Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00223687 Renewal 06/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.48(b)(4)Staff #1 did not complete training in the required area of Recognizing and Reporting Incidents as a part of new employee orientation training after hire as a direct service worker on 9/20/2022.The orientation must encompass the following areas: Recognizing and reporting incident.Staff #1 completed the required training the day after the inspection 6/30/23. In addition, we created a training plan specific for ORIENTATION to prevent this in the future. 06/30/2023 Implemented
2390.49(c)(3)Staff #2 did not complete training in the required area of Client Rights as a part of the 24 hours of annual training completed in training year 1/01/2022 to 12/31/2022.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Staff 2 completed required training the day after the inspection. We also created a Program Specialist Annual Training Plan to include all required trainings. We also turned on AUTO reminder for all trainings coming due or overdue, so we are aware of requirements. We will email the certification showing training was completed. 06/30/2023 Implemented
SIN-00207237 Renewal 06/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.22(d)The governing body did not have a record of a quarterly meeting in Quarter 4 (October, November, December) 2021.The governing body shall meet at least quarterly.We had a meeting scheduled but 2 people cancelled last minute and we did not have a quorum. It was also the last month of the quarter, so we were unable to reschedule. We will schedule all quarterly meetings on the first month of the quarter, allowing 2 additional months for RESCHEDULE should we need. 06/17/2022 Implemented
2390.87Staff #1, Staff#2, Staff#3 received fire safety training on 2/8/21 and didn't receive it again until 3/29/22. Individual #1's date of admission was 4/21/22 and they did not receive fire safety until 5/10/22. Individual #2 received fire safety training on 2/8/21 and didn't receive it again until 5/10/22. This exceeds the requirementStaff, 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.We will always have fire safety training for all annually by the exact date from the previous year. To do this we will maintain a list of who needs what training by date and we have purchased a software package to ensure all dates are known and documented. 07/06/2022 Implemented
2390.104(4)Individual #'1 and Individual #3's records did not include medical information pertinent to diagnosis and treatment in case of emergency.Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency.The individuals both had no medical issues to document but it's necessary in these cases to indicate N/A. 06/20/2022 Implemented
2390.151(a)Individual #2 had an annual assessment completed on 5/3/21 and hasn't had one completed since. Individual #3 annual assessment completed on 1/8/21 and hasn't had one completed since.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.We have completed the plans with the above individuals and looked at all other individuals for 1 year time frame. We trained all involved about the 1 year time requirement and we created a calendar with required timelines unique to each individual - and are entering this into our software system to ensure. 07/05/2022 Implemented
2390.21(u)Individual #1 was informed of their rights on 4/21/22, but the rights have not been updated. Individual #2 was informed of their rights on 3/29/22 and prior to that it was 2/17/2021. Individual #3 was informed of their rights on 3/29/22, but the rights have not been updated. The agencies rights haven't been updated to reflect the current Chapter 2390 regulations. The missing rights include make choices/accept risks, refusal of activities, privacy of person and possessions, access to and security of possession, voice concerns, negotiate choices, and rights may not be modified in accordance with §2390.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the client or others.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.These are all updated now and filled out for all individuals. During the time when these were issued we were shut down, plus we had changes in the CEO and VOc Director and this change was missed. 06/21/2022 Implemented
2390.49(c)(5)Staff #1, Staff #2, and Staff #3 did not receive annual training in the 2021 training year on the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with a client.the training was done prior to inspection, we realized we didn't have it after a discussion with the inspector through email. All the required staff took the training on the ODP website on 6/1/22 06/21/2022 Implemented
SIN-00169154 Renewal 01/28/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 had fire safety training on 2/19/2018. He didn't have it again until 10/9/2019, which exceeds the annual requirement. Individual #2 was admitted on 7/1/2019. He didn't receive fire safety training until 10/9/2019. (Repeat Violation: 2/5/2019)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.Fire training has been scheduled on 2/7/2020 for all individual employees including individual #1 and #2. Fire staff training for all individual employees will be completed upon hire and annually. Fire Training records will be kept in individual employees file. 01/31/2020 Implemented
2390.111(a)Individual #2 was admitted on 7/1/2019. There was no record of a Preadmission interview.A client shall have a preadmission interview.Director of Vocational Services being the responsible staff person for conducting the preadmission interview has reviewed all the requirements of the regulations and developed an internal checklist to be completed and placed in new applicants file of all paperwork required for admission into the program. 02/14/2020 Implemented
2390.151(a)Individual #2 was admitted on 7/1/2019. He didn't have an initial assessment completed until 1/20/2020.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.An Individual employee assessment review list will be developed and upon acceptance each individual employee will have assessment completed within 60 days of their admission date. Completed assessment will be placed in individual employees file and copy will be sent to their Service Coordinator. 01/31/2020 Implemented
