There are  37 surveys for this facility. Please select a date to view the survey results.

CE1
The facility will ensure that clients have the opportunity to participate in social, religious and community group activities.
On April 4, 2026, all of the facility Individuals participated in a community outing. The community outing was documented on the Community Integration Return form upon return; the Program Lead reviewed the document and scanned the document to the Qualified Intellectual Disability Professional (QIDP) for her review.
On or before April 24, 2026, the Senior Director /designee will re-train the Program Lead on the responsibility of ensuring that individuals are participating in social, religious, and community group activities and following the active treatment process through community integration activities for all facility Individuals. The Program Lead will also be retrained to create a monthly activity calendar with the community events(s) listed for the month and the calendar posted for all to view. This training will include the responsibility of ensuring that outings are documented on the Community Integration Return form by staff that participated in the outing, and upon return from the outing, the staff will complete documentation. The emphasis on this training will be focused on the documentation of each individual level of participation, and it will include each individual's response to that activity. These trainings will be documented on a Staff Attendance Sheet (SA) and maintained at the site. A copy of the SA Sheet will be forwarded to the Senior Executive Director to verify completion.
On or before April 27, 2026, the Director of Social Services (DSS) or designee will retrain the QIDP on ensuring that all individuals have the opportunity to participate in social, religious, and community group activities. The training will include their responsibility to ensure that they monitor the community outings for each Individual on their caseload. In addition, the QIDP will review all Community Integration Return forms that are sent by the Program Lead (PL) during the review monthly. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director (SD) to verify completion.
CE2
On or before April 29, 2026, the Program Lead will retrain the facility staff on the responsibility of ensuring that individuals are participating in social, religious, and community group activities and following the active treatment process through community integration activities for all facility Individuals. The training will include their responsibility to ensure that the Community Integration Return forms are completed upon their return from an outing and submit the document to the Program Lead (PL) for review. This training will also discuss following the events/activities listed on monthly calendar. The emphasis of this training will focus on the documentation of each individual level of participation, and it will include each individual's response to that activity. The training will be documented on a Staff Attendance Sheet (SA) and maintained on the site. A copy of the training will be forwarded to the Senior Director to verify completion.
As future employees are hired, the Program Lead will provide training on the responsibility of ensuring that individuals are participating in social, religious, and community group activities and following the active treatment process through community integration activities for all facility Individuals. Documentation of the training will be completed on the six (6) month orientation worksheet and maintained in the Staff Development Office.
CE3
All individuals have the opportunity to participate in social, religious, and community group activities monthly barring medical restraints and or weather conditions permitting.
When there is a community outing or participation in a social or religious event, it is the responsibility of the staff who participated in the activity with the individual(s) to document the event's outcome on a Community Integration Returns Form. The information captured includes the individual's name, date/day of the trip, and the destination. The form also includes reactions of the individual as well as any practiced skill and any problems or concerns that may have occurred. The staff who complete the form will sign off on the form and submit it prior to the end of their shift for the Program Lead to review. The Program Lead ensures that the Community Integration form is completed by the end of their shift. If the Program Lead discovers that the form is not completed, they will ensure that the form is completed on the day of discovery and retrain the staff on their responsibilities to complete the Community Integration Form. The training will be kept in the employees' file. Once reviewed by the Program Lead, the form is sent to the QIDP/Program Manager for review and verification of completion as trips occur. The Community Integration forms will be viewed by the QIDP/Program Manager by the 15th of the month to ensure that all individuals have participated in social, religious, and community group activities within that month. If community outings have not happened, the Program Manager/designee will initiate community outing no later than the end of that month to ensure that all individuals have participated in social, religious, and community group activities for the month. All outings and social events are submitted at the end of the month to the QIDP to be filed and to be incorporated into quarterly reports of the individual. Any anomalies found will be sent to the SD and DSS to address.
CE4
Beginning in May 2026, the QIDP and the Program Manager will conduct audits of the Community Integration Return Forms twice a month by the 15th of the month for 3 consecutive months to ensure that community activities are occurring. Thereafter the Community Integration forms will be viewed once a month by the 15th of the month, to ensure that all individuals are participating in social, religious, and community group activities each month. The Community Integration forms will be viewed by the QIDP/Program Manager by the 15th of the month to ensure that all individuals have participated in social, religious, and community group activities within that month. If community outings have not happened, the Program Manager/designee will initiate community outing no later than the end of that month to ensure that all individuals have participated in social, religious, and community group activities for the month. Any anomalies will be addressed immediately and reported to the Program Lead to address via retraining and/or corrective action. The training will be documented on a Staff Attendance (SA) sheet and will be maintained in the Staff files.


