| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00229071
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Renewal
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08/08/2023
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Written fire drill record shall be kept of the time including designation of AM / PM. The fire drill conducted on 10/18/22 at 7:54 did not include the designation of AM/PM. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drill log was updated to indicate AM/PM. |
08/23/2023
| Implemented |
| 6400.112(d) | The fire drill that was conducted on 10/18/2022 had a recorded evacuation time of 3 minutes, which exceeds the maximum evacuation time of 2 minutes and 30 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Individual that was unable to evacuate under 2.5 minutes has since moved out of the home. |
08/23/2023
| Implemented |
| 6400.141(c)(14) | The record of the physical examination completed on 3/16/2023 for Individual #1 did not document information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical exam paperwork has been updated to include, "medical information pertinent to diagnosis and treatment in case of an emergency. All previous forms were discarded. |
08/14/2023
| Implemented |
| 6400.151(a) | A staff person who comes into direct contact with the individuals shall have a physical examination within 12 months prior to employment and every two years thereafter. Staff #1 had a physical examination on 1/29/2020, then not again until 7/26/2022. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The leadership team met on 8/7/2023 to create a process of ensuring annual physicals are completed in accordance with 6400 regulations. |
08/07/2023
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Robitussin DM Cough syrup, take 1 teaspoon by mouth as needed for cough. The medication administration record (MAR) and the pharmacy label on the bottle did not include the frequency that the medication should be administered (i.e. every four hours, once daily, etc.). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Agency nurse reached out to physician to have them add frequency to the as needed medication. |
08/23/2023
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications. Staff #1 last completed the annual medication administration course renewal requirements on February 18, 2022. The renewal was due February 18, 2023, but there is no record that the staff completed the renewal requirements and has been administering medications. Staff #1 administered medications on 7/01, 7/08, 7/15 and 8/05 of 2023, according to the Medication Administration Records for July and August of 2023. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff person was advised not to administer medication moving forward until they are able to be fully retrained. The staff person is scheduled to retake the medication administration course on 9/20/23 & 9/21/23. |
08/10/2023
| Implemented |
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SIN-00210328
|
Renewal
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08/03/2022
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Located under the basement bathroom sink was a spray bottle that was filled approximately ¼ of the way with a blue liquid with a black marker label on it that said "Kitcha 1/2 Fab water". Also located under this same cabinet was another spray bottle with the label "Professional Spray" and it was filled approximately ¼ of the way with a clear bubble liquid. Staff told the Licensing Representative that it was a sanitizer that was filled from the office. Poisonous material shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | The bottle was removed from the home by House Supervisor. Staff were also reminded that all cleaning products need to be in the original container noted in staff meeting on 8/16/2022. |
08/16/2022
| Implemented |
| 6400.64(e) | The garbage can located next to the dryer was approximately 22 inches tall and it did not have a lid on it. | Trash receptacles over 18 inches high shall have lids. | This can was removed and replaced by a smaller can. |
09/15/2022
| Implemented |
| 6400.65 | The bathroom located in the basement did not have ventilation. The mechanical ventilation was inoperable at the time of inspection. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Ventilation system was repaired by facilities director. |
09/14/2022
| Implemented |
| 6400.82(e) | The shower located in Individual #8's bathroom did not have a nonslip mat. | Bathtubs and showers shall have a nonslip surface or mat. | non slip mat was placed in Individual #8's shower. |
09/15/2022
| Implemented |
| 6400.112(d) | Individuals shall be able to evacuate within 2 1/2 minutes. Fire drill conducted on 7/13/22 at 1:00 AM had an evacuation time of 4 minutes and the fire drill conducted on 7/16/22 at 4:45 AM had an evacuation time of 3 minutes and 35 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | One individual in the home refuses to evacuate. Provider has identified this person is no longer appropriate for this home. Notice was provided to the AE, SC, Family and region explaining our concerns. This letter was sent August 1, 2022. Fire drills have been completed without the individual refusing to exit and have remained in compliance. The house Supervisor and staff are continuously educating this individual on the importance of exiting despite her refusal. This is completed and documented at least three times a month. Fire letter also states that this individual needs full physical assistance to exit the home. |
09/13/2022
| Implemented |
| 6400.32(r) | An individual has the right to lock their bedroom door. All the Individual's bedroom doors in the home did not have locks on the doors | An individual has the right to lock the individual's bedroom door. | The team met and it was discussed that locks on the doors would not be needed. An email stating this would be added to each ISP was received on 9/9/2022. |
09/09/2022
| Implemented |
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SIN-00142835
|
Renewal
|
10/09/2018
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspected on 7/10/2017. It wasn't inspected again until 8/17/2018, which exceeds the annual requirement. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnace in this home is current with inspection. The CLA program now tracks and schedules furnace cleaning within its own program. Beginning July 2019 all furnaces will be inspected; an alert system has been set up in the Directors and Administrative Assistance Outlook calendar to schedule furnace cleanings, the alert is the first Monday of April. |
11/09/2018
| Implemented |
| 6400.112(a) | Fire drills were not held monthly at this residence. There was no documentation of a fire drill being held in February 2018. | An unannounced fire drill shall be held at least once a month. | Fire drill training was conducted on October 17, 2018 during coordinators meeting to review the importance of consistent fire drill in the homes. This included all coordinators selecting a date for each month the unannounced fire dills will be conducted in each of the homes. The first coordinators meeting of each month the coordinators will bring the fire drill log to staff meetings for Director to review. |
11/09/2018
| Implemented |
| 6400.151(a) | Staff #9 had a physical exam on 6/6/2016. She didn't have another physical exam until 8/28/2018, which exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The CLA program now tracks the physical due dates within program and will alert the coordinator when a staff member of their home is a month away from their 2 year physical date.
