Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00205991 Renewal 06/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.62(a)Poisons in the basement cabinet were unlockedPoisonous materials shall be kept locked or made inaccessible to individuals.§ 6500.62. Poisons. (a) Poisonous materials shall be kept locked or made inaccessible to individuals. (b) Poisonous materials may be kept unlocked and accessible to individuals if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individuals ability to safely use or avoid poisonous materials shall be in each individuals assessment. (c) Poisonous materials shall be stored in their original, labeled containers. (d) Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. violation: The caregiver has a cabinet with a lock to store all poisons in the basement. The violation was created because the caregiver did not lock the cabinet. The lock was just hanging on the cabinet with poisons inside the cabinet. Agency review and clarification: The caregiver had all poisons in the cabinet but the lock was not closed. Immediate fix: The violation was corrected at time of inspection. Providers Plan of Correction: 1. , Program Director, will train all Team Supervisors on the regulation no later than 07/13/2022. 2. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 7/15/2022. 3. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 7/31/2022. 4. A program check to validate compliance with 6500.62 will be conducted in all homes not inspected no later than 7/31/2022. If we find violations in any other homes, they will be corrected immediately. Attachments: 1. Attachment Log Sheet to organize all the attachments with a reference number. A copy will be sent to ODP no later 8/12/2022. 2. Training Summary Form for all Team Supervisors. A copy will be sent to ODP no later 08/12/2022. 3. Training Summary Form for all Life Sharing Specialists. A copy will be sent to ODP no later 08/12/2022. 4. Training Summary Form for all Primary Caregivers. A copy will be sent to ODP no later 08/12/2022. 5. The inspector saw the caregiver lock the cabinet during the inspection; however, a picture showing compliance will be sent to ODP with the POC. 6. Program check log sheet will be completed and sent to verify compliance in all homes not inspected no later than 08/12/2022. 08/12/2022 Implemented
6500.83(a)Swimming pool was unlocked at the time of the inspectionAn in-ground swimming pool shall be fenced with a gate that is locked when the pool is not in use.§ 6500.83. Swimming pools. (a) An in-ground swimming pool shall be fenced with a gate that is locked when the pool is not in use. (b) An aboveground swimming pool shall be made inaccessible to individuals when the pool is not in use. (c) A swimming pool does not need to be locked or inaccessible if all individuals in the home understand water safety and can swim. Documentation of each individuals understanding and ability shall be in each individuals assessment McKelvey violation: The caregivers pool was unlocked during inspection. Agency review and clarification: No clarification needed. The pool must be locked when not is use unless the ISP says the individual is independent with pool safety. Immediate fix: The violation has already been corrected by locking the pool. A picture will be sent with the POC to show the correction. Providers Plan of Correction: 1. , Program Director, will train all Team Supervisors on the regulation no later than 07/13/2022. 2. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 7/15/2022. 3. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 7/31/2022. 4. A program check of homes with a pool will completed no later than 7/31/22 to validate compliance with 6500.83. If we find violations in any other homes, they will be corrected immediately. Attachments: 1. Attachment Log Sheet to organize all the attachments with a reference number. A copy will be sent to ODP no later 8/12/2022. 2. Training Summary Form for all Team Supervisors. A copy will be sent to ODP no later 08/12/2022. 3. Training Summary Form for all Life Sharing Specialists. A copy will be sent to ODP no later 08/12/2022. 4. Training Summary Form for all Primary Caregivers. A copy will be sent to ODP no later 08/12/2022. 5. Program check log sheet will be completed and sent to verify compliance in all homes not inspected no later than 08/12/2022. 6. A picture showing the lock on the pool gate will be sent with the POC to show the immediate fix. 08/12/2022 Implemented
