Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210935 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom showers located in the home had residue consistent with dirt and mildew along the seams of the tile near the base of the showers. The bathrooms also had and odor consistent with urine throughout. The top shelf of the refrigerator had two food items not properly covered and not dated.Clean and sanitary conditions shall be maintained in the home. All bathroom showers were cleaned by residential coordinator on 8/31/2022 (Attachment #35). Delta maintenance replaced the caulk in the shower on 9/26/2022. 08/31/2022 Implemented
6400.64(e)Two trash cans located in the garage did not have lids on them. One was filled with trash, the other can had recyclables. Both cans were in regular use without lids. Round lids were located on the floor of the garage, however the can for trash was rectangle.Trash receptacles over 18 inches high shall have lids. Outdoor trashcans were corrected by chief program director on 9/24/2022 (Attachment #36). 09/24/2022 Implemented
6400.67(a)There were damaged floor thresholds at the exits from the living room. The hallway wall on the main level near the bathroom had scuffing that caused paint and wood to be chipped. The sink in the main level bathroom was cracked and repaired with glue. The front left burner of the kitchen oven was damaged and bent inward toward the stove pan.Floors, walls, ceilings and other surfaces shall be in good repair. Damaged floor thresholds were repaired by Delta maintenance on 9/26/2022 (Attachment #37). Hallway was repainted by Delta maintenance on 9/8/2022 (Attachment #38). Sink was replaced by Delta maintenance on 9/12/2022 (Attachment #39). Kitchen stove was replaced by Delta maintenance on 9/12/2022 (Attachment #40). 09/26/2022 Implemented
6400.68(a)The home did not have hot running water. The water at all water sources reached a maximum temperature of 76.1 degrees Fahrenheit. The hot water heater was not functioning.A home shall have hot and cold running water under pressure. Maintenance adjusted the thermostat on the water heater and the water temperature is now 109° (Attachment #41). 09/09/2022 Implemented
6400.81(k)(2)There was no bed frame for the mattress in Individual 1's bedroom. A new bedframe was ordered after inspection on 8/31/2022.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Individual 1 received a new bed frame on 8/31/2022 (Attachment #43). 08/31/2022 Implemented
6400.82(f)The bathrooms in the home did not have paper or hand towels.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. Residential coordinator placed paper towels in the bathroom 8/30/2022 (Attachment #44). 08/30/2022 Implemented
6400.144The health service of testing sugar levels weekly on Mondays with accu-check was not fully logged for Individual 1. The Glucose level checks were marked as completed in August but the levels were not recorded onto the medication record from the device . The diabetes protocol was not located in the individual's binder or file in the office area to notate if recording blood sugar levels were needed.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 residential coordinator contacted the doctor¿s office via phone on 8/31/2022 to request the diabetes protocol. The diabetes protocol sent by the doctor on 9/6/2022 (Attachment #45) was vague and as such, on 9/6/2022 the residential coordinator requested via phone call an updated protocol to specify what follow through is needed based on the reading. Doctor¿s office was contacted via phone again on 9/23/2022 and 9/26/2022 as no updated protocol has been received. After further follow up, the chief program office discovered that the glucose checks were changed to daily, no longer weekly, with the 9/6/2022 order however the residential coordinator and direct support professionals were not completing the checks daily. As a result, on 9/23/022 the Delta incident management coordinator entered a Neglect incident into EIM (9094639) that will be thoroughly investigated by a Delta certified investigator. Delta management will review the investigation, make recommendations for corrective follow up, and follow through that all corrective actions are completed by October 31, 2022. On 9/23/2022 the incident manager requested that the glucose monitor be replaced, pharmacy called, staff trained on new glucose monitor and tracking, and that his team would be notified. A new glucose monitor was purchased by the chief program office on 9/26/2022 and taken to the home the same day. The residential coordinator trained all house staff on daily monitoring on 9/26/2022 (Attachment #46). The pharmacy was contacted by regional director via phone on 9/23/2022 to request the MAR be updated with daily checks. The support coordinator was contacted via email by regional director on 9/23/2022 (Attachment #47). 09/26/2022 Implemented
