156. | Program specialist updated individual #3's assessment to correct discrepancies between the assessment and the ISP. (Attachment 4) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |
| 2390.151(e)(13)(i) | Progress and growth was not addressed in any of the five individual files reviewed in the area of health. Some of the individuals' assessments were identical year to year including unfinished sentences and grammatical errors. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | Program specialist completed new assessments for individuals 1-5 to address each individual's progress over the last year and current level in the area of health. Each individual's next assessment will be completed according to their ISP date as normal. (Attachment 1) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |
| 2390.151(e)(13(ii) | Progress and growth was not addressed in any of the five individual files reviewed in the area of motor and communication skills. Some of the individuals' assessments were identical year to year including unfinished sentences and grammatical errors. | 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. | Program specialist completed new assessments for individuals 1-5 to address each individual's progress over the last year and current level in the area of motor and communication skills. Each individual's next assessment will be completed according to their ISP date as normal. (Attachment 1) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |
| 2390.151(e)(13)(iii) | Progress and growth was not addressed in any of the five individual files reviewed in the area of personal adjustment. Some of the individuals' assessments were identical year to year including unfinished sentences and grammatical errors. | 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. | Program specialist completed new assessments for individuals 1-5 to address each individual's progress over the last year and current level in the area of personal adjustment. Each individual's next assessment will be completed according to their ISP date as normal. (Attachment 1) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |
| 2390.151(e)(13(iv) | Progress and growth was not addressed in any of the five individual files reviewed in the area of socialization. Some of the individuals' assessments were identical year to year including unfinished sentences and grammatical errors. | 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. | Program specialist completed new assessments for individuals 1-5 to address each individual's progress over the last year and current level in the area of socialization. Each individual's next assessment will be completed according to their ISP date as normal. (Attachment 1) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |
| 2390.151(e)(13)(v) | Progress and growth was not addressed in any of the five individual files reviewed in the area of vocational skills. Some of the individuals' assessments were identical year to year including unfinished sentences and grammatical errors. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills. | Program specialist completed new assessments for individuals 1-5 to address each individual's progress over the last year and current level in the area of vocational skills. Each individual's next assessment will be completed according to their ISP date as normal. (Attachment 1) To ensure compliance, this issue will be discussed with all vocational program specialists during a meeting on 4/26/18. |
04/18/2018
| Implemented |