SIN-00127720 Renewal 02/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74There were 8 steps off of garage door without non skid surfaces.Interior stairs and outside steps shall have a nonskid surface. Non-compliance: 6400.74 Do interior stairs and outside steps have a non-skid surface? Explanation: The surface of the stairs or steps should be assessed. If the surface is slippery, or for outside steps if the surface will be slippery when wet, there must be a non-skid surface applied. Wooden and concreate steps may or may not be slippery depending on the finish. For example, smooth finished interior wood stairs are often slippery, oily finished exterior wooden steps are often slippery, concrete that is painted with a smooth finish is often slippery, etc. Non-skid surfaces include carpeting, rubber strips, non-skid wax, etc. Reason: The non-compliance was caused due to the judgement of what is considered slippery. The home had unfinished exterior deck steps that were assessed by the agency as not being slippery. This home has been inspected by ODP for over 20 years and no other inspector thought the steps were slippery. Correction: ¿ Training will be conducted on this regulation including the explanation of this regulation that appears in the LII. Anthony Fisher will provide the clarification and the program specialist will train the staff in the homes. ¿ The program specialist will assess all interior and exterior steps of the home to determine how slippery it could be if wet or dry. They will also assess if the slipperiness of the step could change depending on changes in footwear. ¿ If any step is considered slippery, a non-skid surface will be applied that could be carpeting, rubber strips, non-skid wax, or any other material that would include some type of grit finish. ¿ The program specialist will test the slipperiness of all steps and report findings to Anthony Fisher who will report findings to the ODP lead inspector. Validation: ¿ All training will be completed before 4/15/18. Anthony Fisher is responsible for all corrections and will provide training records to the lead ODP inspector no more than 30 days after ODP accepts the POC. ¿ Pictures of the non-skid surface will be provided after they are applied to the surface. If non-skid wax is used a receipt of the purchase or a picture of the wax will be included since the picture of the step will likely not show enough detail. ¿ The program specialist in all 6400 homes will conduct an inspection of the home and report findings to Anthony Fisher. Anthony will send confirmation to the lead ODP inspector that all slippery steps have a non-skid surface. Attachments: All documents sent for validation will be organized on a list and include attachment numbers for easy reference. All corrections will be made by 4/30/18. 04/30/2018 Implemented
6400.141(c)(14)Individual #1's physical dated 10/3/17 did not include 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. Non-compliance: 6400.141(c)(14) Does each physical examination include medical information pertinent to diagnosis and treatment in case of an emergency? Explanation: The physical examination form must include space or blanks for this item to be reviewed and responded to. Reason: The non-compliance was caused because the doctor only wrote no change in this section of the physical. There was plenty of space to add more information if the doctor wanted to do so. Correction: ¿ The first step in this correction is to train staff on information pertinent to diagnosis and treatment in case of an emergency. ¿ The program specialist will request that the PCP correct the physical that was a violation and the agency will review all physicals in 6400 homes. ¿ If necessary information is missing from the physical, the physical form will be returned to the PCP during the next appointment and asked to make corrections. Validation: ¿ All training will be completed before 4/15/18. Anthony Fisher is responsible for all corrections and will provide training records to the lead ODP inspector no more than 30 days after ODP accepts the POC. ¿ Anthony Fisher will send a copy of the first revised physical showing the correction. Attachments: All documents sent for validation will be organized on a list and include attachment numbers for easy reference. All corrections will be made by 4/30/18. 04/30/2018 Implemented
6400.141(c)(15)Individual #1's physical dated 10/3/17 did not include special instructions for diet.The physical examination shall include:Special instructions for the individual's diet. Non-compliance: 6400.141(c)(15) Does each physical examination include special instructions for the individuals diet? Explanation: The physical examination form must include space or blanks for this item to be reviewed and responded to. Reason: The non-compliance was caused because the physical form did not include the details of the special diet. The physical form only said continue diet. The form should have said continue low sodium diet which is well documented in many other locations in the client record. The form did have space and blanks for the doctor to review and respond to changes. The doctor only