Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
SIN-00237506
|
Renewal
|
01/17/2024
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.106 | The home had a furnace inspection completed on 12/6/22 and then again on 12/28/23. | 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.
| On 8-27-2023 a new furnace was installed into the home, at that time of installation it was serviced and inspected. Then on 12/28/23 our agencies regular furnace technician cleaned and serviced the unit and completed the proper paperwork that it was complaint. However due to the new unit being installed it was not completed earlier by the technician. |
01/31/2024
| Implemented |
|
|
SIN-00133006
|
Renewal
|
04/12/2018
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.163(c) | Individual #1's psychiatric medication reviews completed 9/25/17, 9/28/17, 10/26/17, 12/1/17, 12/21/17, 1/9/18, 2/6/18, 2/27/18 and 3/27/18 did not include the reason for prescribing the medications. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Coordinator has since re-assessed and developed a new form to be taken on psychiatric appointments with clients . On this form all of the medications will be listed, the dosage, the diagnoses, and doctors name. At the appointment the doctor will then make a check mark to ensure that they are prescribing the medication, is dosage is correct and that the client is to continue to take the medication. It was also put into practice that only the supervisor or the coordinator will attend all psychiatric appointments moving forward to ensure that all paperwork is correctly completed. All paperwork from the appointment will then be turn into the agency's medical coordinator who will then check for accuracy and sign off on before the paperwork is filed in the clients book. [Prior to the next medication review, the CEO or designee shall educate all staff persons responsible for ensuring psychiatric medication reviews are completed timely with all required information shall be educated on the aforementioned procedures to ensure all individuals who are prescribed medication to treat symptoms of a diagnosed psychiatric illness have a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Documentation of the trainings kept. (AS 5/4/18)] |
04/20/2018
| Implemented |
6400.186(b) | Individual #2's ISP review end dated 2/16/18 was not signed by Individual #2. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The individual has since signed the document. Moving forward the supervisor will ensure that all paperwork is reviewed with and signed off on by the individual prior to being turned in. The coordinator will double check the documents to ensure all areas are completed and signed off on before the documents are mailed out and filed in the individuals books. |
04/20/2018
| Implemented |
6400.213(1)(i) | Individual #2's record did not include identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| All records were re-assessed to make sure that there were no blanks on any of the clients personal information. If the client did not have information to be entered then a N/A or none was entered. Moving forward when completing updates on the clients information forms the supervisor will ensure that there is information entered in all areas. The Coordinator will ensure to this when quarterly book reviews are completed. [Documentation of quarterly audits shall be kept. (AS 5/4/18)] |
04/20/2018
| Implemented |
|
|
SIN-00114308
|
Renewal
|
05/17/2017
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.68(b) | At 10:17AM, the hot water temperature measured 151.8°F at the bathtub of the bathroom located in the hallway near the bedrooms. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water heater was turned down on site at the time of inspections. The water temperature was checked a week later by the residential operations coordinator to make sure that it was with in regulation. The water temperature will be check now on a monthly basis by the residential coordinator documentation of this will be kept at the house. [Immediately, the CEO will develop and implement policies and procedures to ensure the hot water temperature in bathtubs and showers does not exceed 120°F. Procedures shall include at least monthly monitoring and documentation, a review of documentation by CEO or designated management staff person, procedures for notification and adjustment of water temperature and training for staff who monitor water temperatures and work in community homes. Documentation of trainings, policies and procedures and water temperatures shall be kept. (AS 6/20/17)] |
06/15/2017
| Implemented |
6400.110(a) | The attic of the home where the furnace is located did not have a smoke detector. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | A Smoke detector was installed in the attic on 5-19-2017., Picture sent to e-mail. Detector was added to the list of detectors in the home and will be tested during monthly fire drills. The batteries will be changed on regular basis. [Documentation of monthly checks shall be kept and reviewed by designated management staff to ensure smoke detectors are present in all required locations and operable. (AS 6/20/17)] |
06/15/2017
| Implemented |
6400.111(a) | The attic of the home where the furnace is located did not have a fire extinguisher. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher was installed on 5-19-2017. Picture sent to E-mail Fire extinguisher will be inspected annually along with others in the home. [Documentation of annual fire extinguisher checks shall be kept. (AS 6/20/17)] |
06/15/2017
| Implemented |
|
|
SIN-00092541
|
Renewal
|
04/08/2016
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.77(b) | The first aid kit did not contain a thermometer. | 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. | A digital thermometer was purchased for the first aid kit. There will be monthly checks to the first aid kit to ensure that all items are present and not expired [Designated staff person will check the first aid kits monthly to ensure all items are present and document. Documentation shall be reviewed by CEO or to ensure completion and that first aid kits at all community homes have the required items. (AS 4/18/16)] |
04/08/2016
| Implemented |
6400.101 | The door between the living room and the garage has a key lock on the garage side of the door and a thumb turn on the living room side of the door which prevents entrance back into the home from the garage. There is no man door in the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The door that lock from the garage into the living room was changed to allow egress from the garage into the home, where there are alternative exits. [All staff working in community homes shall be trained prior to working in the homes that all stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. At least quarterly checks of the homes shall be done by the program specialist to ensure stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Documentation of trainings and home checks shall be kept.(AS 4/18/16)] |
04/08/2016
| Implemented |
|
|
SIN-00219483
|
Renewal
|
02/14/2023
|
Compliant - Finalized
|
|
SIN-00201644
|
Renewal
|
03/10/2022
|
Compliant - Finalized
|
|
SIN-00185145
|
Renewal
|
03/23/2021
|
Compliant - Finalized
|
|
SIN-00172338
|
Renewal
|
03/11/2020
|
Compliant - Finalized
|
|
SIN-00153432
|
Renewal
|
04/09/2019
|
Compliant - Finalized
|
|