6400.32(r)The doors to Individuals 1, 2, and 3's bedrooms did not have the ability to be locked.An individual has the right to lock the individual's bedroom door.The individuals and guardians for the residents in this home were contacted by the residential coordinator on 9/23/2022 and all stated they do not want locking doorknobs on the bedroom doors. This communication has been shared with the support coordinators to include in the individuals¿ ISPs (Attachment #48). 09/23/2022 Implemented
SIN-00091503 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff # 34's annual fire safety training dated 12/23/2015 was not conducted by a fire safety expert. Staff # 35's annual fire safety training dated 02/27/2015 was not conducted by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Residential managers , Program Coordinators and Associate Directors participated in an annual fire safety train the trainer session on 10/14/16 Attachment # 16 completed by a fire safety expert Attachment # 17. Managers will participate in this training on an annual basis . Going forward, those managers trained as fire safety experts will complete face to face training for all staff at the homes where they work on an annual basis using the training materials provided by the fire expert Attachment # 18. . Any managers who were not in attendance will be trained by a fire safety expert by 11/30/16. Our trainer who was trained as a fire safety expert will train all new hires. 11/30/2016 Implemented
6400.67(a)There was a broken vanity in Individual # 1's bathroom. The rain gutter located on the back of the home was partially detached. There were multiple broken window blinds throughout the home. Floors, walls, ceilings and other surfaces shall be in good repair. Facilities replaced the broken vanity in individual #1's bathroom on 5/11/16. Attachment # 10 . Facilities fixed the rain gutter on the home on 5/11/16. Attachment # 11. Facilities replaced all broken blinds in the home 5/20/16. Attachment # 12. Going forward Residential Managers will complete Residential Safety Checklists and complete work orders for any facilities concerns that are noted. Attachment # 13. Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists Attachment # 14 . Work orders will be completed for any facilities concerns noted. Attachment # 15. All management staff were trained on licensing requirements on 5/13/16 Attachment # 7. 05/20/2016 Implemented
6400.151(a)Staff # 35's previous physical examination was dated 03/20/2012 and the most recent physical examination was dated 03/14/2015. 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. Delta has changed their employment physical procedures so that employees can now go directly to the occupational health provider for their physical and the provider bills Delta directly for the service. This will ensure employees complete physicals without the need for them to pay for the examination. Physicals can also now be completed without waiting for an available appointment. Human Resources Assistant emails a list weekly to management staff with all employee physicals coming due in the next three months. Attachment # 8. Delta has instituted a policy 9/25/15 that any employee who is 15 days overdue for their biennial physical are placed on administrative leave until their physical is completed. Attachment # 9. 05/12/2016 Implemented
6400.168(d)Staff # 15's annual medication administration training dated 11/18/2015 was invalid as the fourth MAR review was completed on 12/12/2015.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
6400.181(e)(13)(viii)Individual # 2's annual assessment dated 05/18/2015 did not document progress and growth in the area of managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Upon discovery through our self assessment process, the Regional Director updated the template for our annual assessment on 2/1/16 to include managing personal property. Attachment # 4. Individual #2's assessment was completed prior to the revision of the assessment document. His current assessment from May 2016 includes his progress and current level of functioning in managing his personal property. Attachment # 5. All management staff/program specialists were trained on required content of assessments on 5/11/16. Attachment # 6 Going forward, Regional Director and Associate Directors will review assessments prior to mailing to team members and monitor for compliance during routine audits of individual records. All management staff were trained in licensing requirements on 5/13/16 Attachment # 7 05/16/2016 Implemented
SIN-00047508 Renewal 03/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1 moved into the home as a new admission on 10/5/12 and was informed of his individual rights until 10/22/12.(a) Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. New admission will be closely monitor by Program Specialist for completion in a timely manner and will ensure that it is done annually. staff trained 4/3/13 04/22/2013 Implemented
6400.112(f)On 6/17/12, 7/10/12, 8/28/12 and, 1/24/13, 2/25/13, 3/12/13 the front door was used to exit during monthly fire drills.(f) Alternate exit routes shall be used during fire drills. We have revised fire drills forms to note alternate exits used. Staff training was held on 4/5/2013. PD will monitor monthly use of alternate exits. 04/22/2013 Implemented