Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00120550 Renewal 12/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #2's last signed rights statement was completed on 2/10/16.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Non-Compliance Regulation Number: 6400.31(b) Correction of this Non-Compliance: This area of non-compliance was addressed by having the individual sign the necessary forms on 12/4/2017, and then again on 1/5/2018, when the Program Director has all JCHAI residents sign the necessary forms. A copy of the Resident Rights forms (Attachment 6) will be forwarded to Lee Franczyk, along with all other necessary documentation, by Friday, February 23, 2018. Plan for Correction moving forward: The Program Director and Resident Care Supervisor will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director and Resident Care Supervisor will ensure that all forms are completed to ensure compliance with all regulatory guidelines. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: December 4, 2017 and January 5, 2018 for this individual By March 15, 2018 for all other individuals as needed Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 12/04/2017 Implemented
6400.68(b)The water temperature in the home was tested and found to be 143.6 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Non-Compliance Regulation Number: 6400.68(b) Correction of this Non-Compliance: This area of non-compliance was remedied on 12/1/2017 by the Program Director by turning down the heat on the water heater, once he was notified of the temperature reading from the Inspector. A log sheet was made to track the hot water temperature at the house for the end of December 2017 and January 2018 to ensure that the hot water heater was functioning properly. A copy of the hot water temperature log sheet (Attachment 5) will be forwarded to Lee Franczyk, along with all other necessary documentation, by Friday, February 23, 2018. Plan for Correction moving forward: The Program Director will test the hot water temperatures on a quarterly basis, no later than the end of every February, May, August, and November to ensure that all residential homes are within regulatory compliance. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be overseen by the Program Director or another JCHAI Staff person that the Program Director has delegated the responsibility of correction. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: December 1, 2017 for initial compliance issue By March 15, 2018 for any additional compliance issues Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 12/01/2017 Implemented
6400.112(e)There were sleep drills held on 11/15/16 and again on 7/22/17 which is more than six months apart.A fire drill shall be held during sleeping hours at least every 6 months. Non-Compliance Regulation Number: 6400.112(e) Correction of this Non-Compliance: This area of non-compliance cannot be immediately fixed at this time, as the event has already occurred, and it is not possible to make a correction. However, the Program Director and/or Executive Program Director will hold fire drills during sleeping hours at least once every six months, with the next one January 21, 2018. Plan for Correction moving forward: The Program Director and/or Executive Program Director will schedule the fire drills for the individuals being served during sleeping hours at least once every six months immediately following the conclusion of one of these drills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: By January 22, 2018 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 01/21/2018 Implemented
6400.113(a)Individual #2 was trained in fire safety on 1/22/16 and had not been trained on the subject since that date. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Non-Compliance Regulation Number: 6400.113(a) Correction of this Non-Compliance: This area of non-compliance was not adequately addressed at the time of inspection, as the individual had received Fire Safety training on November 28, 2017. However, the Fire Safety forms that all JCHAI residents sign on an annual basis had not been signed since 1/22/2016. This was addressed by having the individual sign the necessary form on 12/4/2017 and then again on 1/5/2018, when the Program Director has all JCHAI residents sign the necessary forms. A copy of the Fire Safety Training information (Attachment 4) will be forwarded to Lee Franczyk, along with all other necessary documentation, by Friday, February 23, 2018. Plan for Correction moving forward: The Program Director and Resident Care Supervisor will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director and Resident Care Supervisor will ensure that all forms are completed to ensure compliance with all regulatory guidelines. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: December 4, 2017 and January 5, 2018 for this individual By March 15, 2018 for all other individuals as needed Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 12/04/2017 Implemented