The Director of Social Services/designee and Senior Director will review the QIDP quarterly reports for the next two quarters to ensure that individuals are participating in social, religious, and community group activities and following the active treatment process through community integration activities for all facility Individuals. Thereafter random reviews will be completed as per chart reviews. Any discrepancies will be addressed through retraining and/or corrective action,

CE5
The Senior Director and the Director of Social Services will be responsible for monitoring the process and reporting any outstanding discrepancies to the Regional Senior Executive Director at the monthly Executive Operations meetings for further address, and if applicable, systemic corrective actions.

CE1
The facility will provide training for employees who work with clients, focused on skills and competencies directed toward client's health need.
The facility Nurse developed a training sheet for Individual #1 medical need which focused on repositioning schedule/techniques.
On 3/27/26, the remaining two facility staff were trained on the repositioning schedule /techniques protocol for Individual #1.
On or before April 24, 2026, the Program Manager will retrain the Program Lead on the importance of ensuring the skill level training directed toward client's health, be trained as staff arrive on shift. The training will emphasize that there must be a trained staff working on each shift until all staff are trained in the client's health need. All training will be documented on a Staff Attendance Sheet to acknowledge the training was completed by the named staff. This training will be documented on a Staff Attendance sheet and a copy forwarded to the Senior Director to verify completion.
On or before April 28, 2026, the Program Lead will retrain all the facility staff on the importance of ensuring that skill level training directed toward client's health, are trained as staff arrive on shift. The training will emphasize that there must be a trained staff working on each shift until all staff are trained in the client's health need. All training will be documented on a Staff Attendance Sheet to acknowledge the training was completed by the named staff. This training will be documented on a Staff Attendance sheet and a copy forwarded to the Senior Director to verify completion.
On or before April 30, 2026, the Health Service Supervisor or designee will retrain all the facility Nurses on training facility staff on skill and competence level directed toward client health. The training will emphasize the importance of training facility staff including Program Lead. The Program Lead will continue to train the remaining facility staff in the client's health need. The Nurse will retrieve the staff attendance sheet from the site, copy (SA) and forward to appropriate IDT members. All training will be documented on a Staff Attendance Sheet and maintained in the Nursing Supervisors office and at the site. A copy of the training will be forwarded to the Associated Executive Director to verify completion.
In addition, the HSS or designee will train all new nursing staff on skill and competence level directed toward client health. The training will emphasize the importance of training facility staff including Program Lead. There must be a trained staff working on each shift until all staff are trained in the client's heath need. The Program Lead will continue to train the remaining facility staff in health care needs. All training records will be documented on a Staff Attendance Sheet (SA) with copies maintained in the nursing and Staff Development offices. A copy will also be sent to the Senior Director to verify completion.

CE 2
The HSS or designee will complete an audit of all facility Individuals client's skill level competencies staff attendance sheets from March 2026 to present to ensure that the trainings were completed with all staff signatures. Any training not completed by the facility staff will be reissued and retrained. Thereafter the Nurse Case Manager will reviews all facility Individuals client's skill level competencies staff attendance sheets for the next 2 months to ensure that current skill level training is completed by all of the facility staff, Any discrepancy will be brought to the attention of the Program Manager/Program Lead and staff will be retrained. Any anomalies will be addressed through retraining and or corrective actions.

CE3
The Nurse will provide the service plan training for client that focuses on skill level and competence directed toward health need. The Nurse emails a copy of the skill level training, and staff attendance sheet to the Program Lead prior to getting to the site. Once at the site, the Nurse will train all staff present at the site including the Program Lead. The Staff completing the training will sign the Staff Attendance Sheet acknowledging they were trained. The Staff Attendance sheet will be left at the site for the Program Lead to continue the training with the remaining staff. The Program Lead will train staff in the skill level training directed toward client's health, as staff arrive on shift. There must be a trained staff working on each shift until all staff are trained in the client's health need. Program Lead will review the Staff Attendance Sheet and cross reference the staff schedule to ensure all staff are trained. On the deadline date for the completion, the SA sheet will be picked up by the Nurse. The Staff Attendance sheet will be reviewed, and the completed SA will be forwarded to appropriate IDT members. A copy of the service plan training Staff Attendance Sheet is kept in the Nursing Department office.

CE4
The HSS/designee and the Program Manager will monitor the above process to ensure training was provided to employees who work with clients, on focused skills and competencies directed toward client's health needs by reviewing the SA sheets, within 7 days after the deadline due date for the training, to ensure all staff have been trained. Any discrepancy will be brought to the attention of the Program Lead and staff will be retrained. Any anomalies will be addressed through retraining and or corrective actions.

CE5
The Senior Director and the Health Service Supervisor will be responsible for monitoring the process and reporting any outstanding discrepancies to the Regional Senior Executive Director at the monthly Executive Operations meetings for further address, and if applicable, systemic corrective action.

