Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216500 Renewal 12/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)There was no trashcan with a lid in the kitchen.Trash receptacles over 18 inches high shall have lids. This area of non-compliance was addressed by purchasing a trashcan with a lid immediately following inspection on 12/21/2022. Pictures (Attachment #1) of the trashcan with the lid will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/21/2022 Implemented
6400.66The middle hanging lamp in the in Livingroom ceiling needed to be replaces, the light appeared to be inoperable outside of back of home, and lightbulb was out in individual #3's bedroom lamp.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. These areas of non-compliance have been addressed by getting new lightbulbs for the different fixtures immediately following inspection on December 21, 2022. Pictures (Attachment #2) showing the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/21/2022 Implemented
6400.68(b)The water temperature exceeded 120 degrees in the upstairs bathroom, which read 129 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. This area of non-compliance was remedied immediately following inspection on December 20, 2022, by turning down the temperature on the hot water heater. Additionally, a log sheet was made to track the hot water temperature at the house for the rest of December and January to ensure that the hot water heater was functioning properly. Documentation (Attachment #3) showing the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/20/2022 Implemented
6400.72(a)There was a screen missing in the left window of the kitchen and in individual #2's bedroom window.Windows, including windows in doors, shall be securely screened when windows or doors are open. These areas of non-compliance have been addressed after inspection by having new screens for the left window of the kitchen and Individual #2¿s bedroom window. Pictures (Attachment #4) showing the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 01/13/2023 Implemented
6400.112(c)The fire drill logs did not have a section to indicate if there were any problems encountered during the drills at the time of the review.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. This area of non-compliance was addressed by revising the existing form immediately following inspection to include a section to indicate if there were any problems encountered during the drills at the time of the review. Documentation (Attachment #5) showing the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/23/2022 Implemented
6400.112(d)At the of the inspection, the fire drill records showed the following: the 5/20/2022 drill took 2.54 seconds; 7/19/2022 drill took 2.40 seconds;10/18/2022 drills took 2.44 seconds; and the 12/6/2022 drill took 2.57 seconds to complete. There were no repeated drills within those months showing that the individuals could evacuate their home within 2 1/2 minutes. In addition, there was no information from a fire expert indicating if there was time specified for an evacuation time that is safe for these individuals. 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. This area of non-compliance will be remedied, moving forward, by ensuring that repeat fire drills will be held should the individuals not be able to evacuate the home within 2 ½ minutes. Additionally, if the individuals continue to not be able to evacuate the home within 2 ½ minutes, a fire safety expert will be contacted to specify an evacuation time that is safe for these individuals. 02/28/2023 Implemented
6400.112(e)At the time of the fire drill record review there were no records indicating that there were asleep drills being conducted every 6 months.A fire drill shall be held during sleeping hours at least every 6 months. This was not an area that had to be remedied at this time, since there were 6 sleep drills conducted throughout the year, including one at least every 6 months. The next sleep drill will be completed no later than February 2023. Documentation (Attachment #6) to verify the sleep fire drills occurred will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 02/28/2023 Implemented
6400.141(c)(14)Individual #1 current physical leaves the info pertinent to diagnosis in the event of an emergency section blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. This area of non-compliance was remedied by having Individual #1¿s PCP complete the information pertinent to diagnoses in case of emergency on the physical dated 1/9/2023. Documentation (Attachment #7) for the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 01/09/2023 Implemented
6400.163(a)Individual #1's prescribed medications saline nasal spray and miralax powder did not have a pharmacy prescription label on them at the time of the inspection.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.This area of non-compliance was remedied by having Individual #1's non-prescription medications kept in their original labeled containers. Should there be any prescribed medications, they will be labeled with a label issued by the pharmacy. Pictures (Attachment #8) for the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/21/2022 Implemented
6400.163(h)Individual #1's rhinocort spray was discontinued on 12/16/22, however the medication was still in the medication box and not destroyed in a safe manner at the time of the inspection.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.This area of non-compliance was remedied by having Individual #1¿s Rhinocort returned to the pharmacy for disposal immediately following inspection on December 20, 2022. 12/21/2022 Implemented