commented with ¿none¿. Correction: ¿ The first step in this correction is to train staff to add the details of the special diet to the physical form. ¿ The program specialist will request that the PCP correct the physical that was a violation and the agency will review all physicals in 6400 homes. ¿ If necessary information is missing from the physical, the physical form will be returned to the PCP during the next appointment and asked to make corrections. Validation: ¿ All training will be completed before 4/15/18. Anthony Fisher is responsible for all corrections and will provide training records to the lead ODP inspector no more than 30 days after ODP accepts the POC. ¿ Anthony Fisher will send a copy of the first revised physical showing the correction. Attachments: All documents sent for validation will be organized on a list and include attachment numbers for easy reference. All corrections will be made by 4/30/18. 04/30/2018 Implemented
SIN-00104663 Renewal 01/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written evacuation plan did not include individual and staff responsibilities. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. 6400.103 Are there written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location? Explanation: The agency form that addresses emergency evacuation procedures in 6400.103 did not include staff and individual responsibilities. The agency form only addressed evacuation procedures, means or transportation and emergency shelter location. Correction: 1. Revise the emergency evacuation plan template to include responsibilities. The template revision will prevent future non-compliance. Anthony Fisher, Program Director, is responsible to make the form revision. 2. Update the emergency evacuation plan in the McKelvey home that includes the template changes and shows staff and individual responsibilities. Anthony Fisher, Program Director, is responsible to make sure the revision is made in all 6400 homes. 3. Program Specialist training on 6400.103, the template revision, and procedures for entering staff and individual responsibilities on the form. Anthony Fisher, Program Director, is responsible to train all Program Specialists on the form revision and procedure to complete the form. 4. This non-compliance was an agency non-compliance so all homes will need to be corrected. FCS only has two 6400 homes. Anthony Fisher, Program Director, will send a completed Emergency Evacuation Plan showing staff and individual responsibilities to BHSL for all 6400 homes. 5. Caregiver training on 6400.103 and reviewing staff and individual responsibilities during emergency evacuation. Kara Shipp and Jessica Coons, Program Specialists, will be responsible to complete training in their respective 6400 homes. Attachments: Revised Emergency Evacuation Plan Template (Attachment #1) Completed Emergency Evacuation Plan for the Eaton home showing staff and individual responsibilities (Attachment #5) Program Specialist training summary (Attachment #3) Caregiver training summary (Attachment #4) 02/28/2017 Implemented
SIN-00081838 Renewal 07/20/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was cleaned in 2013 by Staff #2. The furnace was cleaned in 2014 by Staff #2's son in law listed as staff #3. Neither Staff #2 or #3 work for a professional cleaning company. 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 violation occurred due to applying the 6500 regulations instead of the required 6400 regulations. The violation was corrected on 7/29/15 when a professional company (Snook¿s Plumbing) completed the inspection and cleaning. The Community Home staff and Program Specialist were trained on 7/29/15 on making sure a professional company cleans and inspects the furnace in a 6400 home. Family Care Services, Inc. (FCS) does not have any other 6400 homes with a furnace so there was no need to check other sites; however, all Program Specialists were trained on 7/29/15 to prevent future violations with 6400.106. FCS also made a revision to the Community Home Table of Contents (TOC) to include the requirement for a professional company to complete the furnace cleaning and inspection. The Program Director remains responsible for all program compliance. Please see attachments: #1: Receipt of furnace cleaning and inspection on 7/29/15. All future cleanings and inspections will be completed by a professional company. #2: Program Specialist Training #3: Community Home Staff Training #4: Revised Community Home Table of Contents. 08/15/2015 Implemented
SIN-00174725 Renewal 08/14/2020 Compliant - Finalized
SIN-00175064 Unannounced Monitoring 08/11/2020 Compliant - Finalized
SIN-00151580 Unannounced Monitoring 02/20/2019 Compliant - Finalized
SIN-00150836 Renewal 02/19/2019 Compliant - Finalized
SIN-00065385 Renewal 07/24/2014 Compliant - Finalized