6400.141(c)(14)Individual #2's annual physical dated 10/25/17 did not indicate information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Non-Compliance Regulation Number: 6400.141(c)(14) Correction of this Non-Compliance: This area of non-compliance was addressed on 2/7/2018 at her next appointment with her PCP, by having the individual¿s physician complete another physical form to ensure that all necessary information was filled in, including information pertinent to diagnosis in case of emergency. However, it was found after this appointment that the physician had not completed all sections, and the form was taken back to the doctor to have fully completed. This updated form was finally received by JCHAI on 2/22/2018. A copy of the physicals (Attachment 3) will be forwarded to Lee Franczyk, along with all other necessary documentation, by Friday, February 23, 2018. Plan for Correction moving forward: The Program Director and Resident Care Supervisor will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director and Resident Care Supervisor will ensure that all physicals are fully completed to ensure compliance with all regulatory guidelines. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: February 7, 2018 and February 22, 2018 for this individual By March 15, 2018 all other individual¿s physicians will be contacted for any necessary corrections Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 02/07/2018 Implemented
6400.151(c)(3)Staff #1's annual physical dated 4/27/17 did not include whether or not the person was free of communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Non-Compliance Regulation Number: 6400.151(c)(3) Correction of this Non-Compliance: This area of non-compliance was remedied on 2/1/2018 by the Program Director having the JCHAI staff get another physical to ensure that she was free from communicable diseases, in addition to being free from communicable tuberculosis and any other medical condition(s) that might interfere with the individuals being served. A copy of the physical (Attachment 2) will be forwarded to Lee Franczyk, along with all other necessary documentation, by Friday, February 23, 2018. Plan for Correction moving forward: The Office Manager will review all staff physicals on a quarterly basis, no later than the end of every February, May, August, and November to ensure that all residential homes are within regulatory compliance. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be overseen by the Program Director or another JCHAI Staff person that the Program Director has delegated the responsibility of correction. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: February 1, 2018 for this staff By March 15, 2018 all other staff will be notified to get update physicals as necessary Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 02/01/2018 Implemented
6400.213(1)(i)Individual ##2's record did contain a section for 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. Non-Compliance Regulation Number: 6400.213(1)(i) Correction of this Non-Compliance: This area of non-compliance was addressed on 12/1/2017 and 12/4/2017, by taking current pictures of the individual and updating all personal information on the appropriate forms. The pictures and updated personal information are easily located inside of the individual¿s medical binder. A copy of the updated pictures and personal information (Attachment 1) will be forwarded to Lee Franczyk, along with all other necessary documentation, by Friday, February 23, 2018. Plan for Correction moving forward: The Program Director and Resident Care Supervisor will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director and Resident Care Supervisor will ensure that all pictures and personal information are updated on a regular basis to ensure proper identification and support for the specific individual. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: January 2, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: By March 15, 2018 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 12/04/2017 Implemented
SIN-00105686 Renewal 11/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were blinds covering kitchen windows that were covered with a substane that appeared to be dust and dirt.Clean and sanitary conditions shall be maintained in the home. Correction of this Non-Compliance: This area of non-compliance was fixed by the Program Director by at first having the blinds cleaned and dusted. The blinds were later replaced with new blinds that would be easier to clean and take care of. Pictures of the new blinds will be forwarded to Walter Szott by Friday, January 27th, 2017. Plan for Correction moving forward: The Program Director will inspect the physical aspects of all residential facilities on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that JCHAI has complied with all regulatory areas. JCHAI staff will be encouraged to report all repair needs to their respective House Supervisors, who will then report these needs to the Program Director or Office Manager to coordinate repair services. Additionally, the cleaning service that JCHAI employs will make sure to pay more attention to the cleanliness of the blinds and all other areas in need of cleaning to ensure clean and sanitary conditions. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be initiated by the Program Director, or other repair service that the Program Director or Office Manager has delegated the responsibility of correction to, within 15 days of the quarterly review of residential facilities. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: February 1, 2017 Record Review Date: By February 28, 2017 Corrections Completed Date: By March 15, 2017 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 01/26/2017 Implemented
