Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00119385 Renewal 09/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.40(b)Staff #1 had 16.25 hours of training in the 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 Service Director has counseled staff regarding the requirements for 24 hours of training under the regulations. The training year for the Lancaster program is August 8 through August 7; in 17-18 fiscal year, the program will close effective June 30, 2018. Staff will continue to get training hours through June of 2018, but the program will close prior to the end of the training year. 10/02/2017 Implemented
2390.82(b)The fire notification letter was completed on 12/4/15 and then again on 12/27/16. Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.A letter notifying the local fire department of the address and the number and disabilities of clients was sent on 10/2/17 by the Service Director. As the program site is closing as of June 30, 2018, this letter will suffice to meet the regulation until program closure. 10/02/2017 Implemented
2390.85(c)The 9/13/16 fire drill log indicated individual #4 refused to evacuate the building. Clients shall evacuate the entire building during each fire drill.Lancaster staff have always understood the stairwell is a "fire safe area" so that individuals who refuse to leave the building may stay there safely during a fire alarm. Since there is no written documentation supporting this, no fire drill will be considered successful until all individuals have evacuated the building entirely. Fire drills will be repeated until a successful evacuation of the building occurs, and only then will the fire drill be documented. the MH/ID Compliance Monitor has retrained all staff on the requirements. This will be reviewed at the next fire drill as well. 10/13/2017 Implemented
2390.151(e)(3)(ii)Individual #1's assessment dated 4/17/17 did not include ability to receive, retain, and carry out instructions. The assessment must include the following information: The client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions.Although the assessment referred to the individual's ability to receive, retain and carry out instructions, it did not include any specific information. MH/ID Compliance monitor has retrained staff on the exact requirements of the regulation. the program specialist has added an addendum to the assessment which includes the specific information. Staff are reviewing other files for compliance. 10/13/2017 Implemented
2390.151(e)(8)Individual #1's assessment dated 4/17/17 did not include ability to evacuate. The assessment must include the following information: The client's ability to evacuate in the event of a fire.Although the assessment included the individual's awareness of the fire drill procedure, it did not include the individual's ability to do so. the MH/ID Compliance Monitor has retrained the staff regarding the specifics needed to address the regulation; and the program specialist has added an addendum to the assessment with those specifics. Staff are reviewing other files for compliance. 10/13/2017 Implemented
SIN-00094915 Renewal 06/17/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.153(7)(i)Individual #1's current ISP does not contain the potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming.An email was sent to the Supports Coordinator for the individual with a statement assessing the potential to advance in vocational programming and a request that it be included in the ISP. Other client files are being reviewed to determine if similar action is needed. The file review checklist has been updated to more directly clarify what should be included in this area. The assessment form has been updated to include a specific statement regarding the potential to advance, with a notation to the Supports Coordinator that it must be included in the ISP. 07/13/2016 Implemented
2390.153(7)(ii)Individual #1's current ISP does not contain the potential to advance in community-integrated employment. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.An email was sent to the Supports Coordinator for the individual with a statement assessing the potential to advance in community integrated employment and a request that it be included in the ISP. Other client files are being reviewed to determine if similar action is needed. The file review checklist has been updated to more directly clarify what should be included in this area. The assessment form has been updated to include a specific statement regarding the potential to advance, with a notation to the Supports Coordinator that it must be included in the ISP. 07/13/2016 Implemented
2390.156(c)(4)(ii)Individual #2's current ISP outcome states she will follow the supervisor¿s instructions 60% of the time; this outcome was achieved, but not removed from the ISP. Her ISP reviews state her outcome is she will focus on her work 80% of the time. The ISP review must include the following: The program specialist shall make a recommendation regarding the following, if applicable: The addition of an outcome or service to support the achievement of an outcome.The individual¿s annual ISP review meeting was held June 7, 2016; but the new ISP had not been received as of the site visit on the 17th. It has since been sent out and ISP outcome is now more general: Individual #1 has work skills and is prepared for competitive employment.¿ Her current objective at Goodwill is Individual #1 will let her supervisor know when she needs more supplies or work on 80% of program days each quarter of the year¿ as a necessary skill for competitive employment. The issue was actually corrected as of the new ISP. Other client files are being reviewed to determine for discrepancies. The file review checklist has been updated to more directly clarify what should be included in this area. The assessment form has been updated to include a recommendation for a specific ISP outcome statement, and related goals, with a notation to the Supports Coordinator that it must be included in the ISP. 07/13/2016 Implemented
SIN-00078879 Renewal 03/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #6's annual assessment was completed on 7/3/2013 and then again on 7/22/2014. 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.Individual 6¿s assessment was late due to staff turnover; when the Program Specialist handling the file left, and the new staff person started, there was no easy way to determine due dates. Although the new staff person reviewed all files, an error was made in the dates for this one, and it was discovered five days late. The Manager of Vocational Services has developed a tracking mechanism for all Program Specialists to use; this way all due dates are readily available to both new staff and the Manager, eliminating the possibility of missing the date. 04/30/2015 Implemented