The facility will ensure Nursing Service includes other nursing care as prescribed by the physician.
On 4/8/26, Individual #1 completed the endocrinology appointment at 2:00pm. The Nurse forwarded the consultation sheet to the Primary Care Physician (PCP) for review, and any recommendations were addressed accordingly.
On or before April 27, 2026, the Program Manager will retrain the Program Lead on medical appointment protocol for staff to follow when taking Individual #1, on medical appointments. This training will emphasize the need to ensure the medical packet is brought to the appointment with the Individuals and if the medical office requires additional information, the Nursing Department must be contacted immediately to address the concern. If staff are running late for the appointment, or experience heavy traffic, the Nurse, Medical Suite, Program Lead must be notified as they will alert the doctor's office. The staff must notify nursing and or supervisor before leaving the medical office. This training will be documented on a Staff Attendance (SA) Sheet and will be maintained at the site. A copy of the Staff Attendance Sheet (SA) will be forwarded to the Senior Director to verify completion.
On or before April 29, 2026, the Program Lead will retrain the facility staff on procedure and protocol to follow for medical appointments when escorting Individual (s) to an appointment. This training will emphasize the need to ensure the medical packet is brought to the appointment with the Individuals and if the medical office requires additional information, a call must be made to the Nursing department. If staff are running late for the appointment, or in traffic, the Program Lead will call the Facility Nurse, and he/she will contact the doctor's office. The staff must notify nursing and or supervisor before leaving the medical office. This training will be documented on a Staff Attendance (SA) Sheet and will be maintained at the site. A copy of the Staff Attendance Sheet (SA) will be forwarded to the Senior Director to verify completion.
CE2
On or before April 30, 2026, the Health Service Supervisor (HSS)/or designee will audit all the facility Individuals medical appointments from January 2026 to current to ensure all appointments have been addressed and physician's orders for medical appointments have been completed. Any missed appointments will be addressed and rescheduled to ensure all individuals are receiving nursing care as prescribed by physicians, document findings on an audit form, and send to the Director of Social Service (DSS) and the Senior Executive Director (SD) for review. Any anomalies will be addressed within 7 days by the HSS and/or the DSS.

CE3
The medical Administrative Assistant /Health Service Coordinator sends out the appointment sheet 10-14 days ahead of the scheduled week through email to all the Community Homes. (All packets are made by the Tuesday of the previous week) The Nurse and Case Manager create the packet with the appropriate medical documentation. The Medical AA/HSC checks off that appointment pack was made for the corresponding appointment. Appointment Packets are then delivered to the homes. The day of the appointment the staff will bring the medial packet to the medical appointment and present it the Receptionist at the office. If staff are late for the medical appointment, they must notify the Nurse, Med Suite, Program Lead, so that they can contact the doctor's office. While at the doctor's office, any questions and or missing documents, the Staff will call the Nurse and or contact their Program Manager to report the concern. The Nurse will call the doctor's office and find out what is needed and fax or scan missing information directly to the medical office. After the medical appointment, the Staff brings the medical packet back to the site. The Nurse (2nd shift, Weekend, Case Manager) will pick up the appointment packet within 24-72 hours and bring it back to the Med Suite. The Primary Care Physician (PCP) will review and approve the recommendations within 7 days.
Once a recommendation is reviewed and approved by the PCP, the Nursing Administrative Assistance will send the recommendations (within 7 days of PCP's approval) via email to Qualified Intellectual Disability Professional (QIDP) and the appropriate IDT members.
Any noted concerns throughout the process will be addressed, via retraining and or other corrective actions at the time of discovery, by the department head responsible.
After hours (7pm-7am), Weekends, and Holidays, emergency situations ER visit and or ER discharge, Staff must contact the On-Call Nurse prior to Individual being discharged from Emergency Room visit. The On-Call Nurse will receive a verbal report from ER and ask for the orders to be faxed over. The On-Call Nurse will contact PCP-and give the verbal report. On Call Nurse will notify Nurse on duty of the discharge to ensure a wellness visit is completed within 12 to 24 hours and the discharge paperwork is obtained. Any medication can be filled by Life Tree Pharmacy before 3pm or obtained through local pharmacy. The On-Call Nurse is responsible for trouble shooting this process, contacting the PCP, Nurse on duty and ensuring all recommendation and prescription are obtained.
CE4
The above process will be monitored by the Assistant Health Services Supervisor/designee by reviewing the appointment packets (the Tuesday prior to the appointment date) to ensure all required information is included in the packet. Any discrepancy will be brought to the attention of the Nurse Case Manager, and the Nurses will be retrained. Any anomalies will be addressed through retraining and or corrective actions.

CE5
The Health Service Supervisor and Senior Director will be responsible for monitoring the process and reporting any outstanding discrepancies to the Regional Senior Executive Director at the monthly Executive Operations meetings for further address and, if applicable, systemic corrective actions.