Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00163638 Renewal 10/01/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(d)There was no tape found in the first aid kit in the first aid area during inspection.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors.The first aid kit was restocked with tape (attachment 2). Safety Committee members were retrained on this regulation and reminded to check the first aid kit in the first aid area. Physical site inspection form is being revised to include the list of items needed in each first aid kit; form will be revised and distributed for use by 11/30/19. In addition, the Associate Director will perform unannounced inspections at least once per quarter for the next 12 months. 11/30/2019 Implemented
2390.61Ceiling panels (2) in the lobby area need to be secured to the ceiling to prevent them from falling on someone and open spaces in the ceiling that could potentially be hazardous to individuals in the area. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.  Requested
2390.85(a)-1The Alarm Test Record for Plant #2 located at 365 Andrews Road, dated 09/12/19 was held late, past 90 calendar days.A fire drill shall be held at least every 90 calendar days. This area of non-compliance was identified on the day of the fire drill, which was the 91st day after the previous fire drill. Director of Habilitation immediately retrained Program Specialists on this regulation and a corrective action plan was implemented (please see attachment 1). The attached documentation was reviewed by licensing staff during the inspection. 09/12/2019 Implemented
SIN-00139196 Renewal 07/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.68There was a forklift on the program floor with the keys left in it and it was unattended by staff.Hazardous equipment that is likely to cause physical injury to clients shall have guards and safety devices.Staff have been retrained to remove the keys from the ignition prior to exiting the vehicle or any time they observe an unoccupied forklift that has keys in the ignition (attachment #5). Associate Director will complete and document random spot checks at least once every three months (by 10/31/18, 1/31/19, 4/30/19 and 7/31/19), to monitor for ongoing compliance. Magnetic key boxes were placed on each lift until permanent key boxes can be installed (attachment #6). 08/02/2018 Implemented
SIN-00088415 Renewal 01/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual # 1's previous annual assessment was dated 04/23/2014 and the most recent annual assessment was dated 06/8/2015. Individual # 2's previous annual assessment was dated 05/14/2014 and the most recent assessment was not dated. Individual # 3's previous annual assessment was dated 05/19/2014 and the most recent assessment was dated 06/08/2015. 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.All Program Specialists were retrained on Initial and Annual Assessment Documentation regulations on 2/2/2016 including the definition of annual (365 +14-days or less). Program Specialists will note when an ISP ARU date changes so that the individual record stays in compliance with regulations. Quarterly beginning April 2016, the Associate Director will review a random sample of assessments from each Program Specialist to ensure assessments are signed, dated and completed within the regulated timeframe. 02/02/2016 Implemented
SIN-00064496 Renewal 10/21/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)-Individual #1's assessment, dated 2/18/14, was not sent to the plan team members 30 days prior to the ISP meeting. -Individual #2's assessment, dated 11/14/13, was not sent to the plan team members 30 days prior to the ISP meeting. -Individual #3's assessment, dated 1/2/14, was not sent to the plan team members 30 days prior to the ISP meeting. -Individual #4's assessment, dated 6/30/14, was not sent to the 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).All Program Specialists will print emails or copies of letters to document distribution of the assessment at least 30-days prior to the ISP team meeting. The Program Specialist will develope a tracking record to document the date of the assessment and the date that the assessment was sent to the plan members prior to the ISP meeting, starting within 30 days of receipt of this Plan of Correction. [SW 1.9.15] 11/21/2014 Implemented
SIN-00051027 Renewal 10/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.60(a)The site did not have a first aid area specifically for first aid purposes.(a) A facility shall have a first aid area that is separate from the work area.Provider has creating a separate first aid area that is used exclusively for first aid. The program specialist will review this area on a monthly basis to ensure that it is used exclusively for first aid treatment starting 1/31/14. 12/20/2013 Implemented
2390.151(e)(9)The lifetime medical history for individual # 3 was incomplete.(e) The assessment must include the following information: (9) Documentation of the client's disability, including functional and medical limitations.Each assessment will include complete lifetime medical histories using the correct terminology or document our efforts to obtain the information. Individual #3's assessment was updated to include the lifetime medical history. The program specialist will audit all of the participants assessments to ensure that a lifetime medical history is included by 1/31/14. 12/20/2013 Implemented
2390.151(e)(12)Individual # 2's assessment dated 6/30/13 and individual's # 3 assessment dated 10/2/12 did not have recommendations for specific vocational training. (e) The assessment must include the following information: (12) Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.Provider assessment will include specific areas of vocational training and a specific competitive job title if community employment is recommended. Individual #2 and Individual #3's assessment was updated to include specific vocation training. The program specialist will audit all of the participants assessments to ensure that all required elements of the assessment are included by 1/31/14. The audit will be performed on a monthly basis, on all updated and new assessments to ensure that are complete. 12/20/2013 Implemented
2390.151(f)Individual # 4 was admitted 6/19/13 and the assessment was completed on 7/17/13. The plan meeting was held on 7/9/13.(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).Program Specialists will provide the assessment to plan team members at least 30-calendar days prior to an annual meeting. The Program Director will review the assessments with the Program Specialist to ensure that the assessment is forwarded timely, starting 1/31/14. 12/20/2013 Implemented
2390.156(a)Individuals #1 and #2 quarterly ISP reviews did not report progress for their outcomes.(a) 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.Program Specialists will comment on the quality of work and progress on outcomes. Individual #1 and #2's quarterly ISP's for December, 2013 will reflect an accurate review of their progress on the ISP outcomes. The Program Director will review all participants quarterly ISP reviews to ensure they accurately reflect the participants progress starting 1/31/14. 12/20/2013 Implemented
SIN-00235642 Renewal 12/04/2023 Compliant - Finalized
SIN-00215767 Renewal 12/02/2022 Compliant - Finalized
SIN-00115548 Renewal 06/01/2017 Compliant - Finalized
SIN-00038663 Renewal 07/25/2012 Compliant - Finalized
SIN-00038662 Renewal 07/25/2012 Compliant - Finalized