2390.151(e)(13)(i)Individual #3's assessment did not show progress and growth over the last 365 calendar days and current level in health. 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.The MH/ID Compliance Monitor has retrained the Program Specialists regarding the need for information in this section, including (example) routine medical assessments or appointments, general health stable, etc. The Program Specialists are reviewing files to determine if current assessments require addendums to address all required components. 05/31/2015 Implemented
2390.151(e)(13(iv)Individual #4 and #6' assessment did not show progress and growth over the last 365 calendar days and current level in 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.The MH/ID Compliance Monitor has retrained the Program Specialists regarding the need for information in this section, including (example) social activities, preferences in socialization and changes in social functioning. The Program Specialists are reviewing files to determine if current assessments require addendums to address all required components. 05/31/2015 Implemented
2390.151(f)Individual #4 and #5's assessment was only sent to the supports coordinator and not to all team members.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 Assessment form was revised to include a statement requiring that a copy is sent to all team members including the Supports Coordinator. The MH/ID Compliance Monitor has retrained the program specialist¿s on the need to send copies to the entire team, not just the SC. Program Specialists are currently reviewing files to determine if copies were sent to all team members; if not, copies will be sent. 06/14/2015 Implemented
2390.153(5)Individual #4's ISP did not include a SEEN Plan from 2/14/14 until 9/22/14 when one was completed.A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Individual #4¿s SEEN plan has been included effective 9/22/14 as cited. All client ISP¿s are being reviewed to determine if a SEEN plan should be included; if so, and if it was omitted, Program Specialists will develop plan and submit it to the SC for inclusion. The Manager of Vocational Services has retrained all Program Specialists in the requirements for a SEEN plan in the ISP. 05/31/2015 Implemented
2390.156(d)Individual #4's ISP review for March 20th 2014 was not sent to the team. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The ISP quarterly format has been revised to include specific instructions to send copies of the reviews to team members unless declined. All staff were made aware of the change on 5/18/15. The Manager of Vocational Services has retrained all Program Specialists on the requirement. A final training of all noncompliances will be presented by the MH/ID Compliance Monitor before the end of June. 06/30/2015 Implemented
SIN-00061746 Renewal 03/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(a)There was not a pre-admission interview for Individual #3. A client shall have a preadmission interview.Individual #3 did have a pre-admission interview prior to entering vocational evaluation, but was transferred to pre-vocational rather than started as a new admission again. Documentation: Copy of pre-admission interview for individual #3; copy of pre-admit interview to another individual 07/01/2014 Implemented
2390.111(b)-1REPEAT. Individual #3 was not notified in writing of his acceptance to the program. Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. Individual #3 was notified in writing regarding acceptance within 30 days of interview prior to entering vocational evaluation, but was transferred to pre-vocational rather than started as a new admission again. Documentation: Copy of Letter to Individual #3; copy of letter to another individual 07/01/2014 Implemented
2390.151(d)The assessments for Individual # 2 and Individual #5 were not signed by the program specialist. The program specialist shall sign and date the assessment.1. Program Specialists were reinstructed immediately after inspection and again on 7/1/14 regarding the requirements. See Sign in sheet. Staff having particular difficulty meeting the regulatory requirements received/will receive specific performance plans to insure the standards are met. 2. Program Specialists will immediately begin using the checklist with each file to track documentation due dates throughout the year. (see checklist) 3. Program Specialists will conduct weekly audits of each other¿s file using the licensing documentation checklist. Files were reviewed and any assessment that was not signed was again reviewed and signed by the current PS. Documentation: Signed Assessments 07/01/2014 Implemented
2390.151(f)REPREAT. There was no documentation to indicate the assessment for Individual #4 was sent to plan team members 30 days prior to the ISP meeting.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).Program Specialists were reinstructed immediately after the inspection and again on 7/1/14 regarding the requirements to have the assessment sent to team members at least thirty days in advance of the meeting. These instructions included: a. Notifying the SC that the meeting can not be scheduled with less than 33 days notice to allow the Program Specialist to meet the requirement for the assessment to be sent out at least 30 days in advance. b. Since most SC¿s schedule the annual ISP meeting at the third quarterly review, Program Specialists will complete the assessment in time to send it out 30 days in advance of that third quarterly review. 2. Program Specialists will immediately begin using the checklist with each file to track documentation due dates throughout the year. (see checklist) 3. Program Specialists will conduct weekly audits of each other¿s file using the licensing documentation checklist. Documents: copy of sign in sheet for training; two assessments sent within time frames. 07/01/2014 Implemented
SIN-00045697 Renewal 02/14/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.111(b)-1Client #1's acceptance notice wsa not sent out within 30 days of his interview.(b) Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services.There have been no new admissions since the inspection visit on 2/14 & 15. Staff have been reinstructed regarding the 30 day requirement, and review of other files indicates that acceptance notices were sent out within time frames. supporting documentation will be submitted. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented
2390.151(e)(3)(ii)Client #4's annual assessment is missing the following sections: Communication, Personal Adustment, and Personal Needs.(e) The assessment must include the following information: (3) The client's current level of performance and progress in the following areas: (ii) Communication; ability to receive, retain and carry out instructions.Client #4¿s assessment was completed on 3/22/12; prior to last year¿s finalized plan of correction. As a result of the approved POC, and the additional guidance provided by the finalized regulations, the format for the assessment was revised to include all necessary areas including communication, personal adjustment and personal needs and staff were trained in the requirements. Client #4¿s new assessment was completed on 02/15/13 and includes all the required information. Additional assessment are being provided as supporting documentation as well. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented
2390.151(e)(5)Client #4's annual assessment does not address their ability to self-administer medications.(e) The assessment must include the following information: (5) The client's ability to self-administer medications.Client #4¿s assessment was completed on 3/22/12; prior to last year¿s finalized plan of correction. As a result of the approved POC, and the additional guidance provided by the finalized regulations, the format for the assessment was revised to include all necessary areas including the ability to self administer medications and staff were trained in the requirements. Client #4¿s new assessment was completed on 02/15/13 and includes all the required information. Additional assessment are being provided as supporting documentation as well. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 6. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 7. Training of all Program Specialists in use of the checklist. Target: 4/15/13 8. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 9. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 10. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented
2390.151(e)(10)Client #4's annual assessment did not contain a lifetime medical history. There is just a reference to the ISP.(e) The assessment must include the following information: (10) A lifetime medical history. Client #4¿s assessment was completed on 3/22/12; prior to last year¿s finalized plan of correction. As a result of the approved POC, and the additional guidance provided by the finalized regulations, the format for the assessment was revised to include all necessary areas including the lifetime medical history and staff were trained in the requirements. Client #4¿s new assessment was completed on 02/15/2013 and includes all the required information. Additional assessment are being provided as supporting documentation as well. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 11. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 12. Training of all Program Specialists in use of the checklist. Target: 4/15/13 13. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 14. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 15. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented
2390.151(f)Client #4's annual assessment completed on 3/22/2012 was not sent out prior to the meeting which also occurred on 3/22/2012.(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).Client #4¿s assessment was completed on 3/22/12; prior to last year¿s finalized plan of correction. An additional difficulty was that the program specialists incorrectly assumed that the date of the assessment was to be the same date as of the meeting, so the forms were completed in error even when the assessment had been completed prior to the 30 days in advance. Staff were, in some cases, sending the assessments via email without retaining proof of sending, which complicated the issue. Staff have been retrained in the requirements, including the need for documentation to support that the staff member did send it 30 days in advance as needed. Client #4¿s new assessment was completed on 02/15/2013 and was sent out 30 days in advance of the ISP meeting on 3/15/13. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 21. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 22. Training of all Program Specialists in use of the checklist. Target: 4/15/13 23. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 24. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 25. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented
2390.154(b)Client #2 only had 2 Team members present at their 8/1/2012 annual ISP planning meeitng.(b) At least three plan team members, in addition to the client, if the client chooses to attend, shall be present for the ISP, annual update and ISP revision meetings.Staff were retrained by the Manager of Vocational Services regarding the requirement, and there have been several meetings since that have the required number of team members present; supplemental documentation will be sent. In this case, three members were invited, (Program Specialist, Supports Coordinator and Mother) but the Mother did not show up although she was expected. In these instances, staff have been directed to either find another Goodwill staff member who is familiar with the individual to attend or to reschedule the meeting until such time that all members can be present. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented
2390.156(c)(2)Client 3's ISP quarterly reviews are not addressing progress in regard to their current SEEN/BSP.(c ) The ISP review must include the following: (2) A review of each section of the ISP specific to the facility licensed under this chapter.The quarterly review format has been revised to include specific questions addressing the SEEN or BSP and staff have been instructed in using it. See supporting documentation. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 6. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. In progress 7. Training of all Program Specialists in use of the checklist. Target: 4/15/13 8. Annual training in documentation for all staff. (Initial training scheduled in Lancaster 6/11/13) 9. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. In process. 10. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress. AH 07/31/2013 Implemented