Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226505 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 10/27/22 did not assess compliance with 6400.213(3).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. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation - 7/11/22) The self-assessment for the home completed on 10/27/22 did not include a written summary of corrections for the following violations: 6400.21a, 6400.21c, 6400.21d, and 6400.144.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
6400.22(c)Individual #1 pays for food as part of their room and board costs and also receives a monthly SNAP benefit. Individual #1 paid for their own snack food out of pocket 11 times since 10/1/22, totaling $309.02. This food should have been paid for with Individual #1's SNAP benefits or by the provider from room and board payments. Additionally, Individual #1's SNAP benefits are collected by the provider to utilize for the entire household's food. Individual #1 has not consented to this practice.Individual funds and property shall be used for the individual's benefit. Director of Finance each individual shall be provided a consent form for Friendship Community to utilize their SNAP benefits and given back to the Director of Finance by 9/3/23. Finance Department is working on a system for the individuals to utilize their SNAP benefits in a retail location within their home by 10/1/23. 10/01/2023 Implemented
6400.141(c)(11)The health maintenance needs and need for blood work and recommended intervals section of Individual #1's 10/27/22 annual physical examination was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Individual#1 physical examination section for health maintenance needs, medication regiment, and the need for blood work was updated and faxed to the PCP on 8/4/2023. 10/01/2023 Implemented
6400.151(a)Staff person #9 had a physical examination on 2/25/20 and not again until 3/15/22. 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. A reminder shall be provided to all staff regarding the need for physical examinations to be completed by regulated time frames. This communication will occur on or before 8/18/23. 08/18/2023 Implemented
6400.24As per SNAP Policy in Chapter 511.71/7CFR 273.1(b)(7)(vi), in order for an individual to qualify for SNAP Benefits in a Group Living Arrangement, "The site must serve over 50% of three meals daily, not be authorized to accept food stamps, and be certified by the Department of Public Welfare as meeting ALL of the following requirements: Serve no more than 16 residents, be in a residential setting, be a nonprofit organization, and be certified by DHS as meeting the requirements of Section 1616(e) of the Social Security Act. Because the provider agency was authorized to accept SNAP Benefits, Individual #1 was not to be approved to individually receive SNAP Benefits.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Director of Finance each individual shall be provided a consent form for Friendship Community to utilize their SNAP benefits and given back to the Director of Finance by 9/3/23. Finance Department is working on a system for the individuals to utilize their SNAP benefits in a retail location within their home by 10/1/23. 10/01/2023 Implemented
6400.32(c)Individual #1 pays for food as part of their room and board costs and also receives a monthly SNAP benefit. Individual #1 paid for their own snack food out of pocket 11 times since 10/1/22, totaling $309.02. This food should have been paid for with Individual #1's SNAP benefits or by the provider from room and board payments. Additionally, Individual #1's SNAP benefits are collected by the provider to utilize for the entire household's food. Individual #1 has not consented to this practice. This results in the exploitation of Individual #1's benefits, resulting in financial loss for the individual.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Friendship Community stated a certified investigation of exploitation for individual #1 on 7/6/23. Director of Finance each individual shall be provided a consent form for Friendship Community to utilize their SNAP benefits and given back to the Director of Finance by 9/3/23. Finance Department is working on a system for the individuals to utilize their SNAP benefits in a retail location within their home by 10/1/23. 08/10/2023 Implemented
6400.52(c)(6)Staff persons #9, 10, 11, and 12 did not receive training on implementation of individual plans in training year 2022. While the staff read Individual Support Plan documentation and signed confirming they read the document, part of this training must be in-person with the individual present.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff persons 9, 10, 11, and 12 will receive in-person training with the individual present on the current ISP. This will occur by 8/18/23, or as soon as possible depending on staff's next scheduled shift. 09/30/2023 Implemented
6400.166(a)(1)Individual #1 has the following PRN medications that are not currently listed on their Medication Administration Record: Acetaminophen, Tussin, Bisacodyl, Loperamide, Bacitracin, Hydrocortisone, and Coricidin. The medications have been added to the record when administered, however, per regulation, all PRN medications must be present on the Medication Administration Record at all times.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name.Individual #1 PRNs are on the medication record on 7/15/2023. 10/01/2023 Implemented