6400.67(a)Two knobs were missing from drawers in the kitchen. Two shelves in the refridgerator were held together by duct tape. There was a broken light cover over the vanity located in the upstairs bathroom. The bathroom located next to the kitchen had missing 2 ceiling tiles. Floors, walls, ceilings and other surfaces shall be in good repair. Correction of this Non-Compliance: This area of non-compliance was fixed by the Program Director by having new knobs installed on the two kitchen cabinets, by ordering and installing new shelves for the kitchen refrigerator, by removing the seldom used light fixture on the top of the bathroom vanity and placing a cover over top for safety, and by installing two ceiling tiles into the ceiling of the kitchen bathroom. Pictures of the fixed items and/or receipts of the new items will be forwarded to Walter Szott by Friday, January 27th, 2017. Plan for Correction moving forward: The Program Director will inspect the physical aspects of all residential facilities on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that JCHAI has complied with all regulatory areas. JCHAI staff will be encouraged to report all repair needs to their respective House Supervisors, who will then report these needs to the Program Director or Office Manager to coordinate repair services. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be initiated by the Program Director, or other repair service that the Program Director or Office Manager has delegated the responsibility of correction to, within 15 days of the quarterly review of residential facilities. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: February 1, 2017 Record Review Date: By February 28, 2017 Corrections Completed Date: By March 15, 2017 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 01/26/2017 Implemented
6400.144Individual #1 medication Paroxetine 30mg tab has a label that indicates giving 1 or 1 and half tablets of the medication.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. Correction of this Non-Compliance: This area of non-compliance was addressed on 11/21/2016 by communicating with the individual¿s psychiatrist to ascertain a new prescription and pharmacy label, and the psychiatrist gave JCHAI staff verbal instructions to give one and a half tablets daily of the individual¿s Paroxetine 20mg, which would be a total dosage of 30mg daily. However, it was found that the psychiatrist had not sent a new prescription in to the pharmacy to allow for the correction on the pharmacy label. The psychiatrist was contacted again on 1/25/2017 to submit a corrected prescription to the pharmacy so that the pharmacy label would match the psychiatrist¿s orders. The psychiatrist faxed JCHAI a copy of the new prescription that states that he is to take one and a half tablets daily of his Paroxetine 20mg, which would be a total dosage of 30mg daily. A copy of the new prescription will be forwarded to Walter Szott, along with all other necessary documentation, by Friday, January 27th, 2017. Once his medication is filled, a picture of this new pharmacy label will be forwarded as well. Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all medications for individuals on their Medication Administration Records correspond to their respective pharmacy labels. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: February 15, 2017 Record Review Date: By February 28, 2017 Corrections Completed Date: By March 15, 2017 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 01/26/2017 Implemented
6400.164(a)Individual #1 medication Paroxetine has a label for administration to give 1 or 1 and a half tablets while the MAR states to give 1 and a half tablets. The MAR states dosage at 30 mg, The bottle in the med. box has dosage of 20 mg. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Correction of this Non-Compliance: This area of non-compliance was addressed on 11/21/2016 by communicating with the individual¿s psychiatrist to ascertain a new prescription and pharmacy label, and the psychiatrist gave JCHAI staff verbal instructions to give one and a half tablets daily of the individual¿s Paroxetine 20mg, which would be a total dosage of 30mg daily. However, it was found that the psychiatrist had not sent a new prescription in to the pharmacy to allow for the correction on the pharmacy label. The psychiatrist was contacted again on 1/25/2017 to submit a corrected prescription to the pharmacy so that the pharmacy label would match the psychiatrist¿s orders. The psychiatrist faxed JCHAI a copy of the new prescription that states that he is to take one and a half tablets daily of his Paroxetine 20mg, which would be a total dosage of 30mg daily. A copy of the new prescription will be forwarded to Walter Szott, along with all other necessary documentation, by Friday, January 27th, 2017. Once his medication is filled, a picture of this new pharmacy label will be forwarded as well. Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all medications for individuals on their Medication Administration Records correspond to their respective pharmacy labels. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: February 15, 2017 Record Review Date: By February 28, 2017 Corrections Completed Date: By March 15, 2017 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 01/26/2017 Implemented