SIN-00147569 Renewal 02/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Staff #1 completed fire safety training in February of 2017. She had the fire safety training in June of 2018.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 current documentation of staff and Client's Fire Safety Trainings/Use of Fire Extinguishers (Initially and/or Annually) will be kept in their master files and the original documentation will be kept in the current Staff/Client training file in the Director of Vocational Services office. Annual Fire Safety Training/Use of Fire Extinguishers will be completed one year prior from the last date of the previous year's training. Maintenance of records of any staff/client missing from training and follow up trainings will be completed quarterly. Documentation of reasons for missed trainings by staff/clients will be noted and placed in their master files. All new Staff and Client's will upon initial admission and initial employment will be trained in the use of extinguishers and general fire safety. Documentation will be kept in their master files and current training file located in the office of Director Vocational Services. 02/26/2019 Implemented
2390.124(5)Individuals 1, 2, and 3 did not have physical exams in their files. Staff admitted none of the consumers have physicals in their files. CTC did already obtain copies of physicals for Individuals #2 and #3. All individuals must have physical examinations on file.Each client's record must include the following information: Physical examinations.All current client's files receiving funding have been updated to included most recent Physical Examination Form. Including Individuals 1,2, 3. All new clients will be required to present a current Physical Examination form prior to their start date which will be part of their master file. Individual #1 Physical Examination From was completed and received at CTC on 2/25/2019 and emailed to State License Inspector on 2/25/2019. ((All individuals attending the facility shall have a physical examination on file regardless of funding -CH 3/6/2019)) 02/26/2019 Implemented
SIN-00129212 Renewal 02/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.32(c)Staff #1 did not meet the work experience criteria when hired as the CEO. Staff #1 possessed a Bachelor's degree at the time of hire as CEO but did not have the required number of years of work experience.A chief executive officer shall meet one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years of work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years of work experience in administration or the human services field.April 13,2018 will be the last date of employment for the current CEO. Board Members are currently screening candidates with appropriate credentials for CEO position. 03/23/2018 Implemented
SIN-00108244 Renewal 03/30/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(2)This section wasn't evaluated in Individual #1 and Individual #2's assessments.The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.New work service assessment has been develped and will be used for all future assessments. Now includes ; likes, dislikes and interest of clint including vocational and employment intersts of the client. 04/03/2017 Implemented
2390.151(e)(5)This section wasn't evaluated in Individual #1 and Individual #2's assessments. The assessment must include the following information: The client's ability to self-administer medications.Question was added to the new assessment ; the client's ability to self-administer medications 04/03/2017 Implemented
2390.151(e)(6)This section wasn't evaluated in Individual #1 and Individual #2's assessments. 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.Question was added to the new assessment ; The client's ability to safely use or aviod poisonous materials, when in the presence of poisonous materials. 04/03/2017 Implemented
2390.151(e)(7)This section wasn't evaluated in Individual #1 and Individual #2's assessments.The assessment must include the following information: The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.New question was added to the new assessment; client's knowledge of the danger of heat sources and ability to sense and move away quickly : 04/03/2017 Implemented
2390.151(e)(8)This section wasn't evaluated in Individual #1 and Individual #2's assessments. The assessment must include the following information: The client's ability to evacuate in the event of a fire.Added to the new assessment question; client's ability to evacuate in the event of a fire 04/03/2017 Implemented
2390.151(e)(9)This section wasn't evaluated in Individual #1 and Individual #2's assessments.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.New question was added to the assessment; Individuals disaility, including functional and medical limitations. 04/03/2017 Implemented
2390.151(e)(10)This section wasn't evaluated in Individual #1 and Individual #2's assessments.The assessment must include the following information: A lifetime medical history.Question was added to the new assessment; Individuals lifetime medical history 04/03/2017 Implemented
2390.151(e)(11)This section wasn't included in Individual #1 and Individual #2's assessments.The assessment must include the following information: Psychological evaluations, if applicable.Question was added to new assessment; Individuals most recent psychological evaluation. 04/03/2017 Implemented
2390.151(e)(13(ii)Motor skills weren't evaluated in Individual #1 and Individual #2's assessments.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.Question was added to the new assessment; Individuals progress and growth in the areas of socialization. 04/03/2017 Implemented
2390.151(e)(13(iv)This section wasn't evaluated in Individual #1 and Individual #2's assessments. 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.Question was added to the assessment; Individuals progress and growth in the area of socialization 04/03/2017 Implemented
SIN-00092123 Renewal 02/25/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(b)-2There is no record of the fire alarm system being checked during the following months: February 2015; March 2015; May 2015; June 2015; September 2015; and October 2015. A written record shall be kept showing the date checked, the name of the person checking the alarm and whether or not the alarm was operative.Both the Fire Drill Report and Safety Commmittee Building Montlhy Inspectoin forms now relfect Manual Fire Alarm Testing. Frank Kew, Production Manager will be checking the alarms monthly 03/01/2016 Implemented
SIN-00073010 Renewal 01/08/2015 Compliant - Finalized
SIN-00043363 Renewal 11/09/2012 Compliant - Finalized