SIN-00207950 Renewal 07/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 12/22/21 identified the following violations: 73b. There was no written summary of correction for this violation.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations retrained all Associate Directors of Operations on the expectations surrounding the compliance of completing plan of corrections for self-assessments on 7/15/22. 07/15/2022 Implemented
SIN-00157447 Renewal 08/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification letter that was sent to the fire department on 8/7/19 states that individuals # 1 and #2 live at the residence, with individual #1 requiring assistance to evacuate the home and potentially individual#2 as well. The floor plan attached to the letter listed the bedroom locations for individuals with the initials DC, EB and TF. Individuals DC and EB no longer live at the residential location.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Immediate: Updated Notification letter with correct floor plan indicating the bedroom locations for each of the 2 Individuals currently residing in the home was sent to the local fire chief on 8/20/19 by Program Manager. Documentation to reflect both items were sent have been filed in the home¿s Emergency Preparedness Binder. Retraining was provided by the Director of Operations with the Program Manager and Program Coordinator on the need to have a floor plan attached to the notification letter on 8/15/19 and documentation of retraining shall be kept on file. Global Immediate: Director of Operations provided retraining to Program Managers, Program Coordinators, and Associate Directors of Operations on 8/15/19 regarding the necessity of providing correct floor plans that include current Individual¿s initials for the appropriate bedroom on the floor plan. Documentation of retraining shall be maintained. Program Managers shall verify that all notification letters have correct floor plans attached and provide necessary documentation to the Associate Directors of Operations by 9/13/19. Global Preventative: Operations Leadership shall review and develop a standardized system for storing and accessing Fire Safety documentation, including but not limited to Notification Letters with Floor Plans attached by 9/13/19. Program Managers shall add floor plans for their specific program to the Fire Department Notification Letter template by 9/30/19. Program Coordinators shall provide verification that all floor plans have been included in the Notification Letter template and the standardized system for storage has been implemented to the Associate Directors of Operations by 10/1/19. The admission, discharge and transfer checklists utilized during transitions to/from a program shall be updated by Operations Generalist on or before 9/30/19 to include a prompt to adjust the Notification Letter template and send a new letter with attached floor plan immediately upon an Individual¿s transition to/from a program. All training/retraining documentation shall be kept on file. 10/01/2019 Implemented
6400.112(a)An unannounced fire drill was not held for the month of June 2019. An unannounced fire drill shall be held at least once a month. Immediate: Program Manager received immediate retraining by ODP Licensing Inspector on the need to complete successful unannounced fire drills once monthly on 8/15/19. Global Immediate: Program Manager and Program Coordinator Teams received retraining by the Director of Operations on the need to complete successful unannounced fire drills once monthly on 8/15/19. Global Preventative: Associate Directors of Operations shall review each Programs¿ Monthly Fire Drill records for 6 months, to end February 2020, to ensure all fire drills have been successfully completed within the designated evacuation time frame. Friendship Community procedure shall be updated to require all fire drills in 6400 programs be completed within the first 3 weeks of each calendar month. Retraining on this requirement shall be completed by Associate Directors of Operations by 9/24/19. All training/retraining documentation shall be kept on file. 09/24/2019 Implemented
6400.112(c)According to the fire drill record and the smoke detector check log, a fire drill was held on 2/7/19 with one smoke detector, (individual # 1's detector) being checked for operability on 2/7/19. According to the smoke detector log, the rest of the smoke detectors in the home weren't checked for operability until 2/9/19, over 24 hours after the fire drill was held.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. Immediate: Program Manager received retraining by ODP Licensing Inspector on 8/15/19 regarding the need to complete smoke detector checks within 24 hours after each fire drill, rather than prior to a fire drill. Global Immediate: Program Manager and Program Coordinator Team received retraining by ODP Licensing Survey Team on 8/15/19 regarding the need to complete smoke detector checks within 24 hours after each fire drill. Global Preventative: Friendship Community Fire Drill Record shall be updated by Operations Generalist to include that all smoke detectors be checked within 24 hours after each fire drill and retraining for Program Leaders shall include the emphasis on checking every detector immediately following each drill. Retraining shall occur by 8/31/19, with implementation in September 2019. All training/retraining documentation shall be kept on file. 08/31/2019 Implemented
