Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217589 Unannounced Monitoring 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The dishwasher was not operable, when opened a foul smell was coming from the nonoperative machine and the bottom of the enclosure has an unknown residue caked on it.Clean and sanitary conditions shall be maintained in the home. A dishwasher was ordered through Appliance Alliance on 1/10/23 ¿ waiting for a delivery date. 01/10/2023 Implemented
6400.64(f)There was a trashcan in the backyard area with no lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The trash can that did not have a lid but was observed on our property was not our trashcan, it was the next door neighbors. The trashcan was returned to the neighbors. We do not believe this should be a citation as we can not control whether the neighbors have lids on their trashcans. 01/10/2023 Implemented
6400.67(a)The ceiling in the upstairs hallway has extreme peeling and was in need of repair.Floors, walls, ceilings and other surfaces shall be in good repair. The ceiling was repaired and painted. 01/24/2023 Implemented
6400.72(b)The top pane on the left window located in the dining room area would not remain up when opening the bottom window. It would shut quickly and could cause a safety hazard. Screens, windows and doors shall be in good repair. The property owner of the home was notified of the broken window. An order was placed for a new window on 1/27/23. Waiting for the delivery and installation of the window. 01/27/2023 Implemented
6400.76(c)The first bathroom located in the upper front area (Individual 1's room) of the home had a dresser that 2 of the drawers were broken of the hinges and needed to be replaced.Furniture shall be comfortable and home-like. The dresser drawer was repaired. 01/12/2023 Implemented
6400.77(b)The house's first aid kit did not have medical tape. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The tape was purchased on 1/10/2023 and placed into the First Aid kit. 01/10/2023 Implemented
6400.82(e)The inlaid nonslip surface in the bathroom tub was not in good condition, therefore the home needs a nonskid mat for the bathtub for safety reasons. Bathtubs and showers shall have a nonslip surface or mat. A non-stick mat was purchased for the tub on 1/11/2023. 01/11/2023 Implemented
6400.82(f)There was no paper towels or hand soap in the upstairs bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Paper towels and hand soap were placed in the bathroom. 01/10/2023 Implemented
6400.144Pharmaceutical services are not being fully rendered for Individual 1. Their medication kit was missing several medications that were listed on their MAR: Benzoyl Peroxide gel and Lotrimin 1% cream. The orders for these medications are written as regular prescriptions with set administrations, but on the MAR, their administrations have been recorded inconsistently, with signatures missing on many dates. (The Benzoyl Peroxide gel's order indicates it should be applied twice a day to their beard area, but was only signed for in the MAR on 1/1/23, 1/2/23, 1/6/23, and 1/9/23; the Lotrimin cream order listed on the MAR indicates it should be applied to a facial rash twice per day but was only signed for on the evenings of 1/1/23 through 1/3/23, 1/6/23, and 1/9/23, and the morning of 1/3/23.)Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All medication errors were appropriately documented. 01/11/2023 Implemented
6400.32(r)There was no door lock for both individuals' bedroom should they choose to lock their bedroom doors. There was also no record on file indicating any discussion with the individual's team referring to their preference.An individual has the right to lock the individual's bedroom door.Team meetings were held on 1/17/2023 for both Individual 1 and Individual 2. It was explained to both individuals the option of having a lock on their bedroom door. Both individuals declined to have a lock placed on their doors and their assessments were updated to reflect their wishes and team agreement. 01/17/2023 Implemented
6400.163(a)Individual 2's Flonase spray was stored in a box with an illegible, faded pharmacy label; its expiration date could not be read.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.A new pharmacy label for Flonase spray was delivered on 1/13/23. 01/13/2023 Implemented
6400.163(h)Several medications were kept in Individual 2's medication kit beyond the expiration date on their pharmacy labels: PRN Tylenol 325 mg., expired 1/4/23, and Debrox 6.5% ear drops, expired 11/29/22.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.PRN Tylenol was discontinued by the PCP on 1/10/2023. This had been previously ordered when Individual 2 had dental surgery and was not an active, currently utilized prescription. D/C Order included. There was an updated Debrox 6/5% prescription medication available on site, it was not in Individual 2¿s medication kit at the time of the inspection. It was placed into the box on 1/10/23. 01/10/2023 Implemented
6400.166(a)(13)Several administrations of Individual 2's medications were not signed for on their MAR, with the signature boxes on the following dates and times found to be blank: Debrox ear drops 6.5% on 1/8/23, 8PM; Peridex 0.12% liquid, 1/5/23 and 1/8/23, 8PM; Prevident cream on 1/8/23, 8PM; Atarax 25 mg. on 1/8/23 at 8PM; and Thera Tears on 1/9/23, 8PM. Also, Individual 1's Selsun Blue shampoo was not signed for on the evening of 1/8/23.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.All medication errors were appropriately documented 01/11/2023 Implemented