Staff #9 is Linda Russell since the other staff is a new hire that started May 2018. |
11/09/2018
| Implemented |
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SIN-00125312
|
Renewal
|
12/05/2017
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | At the time of this inspection, self-assessments have not been completed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| 1. The coordinator and the assistant director were offered retraining on the self-inspection tool as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The directorship (Director and Assistant Director) of the program will utilize an Outlook Calendar in order to prompt them to begin the self-inspection process within the 3-6 months prior to the expiration date. The directorship will be responsible for assisting the house managers in completing the inspections.
3. Future audits of all homes self-inspection tools will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
4. Supporting documentation of retraining will be emailed. |
03/02/2018
| Implemented |
| 6400.167(a) | Staff #1 was hired on 7/10/2017 & does not have medication administration training. Staff #2, staff #3 and staff #4 do not have med practicums. All 4 staff have been passing medications. | Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. | 1. The staff and supervisor was offered retraining on the medication administration requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The home's staff were trained on Medication Administration Course 1/3/2018 and 1/9/2018. The practicums will be done yearly and tracked on a programs spreadsheet.
3. The directorship of the program will be responsible for ensuring that all approved trainers teaching medication administration to staff have a current certification.
4. The home¿s supervisor will closely monitor all future medication training of staff to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for timely medication certification by an approved trainer.
5. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
6. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(a) | Staff #1 was hired on 7/10/17. She does not have medication administration training and has been passing medications. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | 1. The coordinator and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The coordinator will ensure that all new staff are trained prior to administering medications. The home's staff were trained on 1/3/2018 and 1/9/2018.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication training of staff to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for timely medication certification by an approved trainer.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(c) | Staff #5 and staff #6's trainer certifications both expired 3/4/2017. Because of this, staff #1's initial training (11/3/17) and Staff #2 & Staff #3's practicums (both 7/1/17) are not valid. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | 1. The staff and supervisor was offered retraining on the medication administration requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The certified trainer who completed the Department¿s Medication Administration Course for Certified Trainers was completed by 12/13/2017. The home's staff were trained on Medication Administration Course on 1/3/2018 and 1/9/2018. Practicums will be completed yearly and tracked on program spreadsheet.
3. The directorship of the program will be responsible for ensuring that all approved trainers teaching medication administration to staff have a current certification.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(d) | Staff #4 does not have a Med Practicum and has been administering medications. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. The staff and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The home's staff were trained in the Medication Administration Course on 1/3/2018 and 1/9/2018. Practicums will be done yearly and tracked on a program spreadsheet.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication practicums of staff are in compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and have completed and passed the medication administration course practicum yearly.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(e) | Documentation of initial med training for staff #7 was not kept. Documentation of med practicums for staff #4 was not kept. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 1. The staff and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018
2. All documentation of the dates and locations of medications administration training for trainers and staff, along with copies of the annual practicum, will be kept in a master file at the office along with the home.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication trainings and practicums of staff are in compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and have completed the training and passed the medication administration course practicum yearly.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
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SIN-00108682
|
Renewal
|
01/18/2017
|
Compliant - Finalized
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | Furnace inspection was late. Inspected on 07/06/15 and then not again until 07/26/16. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Department Secretary has set up a system scheduling furance inspection two months before they are due for inspection to stay withing compliance of regulation through FRITCH inspection company. |
02/02/2017
| Implemented |
| 6400.110(e) | The attic smoke detector is not interconnected and not audible throughout the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The Attic was sealed off by our maintenanance Department. This change has allowed use to not have the home consider a three story home. Maintenanance department will over see this ares related to smoke detectors in the homes.
(attic made inaccessible -CH 4/18/17) |
01/20/2017
| Implemented |
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SIN-00089700
|
Renewal
|
12/23/2015
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(d) | During the training year of 7/1/14 -6/30/15, the Direct Support Staff #2 has a record of 17.75 total training hours. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | Citation : 46 (d)
Direct care staff completed 7 hours of training to complete her total of 24 hours of training on 12/30/15
Abuse- 1 Hour
Health/Wellness- 3 Hours
Safety/ OSHA- 1 Hour
Workforce Develpment Skills- 2 Hours
Compliance Monitor has been hired to conduct on going monthly, and quartely checks of staff annual training to ensure they have complete annual training and scheudle them for needed trainings. |
12/30/2015
| Implemented |
| 6400.106 | The furnace was inspected on 5/12/14 and again on 7/6/15 (61 days late). | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Citation 151 (a)
Furnance was inspected 61 days late on 7/6/2015.
Compliance Monitor has been hired to conduct quarterly checks of furnace to ensure they have been inspected.
Written documentation will be kept in a chart for furnace inspection dates, and renewals of service.
30 days before expire date compliance monitor will schedule for a professional furnace company to come out to the home to inspect furnace. |
12/01/2015
| Implemented |
| 6400.151(a) | The most recent physical for Direct Care Staff #2 was completed on 10/18/2012. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Citation : 151(a)
Direct care staff last physical completed on 10/18/2012
Direct care staff completed her physical on 2/3/2015
Compliance monitor was hired to condcut quarterly reviews of all staff annual physicals to ensure they have completed there physcials and have turned in document of completion. |
02/03/2016
| Implemented |
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SIN-00066641
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Renewal
|
10/14/2014
|
Compliant - Finalized
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|
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SIN-00052554
|
Renewal
|
08/14/2013
|
Compliant - Finalized
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