6400.112(d)According to the 2/7/19 fire drill log, Individual #3 took 5 minutes to evacuate the home during the fire drill. The residential location does not have an extended evacuation time. 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. Immediate: Associate Director of Operations provided retraining to Program Manager and Program Coordinator on 8/15/19 regarding the necessity of completing fire drills within the approved evacuation time, with the evacuation time ending after all Individuals have crossed the threshold of the home. Global Immediate: Director of Operations provided additional retraining to the Operations Leadership Team on proper evacuation timekeeping on 8/15/19. Retraining also included the need to document any issues encountered during the drill on the fire drill record. Global Preventative: Associate Directors of Operations shall review each Programs¿ Monthly Fire Drill records for 6 months, to end February 2020, to ensure all fire drills have been successfully completed within the designated evacuation time frame. Friendship Community procedure shall be updated to require all fire drills in 6400 programs be completed within the first 3 weeks of each calendar month. Retraining on this requirement shall be completed by Associate Directors of Operations by 9/24/19. All training/retraining documentation shall be kept on file. 09/24/2019 Implemented
SIN-00137751 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(f)Individual #1's lamp was removed out of his bedroom without his permission on 8/21.An individual has the right to receive, purchase, have and use personal property. 33 (f): Immediate: Individual #3 received his lamp back in his bedroom on 8/22/2018 immediately following his expressed concern to ODP¿s Licensing Surveyor regarding the removal of his lamp by Team Members on 8/21/2018. A certified investigation for an allegation of a rights violation was initiated on 8/23/2018 and was confirmed that this item was removed from his room due to safety concerns on 8/21/2018 until a power strip could be obtained. Global Immediate: Associate Director of Operations provided retraining to Program Managers and Program Coordinators on 8/28/2018 regarding individual rights and consent to any removal of personal belongings, including the need to obtain written, formal consent from the Individual and/or their guardian prior to removing Individual¿s belongings from possession. Documentation of retraining shall be maintained. Global Preventive: The Learning Enhancement Coordinator shall coordinate an in-service training to occur no later than December 31, 2018 regarding individual rights, with mandatory representation from each program in attendance. A confirmation of representation shall be documented via a sign-in sheet. Training shall include strategies to address health and safety concerns with Individuals without infringing upon their rights. 12/31/2018 Implemented
6400.64(a)Individual #1's bar of soap not stored in covered/labeled container.Clean and sanitary conditions shall be maintained in the home. 64 (a): Immediate: Program Manager immediately placed Individual #3¿s bar of soap into his designated bathroom drawer to ensure that it was properly identified as his and stored in a clean/sanitary location. Global Immediate: Each Program Manager shall confirm via email that each Individual¿s personal items are stored in clean, sanitary conditions (i.e. individually labeled containers) on or before 9/23/2018. Global Preventive: An Associate Director of Operations provided a retraining on clean and sanitary conditions within the home on 8/28/2018, specifically outlining that appropriately labeled containers shall be used for storage of each Individual¿s hygiene products. 09/23/2018 Implemented
6400.67(a)The edge of the floor to the right of the steps was duct taped.Floors, walls, ceilings and other surfaces shall be in good repair. 67 (a): Immediate: Maintenance Team Members repaired the step¿s transition piece on 8/27/2018 and provided photographic evidence to Associate Director of Operations verifying that the repair had been completed. Global Immediate: Program Managers shall complete a physical site review to identify any floors, walls, ceilings and other surfaces that may need to be repaired at each physical site, with the expectation to communicate all repair needs to the Maintenance Team on or before 9/23/2018. Global Preventive: Associate Director of Operations retrained Program Managers on 8/28/2018 regarding the requirement to ensure that all floors, walls, ceilings and other surfaces are maintained in good repair at all times, including the expectation that any needed repairs noted to surfaces are requested of the Maintenance Team immediately upon discovery. Additionally, a physical site checklist shall be completed by a designated Team Member at each program on a monthly basis for a period of 6 months (beginning September 2018), to include assessment of all floors, walls, ceilings and other surfaces to ensure they are maintained in good repair. Documentation of monthly assessment shall be maintained on file, including any follow-up actions taken to address concerns noted, as applicable. 09/23/2018 Implemented