6400.167(a)(1)Individual 2's MAR and medication blister packs indicate there was a missed dosage on 1/9/23 for their Cogentin 0.5 mg medication: there was no signature on the MAR for that date and the pill count is off, with the MAR indicating 21 pills were left but 22 pills were found in the blister pack.Medication errors include the following: Failure to administer a medication.All medication errors were appropriately documented. 01/11/2023 Implemented
SIN-00120538 Renewal 09/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were dark stains consistent with dirt on the carpet on the second floor of the home. It appeared the carpet has not been cleaned for a while.Clean and sanitary conditions shall be maintained in the home. This carpet had actually just been cleaned approximately one week prior to the inspection. It is permanently stained. As we rent this property we have requested that the landlord replace the carpet but they have not agreed to this. We will continue to document requests to landlords to repair or replace items in our rented homes. 09/29/2017 Implemented
6400.67(a)The night stand and the bedroom chest in Individual #1's bedroom were missing a knob each. there was water leak from the roof on to the ceiling in the dining room area. The handles on the laundry room door down the basement were detached and falling off the door.Floors, walls, ceilings and other surfaces shall be in good repair. The knobs and handles were repaired. The landlord was contacted several times with regard to the water leak. They have come out to evaluate the roof and will begin repairs once PECO has sleeved the electrical wires over the house. We will continue to document requests to our landlords to address issues. Again, Program Coordinators have been advised to routinely monitor the homes under their supervision for damage. 09/22/2017 Implemented
6400.68(b)The water temprature was 126.05 degree fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was reduced at inspection and checked daily for a week to insure it remained at 120 or below. The Program Coordinators as well as other members of the management team checked the water at other locations and found no similar violations. Water temperature is monitored by the Quality Assurance Coordinator and by other members of the management team Thermometers have been purchased for homes that did not have one so that Program Coordinators can accurately check the water temperature. 09/29/2017 Implemented
6400.141(c)(14)Individual #2's physical examination dated 3/8/17 did not include information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physician wrote: Ø. The Physical and the lifetime medical history accompany individuals to all appointments and emergency room visits to insure proper treatment. We will request physicians put additional information in that section. Physicals were reviewed and Program Coordinator's were informed to request all sections of the physical be completed thoroughly. 09/22/2017 Implemented
6400.141(c)(15)Individual #2's physical examination dated 3/8/17 did not include special dietry instructions.The physical examination shall include:Special instructions for the individual's diet. Individual #2's physical did include a recommendation to eat 5 servings of fruits and vegetables daily, however it was in the health promotion section of the physical just above the dietary guidelines question. (attachment #2). I do not believe this should have been a citation. 09/15/2017 Implemented
6400.142(a)Individual #2's previous dental examination was on 6/15/16 and the current dental exam was completed on 7/27/17An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The appointment had been scheduled for June 22, 2017 however, as the dental care was to be done under anesthesia, consents were needed from the individual's parent. The parent did not complete the consents and thus the appointment had to be rescheduled. In the future, we will contact the dentists a week prior to the appointment to insure consents are received and follow up with the guardian if they have not . 09/22/2017 Implemented
SIN-00060853 Renewal 01/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 was seen by the PCP on 5/20/13, with recommendations to follow up in 6 months. As of the date of the inspection the follow up had not occured. Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The follow up appointment was completed on 2/20/14. In the future, follow up appointments will be scheduled before leaving the doctor's office. The Health Care Specialist will request the date for follow up appointments when the original medical visit form is received to insure the appointment is made. 05/02/2014 Implemented
SIN-00045662 Renewal 02/20/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.183(5)Staff who implement the Social Emotional and Environmental Support Plan (SEEP) were not trained in the application of the SEEP.(5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The Program Specialist liaised with Program Coordinator and Behavior Specialist to conduct the relevant training class for the individual's support staff as early as possible. This meeting has been scheduled for 4/11/13. Additionally, the Program Specialist contacted the Supports Coordinator to edit his Individual Supports Plan to include the responsible persons. This request was made on 3/21/13. In the future, the Residential Program Specialist will coordinate with the Program Coordinators, Behavior Specialists, and Supports Coordinators to schedule trainings on the Behavior Support Plans on the first scheduled `house meeting¿ date after the ISP. If for any reason this date is unavailable the next available date will be used. The Program Coordinator will insure all appropriate staff are trained by review of the training history for each employee which is distributed monthly. 04/13/2013 Implemented
SIN-00249234 Renewal 08/06/2024 Compliant - Finalized