| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.55(a) | Clean and sanitary conditions shall be maintained in the facility. The base of both of the toilets located in the women's bathroom in the "life skills area" were splattered with brown and black substance. The plastic molding around the floor in the men's bathroom located in the 'life skills area" was very dirty as the entire plastic molding was covered in a brown substance. The walls in this same men's bathroom were also dirty with several stains on them. Along the top cinder blocks and the ceiling in the outside porch area located outside of "classroom #4" was a black mold like substance. (Repeat Violation 12/21/21) | Clean and sanitary conditions shall be maintained in the facility. | Clean and sanitary conditions shall be maintained throughout the facility daily completed by employees and tracked through spreadsheets and signed off by Program Director. All molding to be replaced throughout both male and female bathrooms by 03/06/2023 and compliance given to regulatory bodies. Tru Pro restoration was contacted today 01/10/2023 to come in to review moldy substance and give quote. They¿re coming 01/11/2023 to complete review and give quote, this action will be completed, and compliance will be given to regulator body no later than 02/24/2023 |
02/10/2023
| Implemented |
| 2380.58(a) | Floors, walls, ceilings and other surfaces shall be in good repair. The women's bathroom located in the main hallway's door handle mechanism protector was not attached to the main door itself. The first bathroom stall in this same bathroom did not have a door handle. The black cabinets in the "main area" were missing two handles from them, and one cabinet handle was loose. The black cabinet in '" classroom 3" was missing a handle, and the heating element had rust all over it in this room. The heating element along the wall in "classroom #4" was pulling off/away from the way approximatively 1 inch and causing the paint to peel. 3 ceiling tiles located in "classroom #6" appeared to have water damage as they had brown spots on them, and one had a black mold like substance on it. Administration was advised to have this substance evaluated. The wood paneling was pulling away from the wall in the hallway going down to the "geriatric area". (Repeat Violation 12/21/21) | Floors, walls, ceilings and other surfaces shall be in good repair. | Floors and walls will be maintained through staff cleaning schedules which will be signed off on by Program Director on a daily basis. Repairs to female bathroom in main hallway (main entrance) door handle, and stall without handle completed by 03/01/2023. All black cabinets have been thrown out as presented in pictures sent to your e-mail on 01/06/2023. Cup is having a electrician come in on 01/11/2023 to review all heating systems throughout all rooms in the building. Heating systems will be fixed and compliance of this action being completed by 03/03/2023. Cup had Smith and Miller roofing and siding come in to give an estimate on the roof on 01/06/2023. The organization is waiting on the quote from this estimate and the board of the organization will vote to have this completed on 01/11/2023. The mold is being reviewed by Tru Pro Restoration on 01/11/2023 |
03/03/2023
| Implemented |
| 2380.58(b) | Floors, walls, ceilings and other surfaces shall be free of hazard. In "classroom #1" The air conditioning cord and the wall clock cord were hanging down and not secure posing a choking risk/hazard. A ceiling tile was missing in the hallway going down to the "geriatric area" exposing wires. (Repeat Violation 12/21/21) | Floors, walls, ceilings and other surfaces shall be free of hazards. | Cup will have the air conditioning cord and wall clock cord secured to wall with covering in classroom #1. This action will be completed by 01/31/2023 compliance given to governing body by this date. The ceiling tile was completed and displayed through e-mail on 1/06/2023 |
01/06/2023
| Implemented |
| 2380.113(a) | Staff person who comes into direct contact with the individuals shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #4 had a physical examination on 1/7/19 and then not again until 3/16/21. This exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff will have a annual physical completed prior to date of hire, and will maintain compliance with having a physical examination completed prior or on the date of that physical every two years |
03/01/2023
| Implemented |
| 2380.113(c)(2) | Staff shall have Tuberculin skin testing with negative results every 2 years. Staff #4 had a Tuberculin Skin test with negative results on1/9/19 and their next one was on 3/18/21. This exceeds the requirement. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Staff will have a Tuberculin skin test completed prior to date of hire, and will maintain compliance with having a Tuberculin skin test completed prior or on the date of their annual physical every two years |
03/01/2023
| Implemented |
| 2380.181(a) | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility. Individual #1's date of admission is 4/12/22 and their assessment is dated 10/3/2022. This exceeds the requirement. | Each individual 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 consumers as new admissions will have an assessment completed within 60 days of joining the day program. They will have an assessment completed annually thereafter to remain in compliance and when isp meeting are conducted. |
03/01/2023
| Implemented |
| 2380.181(e)(3)(i) | Individual #1's assessment dated 10/3/22 and Individual #2's assessment dated 2/8/22 did not address their current level of performance and progress in the area of their acquisition of functional skills. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for individual #1 and Individual #2. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Acquisition of functional skills. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above section. This assessment addressed the Acquisition functional skills area. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(3)(ii) | Individual #1's assessment dated 10/3/22 and Individual #2's assessment 2/8/22 did not address their current level of performance and progress in the area of their communication. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for individual #1 and Individual #2. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above section. This assessment addressed the area of performance and communication. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(3)(iii) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of personal adjustment. Under this section in their assessments, it stated "see summary", but the summary documentation is not kept with the assessment and this annual summary document does not address or assess this area for Individual #2. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addressed the area of progress over the last 365 days of the calendar year for the current level of personal adjustment. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(3)(iv) | Individual #1's Assessment dated 10/3/22 did not address their current level of performance and progress in the area of personal needs with or without assistance from others as this section of the assessment was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addressed the area of progress for personal needs with and without assistance. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(4) | Individual #2's assessment dated 2/8/22 did not address their need for supervision. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment. | The assessment must include the following information: The individual¿s need for supervision. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresse¿s the area of supervision. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(9) | Individual #1's assessment dated 10/3/22 and Individual #2's assessment 2/8/22 did not include documentation of the individual's disability, including functional and medical limitations. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for individual #1 and Individual #2. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of functional and medical limitations. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(10) | Individual #1's assessment dated 10/3/22 and Individual #2's assessment 2/8/22 did not include a lifetime medical history. This section of their assessments stated, "see physical". Their assessments should include a lifetime medical history for the individual. | The assessment must include the following information: A lifetime medical history. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of physicals and lifetime medical history. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(12) | Individual #1's assessment dated 10/3/22 and Individual #2's assessment 2/8/22 did not include recommendations for specific areas of training, vocational programming, and competitive community-integrated employment. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for individual #1 and Individual #2. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the areas of recommendations specific to training in, vocational programming, competitive community-integrated employment. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good |
01/09/2023
| Implemented |
| 2380.181(e)(13)(i) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of health. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for Individual #2. | 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. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of health. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(13)(ii) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of motor and communication skills. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for Individual #2. | 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. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the areas of motor and communications skills over the last 365 days displaying progress. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(13)(iii) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of personal adjustment. Under this section in their assessments, it stated "see summary", but the summary documentation is not kept with the assessment and this annual summary document does not address or assess this area for Individual #2. | 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. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of personal adjustment and progress over the last 365 days. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(13)(iv) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of Socialization. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for Individual #2. | 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. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of socialization and progress made over the last 365 days. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(13)(v) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of Recreation. Under this section in their assessments, it stated "see summary but a summary was not attached/included with the assessment for Individual #2. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of recreation and progress made over the last 365 days. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.181(e)(13)(vi) | Individual #2's assessment 2/8/22 did not address the individual's progress over the last 365 calendar days and current level in the area of Community-Integration. Under this section in their assessments, it stated "see summary", but a summary was not attached/included with the assessment for Individual #2. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | Creating unlimited possibilities completed and submitted a new assessment to address the violation state in the above. This assessment addresses the area of community-integration and progress made over the last 365 days. It was sent to the licensor through e-mail on 01/09/2023. Licensor stated through a phone call on that date the new assessment was good. |
01/09/2023
| Implemented |
| 2380.21(u) | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. Individual #1's date of admission is 4/12/22 and their individual rights were dated 4/13/22. This exceeds the requirement. (Repeat Violation 12/21/21) | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | Cup will complete individual rights packets during admission, and annually thereafter. This will be documented through excel worksheets and reviewed and updated on a continuous basis |
03/01/2023
| Implemented |
| 2380.36(c) | There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by a person certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. Staff #1's training expired on 8/2017 and they became retrained on 11/14/2022. Staff 2's training expired on 8/2017; Staff #'3's expired on 8/2019; Staff#4's expired on 2/1/2022; Staff#5 training expired on 8/2017. Staff #1 and Staff #5 became retrained on 11/14/2022 after the licensing representative brought the noncompliance issue to the agency's attention on 11/14/2022. Staff #6 expired on 8/2019; Staff #7 expired on 8/2017; and Staff #8 was trained on 1/19/2021.Staff #8 was the only staff person trained at the facility since 2/1/2021, and their last day with the agency was 10/17/2022. Therefore, the agency had 0 staff persons at the facility trained in in first aid, Heimlich techniques and cardio-pulmonary resuscitation from 10/17/2022 until 11/14/22 when staff #1 and staff #6 became trained. This exceeds the requirement. | There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification. | Cup has reviewed and was notified that online applications for cpr/first aid are not accepted. Cup has called American Red Cross to set up a class for all staff to be trained. This action was completed on 01/10/2023. Jim one of the instructors told Jarvis Wright (Executive Director) the earliest they could provide a class is in two weeks. Completed by and turned to regulator body by March 13,2023 |
03/13/2023
| Implemented |
| 2380.181(f) | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. Individual #1's assessment was completed on 10/3/2022 and their annual Individual plan meeting was 10/7/2022. According to the documentation on the assessment dates 10/3/2022 it was faxed and in person sent to team member Laura Theroux, Supports Coordinator, on 10/28/22 and 11/1/22.This exceeds the requirement. There is no documentation that Individual #2's assessment dated 2/8/22 was sent to their individual plan team members prior to their meeting on 3/28/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Creating Unlimited Possibilities a monthly basis will review consumers isp to make sure when meetings should occur and will send out assessments according even if supports coordination has not set up the annual isp meeting. |
03/01/2023
| Implemented |