SIN-00077061 Renewal 06/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1's previous physical examination was dated 09/05/2013. The most recent physical examination was dated 09/29/2014.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Non-Compliance Regulation Number: 6400.141(a) Correction of this Non-Compliance: This area of non-compliance cannot be immediately fixed at this time, as the event has already occurred, and it is not possible to make a correction. However, the Program Director is reviewing all other residents¿ records, as needed, to ensure that all physical examinations are occurring on an annual basis, with the permitted 15 day grace period. Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all necessary physical examinations have taken place within the allowed time frame. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 5) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.141(c)(8)Individual #1's previous mammogram was dated 03/17/2014. The most recent mammogram was dated 05/04/2015.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Non-Compliance Regulation Number: 6400.141(a) Correction of this Non-Compliance: This area of non-compliance cannot be immediately fixed at this time, as the event has already occurred, and it is not possible to make a correction. However, the Program Director is reviewing all other residents¿ records, as needed, to ensure that all mammograms are occurring on an annual basis. Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all necessary mammograms have taken place within the allowed time frame. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 5) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(ii)Individual #1's assessment, dated 06/17/2014, did not include progress and growth in the area of motor and communication skills.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. Non-Compliance Regulation Number: 6400.181(13)(ii) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of motor and communication skills for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(iii)Individual #1's assessment, dated 06/17/2014, did not include progress and growth in the area of activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Non-Compliance Regulation Number: 6400.181(13)(iii) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of activities of residential living. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment, dated 06/17/2014, did not include progress and growth in the area of socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. Non-Compliance Regulation Number: 6400.181(13)(v) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of socialization for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(vi)Individual #1's assessment, dated 06/17/2014, did not include progress and growth in the area recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. Non-Compliance Regulation Number: 6400.181(13)(vi) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of recreation for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(vii)Individual #1's assessment, dated 06/17/2014, did not include progress and growth in the area of financial independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. Non-Compliance Regulation Number: 6400.181(13)(vii) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of financial independence for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(viii)Individual #1's assessment, dated 06/17/2014, did not include 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. Non-Compliance Regulation Number: 6400.181(13)(viii) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of managing personal property for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(e)(13)(ix)Individual #1's assessment, dated 06/17/2014, did not include progress and growth in the area of community-integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.Non-Compliance Regulation Number: 6400.181(13)(ix) Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate the progress and growth that has been made in the area of community integration for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the progress and growth that has been made. Please see attached Annual Assessment (attachment 3). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all Annual Assessments reflect the progress and growth in the area of motor and communication skills. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.181(f)Individual#1's assessment, dated 06/17/2014, was not sent to the team members.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Non-Compliance Regulation Number: 6400.181(f) Correction of this Non-Compliance: This area of non-compliance cannot be immediately fixed at this time, as the event has already occurred, and it is not possible to make a correction. However, the Program Director is reviewing all other residents¿ records, as needed, to ensure that all Annual Assessments are sent out to the team at least 30 days prior to the ISP meeting. Please see attached (attachment 4). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all necessary Annual Assessments have been sent to their respective teams at least 30 days prior to the ISP meeting. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.185(a)Individual #1's Individual Support Plan (ISP) review covering the period from 10/04/2014 to 12/31/2014 was not implemented by the ISP start date of 10/15/2014. The ISP shall be implemented by the ISP's start date. Non-Compliance Regulation Number: 6400.185(a) Correction of this Non-Compliance: This area of non-compliance cannot be immediately fixed at this time, as the event has already occurred, and it is not possible to make a correction. However, the Program Director has reviewed all resident records to ensure that quarterly reviews of their ISP Programs will be determined by the beginning of their ISP Plan start date. Please see attached quarterly review (attachment 1). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all quarterly reviews of resident ISP Programs will be completed at least every 90 days and will follow the start date of the ISP Plan for that year. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
