Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00166427 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The Range Hood over the stove was not clean and sanitary.Clean and sanitary conditions shall be maintained in the home. The grease has been cleaned from the stove hood 10/1/19. A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.66There was no light in individual #2's bedroom.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light switch in Individual #2's room has been fixed 9/26/19. (Attachment #28) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.67(a)The kitchen cabinets were missing knobs.Floors, walls, ceilings and other surfaces shall be in good repair. The knob on the kitchen cabinet has been replaced 9/24/19. (Attachment #29) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.67(b)There was Lint build-up found in the dryer. The Inspector was unable to access the homes attic based on safety. The Ladder was not in good repair. Floors, walls, ceilings and other surfaces shall be free of hazards.The flexible hose on the dryer vent has been cleaned 10/22/19. (Attachment #30) The attic access has been moved to the kitchen on 10/11/19 (Attachment #31) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.181(e)(14)Individual #1's assessments completed on 3/11/19 and 3/11/18 have inconsistencies. Under the likes section, it states individual #1 likes to swim, however under the water skills section it states he doesn't like to swim. Also, the Knowledge of water safety is not fully addressed in the assessment.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Assessment template redone on 10/1/19 to update and amend to include clear likes and water skills. (Attachment # 3) Individual # 1's assessment has been redone on the new template and sent to his team. (Attachment #32) Going forward all assessments will be completed on the new template by the Program Specialists. 12/10/2019 Implemented
SIN-00091515 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were three tubs of Great Valve powered laundry detergent which indicated to contact poison control if ingested, found unlocked in the laundy roomPoisonous materials shall be kept locked or made inaccessible to individuals.The laundry detergent had been removed from the laundry room and stored in a locked cabinet on 5/9/16. Attachment # 19. Going forward Residential Managers will complete Residential Safety Checklists to ensure any poisons are properly stored. Attachment # 13. Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists Attachment # 14 to ensure any poisons are properly stored. Any poisons discovered, will immediately be removed and placed in proper storage. All management staff were trained in licensing requirements on 5/13/16 Attachment # 7. 05/13/2016 Implemented
6400.168(a)Staff # 26's initial practicum observer training dated 11/15/2013 is invalid as the observation were incomplete. 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. 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
6400.168(d)Staff # 26's annual medication administration training dated 10/19/2015 was invalid as the fourth MAR review was completed on 12/08/2015. Staff # 27's annual medication administration training dated 11/04/2015 was invalid as the fourth MAR review was completed on 11/10/2015.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