6400.112(c)The smoke alarm system was not tested monthly.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. 112 (c): Immediate: An operational check of site¿s smoke detectors was completed on 8/22/2018 and retraining occurred for the Program Manager, Program Coordinator, and Associate Director by ODP Licensing Surveyor on 8/22/2018. Documentation of checking the site¿s smoke detectors that was completed on 8/22/2018 shall be kept on file with the site¿s fire drill records. Global Immediate: The Associate Directors of Operations provided retraining to Program Managers and Program Coordinators on 8/28/2018 regarding the necessity to determine if every smoke alarm is operational. Documentation of this retraining Global Preventive: The Associate Director of Operations Team shall implement a task system utilizing Microsoft Outlook on or before 10/23/2018 relating to fire drills with a feature associated with an operational check of all of the site¿s smoke detectors within 24 hours of conducting a fire drill. Each Program Manager and Program Coordinator shall acknowledge the fire drill and smoke detector/extinguisher checks as appointments on their Outlook calendars within 2 business days of appointments being received by the Associate Director of Operations Team. Adherence to this schedule shall be monitored and documented by Program Coordinators on at least a monthly basis. 10/23/2018 Implemented
SIN-00076707 Renewal 02/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144The physical for Individual #1 stated that he had no known allergies. Individual #1's Individual Support Plan stated he had seasonal allergies. 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. It was verified through PCP documentation that individual #1 did not have a seasonal allergy diagnosis. Individual #1's supports coordinator ws notified of this change that will need to be updated in his ISP. Using care tracker training and documentation will occur with each supervisor to educate them in the importance of correct of ducumentation of diagnoses. Implemented
6400.181(e)(13)(ii)Individual #1's assessment did not contain progress and growth in the area of motor and communication. Individual #1's assessment stated ¿no need for growth.¿The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Assessment for individual #1 was updated on 5/11/2015, to inlcude current information related progress and growth in motor and communication skills, activities of residential living, personal adjustment, socialization, recreation, financial independence, managing personal property, and community integration. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in motor and communication skills, activities of residential living, personal adjustment, socialization, recreation, financial independence, managing personal property, and community integration. Implemented
6400.186(c)(2)The Individual Support Plan (ISP) reviews for Individual #1 completed on 4/8/14, 7/14/14, 10/14/14, and 1/13/15 did not review his maladaptive behavior plan. The monthly data sheets completed for Individual #1 in regards to his maladaptive behavior plan were not reflected in his ISP reviews as they were recorded in his monthly data sheets. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. ISP quarterly review was updated to reflect an update of maladaptive behavior plan on 4/15/2015. Each subsequent (since 2/20/2015) ISP quarterly review will be reviewed to assure that it inlcuded a summary of the behavior support plan and progress. Using care tracker for documentation and training, each program specialist will be trained to include a behavior support plan summary in the ISP quarterly review. Implemented
6400.216(a)A staff communication book was kept out in the kitchen area and it contained behavior support plan information for an individual living in the home. Individuals¿ records must be kept locked when unattended. An individual's records shall be kept locked when unattended. BSP information was removed from the staff communication book on friday 2/20/2015. Supervisor from each home will verify that each individual's records are secured properly. Using care tracker, all supervisors will be trained on the necessity to maintain confidentiality of all individual records, including the need to establish an alternate system to providing individual updates for team members. Implemented
SIN-00061185 Renewal 02/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1 was hired on 8/15/13, but has not been CPR trained within the regulatory requirement of within 6 months. (i) Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Resource Program Coordinator will issue a memo of retraining to all Team Members identified to be out of compliance with CPR Training within 6 months of hire date and/or within each subsequent 2 year time frame, outlining the requirements to remain within compliance. Associate Director of Residential Services will train Program Staff, including Supervisors, Coordinators and Specialists of the requirement to receive CPR Training within the required time frame. Team Members will not be scheduled to work with Individuals if the regulatory requirements are not satisfied. 04/30/2014 Implemented
6400.106The furnace cleaning/inspection was completed late. It was done on 10/11/12 and then not again until 12/4/13. 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. Program Coordinator will re-train the Program Specialist regarding regulation of annual furnace inspection, specifically related to timely completion for safety and regulatory reasons. Associate Director of Residential Services will train Program Staff, including Supervisors, Coordinators and Specialists on timelines regarding furnace inspections as a function of safety practices. 04/30/2014 Implemented