6400.186(a)Individual # 1's Individual Support Plan (ISP) review ending on 06/30/2014 was completed by the program specialist on 07/18/2014. Individual # 1's ISP review ending on 09/30/2014 was completed by the program specialist on 10/17/2014. Individual # 1's ISP review ending on 12/31/2014 was completed by the program specialist on 01/16/2015. Individual # 1's ISP review ending on 03/31/2015 was completed by the program specialist on 04/16/2015. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Non-Compliance Regulation Number: 6400.186(a) Correction of this Non-Compliance: This area of non-compliance cannot be immediately fixed at this time, as the event has already occurred, and it is not possible to make a correction. However, the Program Director has reviewed all resident records to ensure that quarterly reviews of their ISP Programs will be completed no more than 15 days past the end date of the quarter being reviewed. Please see attached quarterly review (attachment 1). Plan for Correction moving forward: The Program Director will review all resident records on a quarterly basis, no later than the end of every February, May, August, and November. The Program Director will use the Licensing Inspection Instrument to ensure that all quarterly reviews of resident ISP Programs will be completed at least every 90 days. The Program Director will use the Inspection Scoresheet to be made aware of any compliance corrections that may need to be completed. All corrections will be made by the Program Director, or another JCHAI Staff person that the Program Director has delegated the responsibility of correction to, within 15 days of the quarterly review of resident records. The Licensing Inspection Scoresheet will be signed and dated by the Program Director and will show any compliance issues, how they were fixed, and when they were fixed. Plan Start Date: November 1, 2015 Record Review Date: By November 30, 2015 (See attachment 2) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these reviews on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/01/2015 Implemented
SIN-00061322 Renewal 05/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff A's criminal history check dated 12/23/13, was not submitted to the Pennsylvania State Police, but was submitted and recieved through a private investigation company. An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Non-Compliance 6400.21(a) JCHAI Staff A criminal history check dated 12/23/13, was not submitted to the Pennsylvania State Police, but was submitted and received through a private investigation company. Upon notice of this BHSL compliance issue, JCHAI had all employees, including Individual #1, have a criminal history check submitted to the Pennsylvania State Police on 6/11/2014. A updated criminal history check has been submitted to BHSL. Purpose: To help JCHAI better manage their employee records, to remain compliant with BHSL licensing guidelines. Plan Start Date: June 11, 2014 Plan: JCHAI will ensure that all employees have an application for a Pennsylvania criminal history record check submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, prior to the prospective employee being hired. This will be completed by speaking with Commercial Investigations, the company JCHAI uses to conduct background investigations, and informing them of the necessary requirements of a thorough background check, per BHSL licensing guidelines. Ongoing Monitoring: The Office Manager will be responsible for contacting Commercial Investigations, or other agencies as needed, to have background investigations performed on all new employees. Upon receipt of the background investigation information, the office manager will keep one copy for her records and will provide the Executive Program Director with another copy for their records. 06/11/2014 Implemented
6400.141(c)(4)Individual #1's most recent hearing screening was dated 7/24/12.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Non-Compliance 6400.141(c)(4) Individual #1's most recent hearing screening was last dated 7/24/2012 on the annual physical and was not completed during the time of the following physical in July of 2013. Upon notice of this BHSL compliance issue, Individul #1 was seen by the primary physician on 6/4/2014 to have a hearing screening performed. Documentation has been submitted to BHSL. Purpose: To help JCHAI staff better manage their residents, appointments and to remain compliant with BHSL licensing guidelines Plan Start Date: June 9, 2014 Plan: JCHAI House Supervisors will use the medical appointment schedule (attached to this plan) for each of their residents to track their past medical appointments, when they need their next appointment, and when the new appointment is scheduled. Each sheet will be kept in the front of the resident's medical books to easier see and manage each type of medical appointment and will be updated quarterly. Ongoing Monitoring: The Program Director will be responsible for reviewing these appointment schedules on a quarterly basis to ensure that all necessary actions are being taken to manage these medical appointments per BHSL licensing guidelines. 05/30/2014 Implemented
SIN-00153710 Renewal 03/29/2019 Compliant - Finalized
SIN-00050725 Renewal 06/06/2013 Compliant - Finalized