6400.165(c)Individual #1's medication buspropian HCL SR 50 mg, 1.5 tab was being administered at 8am with additional medications inside a pillow pack, but this medication is not listed on the MAR as a current medication. Nor is this medication being signed off as given when administered, due to it not being present on the MAR.A prescription medication shall be administered as prescribed.This area of non-compliance was remedied by having Individual #1¿s Bupropion HCL ER 100 mg added to the MAR for an 8am administration, and by having all staff document on the MAR on a daily basis. Documentation (Attachment #9) for the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/21/2022 Implemented
6400.166(b)Individual #1's medication buspropian HCL SR 50 mg, 1.5 tab was being administered at 8am with additional medications inside a pillow pack, but this medication is not listed on the MAR as a current medication. Nor is this medication being signed off as given when administered, due to it not being present on the MAR.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.This area of non-compliance was remedied by having Individual #1¿s Bupropion HCL ER 100 mg added to the MAR for an 8am administration, and by having all staff document on the MAR on a daily basis. Documentation (Attachment #9) for the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/21/2022 Implemented
SIN-00198267 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The last furnace inspection was completed in 10/2020. A current inspection was not completed at time of inspection.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. This area of non-compliance was remedied by having the furnace inspected in December 2021. 12/20/2021 Implemented
SIN-00179905 Renewal 12/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The lower kitchen cabinet to the left of the stove did not close all the way and the lower cabinet to the right of the sink that contained the cutting boards was missing a knob The white coffee table's surface in the living room was chipped and worn down on one of the legs.Floors, walls, ceilings and other surfaces shall be in good repair. Correction of this Non-Compliance: This area of non-compliance was remedied on 12/10/2020 by the Program Director replacing the knob with a new one, and the cabinet door hinge was tightened to make it close completely. Pictures of this area at the Actman House on City Ave will be forwarded to Licensing, along with all other necessary documentation, by Friday, December 25, 2020. Plan for Correction moving forward: The Program Director will inspect all group homes 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: December 10, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: December 10, 2020 for initial compliance issue By March 15, 2021 (and on-going) 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. 12/10/2020 Implemented
6400.151(b)Staff #1's annual/initial physical was completed prior to being hired. However, the exam record was not dated by the physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Correction of this Non-Compliance: This area of non-compliance has not been remedied as of yet. The staff member was to have an appointment on 12/21/2020, but the appointment was rescheduled by the office. The staff member is currently attempting to get an earlier appointment date. This area of non-compliance will be remedied by the staff member having a physical and TB screening completed and having the appropriate forms filled out. A copy of this form will be forwarded to Licensing, along with all other necessary documentation, as soon as possible. Plan for Correction moving forward: The Office Manager and/or Program Director 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: December 3, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: Pending for initial non-compliance issue By March 15, 2021 (and on-going) 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. 12/21/2020 Implemented
6400.46(b)All three selected staff, #1, #2 and #3 were not trained in fire safety since October and November of 2019.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Correction of this Non-Compliance: This area of non-compliance has not been fully remedied at this point, but contact has been made with the Lower Merion Fire Department to conduct a virtual Fire Safety Training in January 2021 for all staff and residents. Additionally, attempts to reach out to the Radnor Fire Department have gone unanswered at this time. In the meantime, a power point presentation on fire safety was found created by the National Fire Protection Association and reviewed by the Program Director on 12/21/2020. There was also a short quiz that went along with the presentation, which was completed as well. This fire safety presentation and quiz was disseminated to all staff on 12/21/2020. A copy of the fire training information will be forwarded to Licensing, along with all other necessary documentation, by Friday, December 25, 2020. Plan for Correction moving forward: The Program Director will make sure to schedule Fire Safety Trainings annually by reaching out to the local fire department and having them conduct a fire safety training for all staff and individuals. A sign-in sheet and credentials from the trainer will be saved to produce at inspection time. 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: December 17, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: December 21, 2020 January 2021 for virtual fire safety training 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. 12/21/2020 Implemented
6400.163(a)Some of the prescribed medication for individual #1 was not labeled with a pharmaceutical label. The following prescribed daily medications did not have a pharmaceutical label: Triamcinolone Cream at .1% concentration to be taken once daily at bedtime, the multivitamin tablets which were a gummie chewable to be taken once daily and the Coromega liquid packets to be taken at breakfast at dinner.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Correction of this Non-Compliance: This area of non-compliance has not been remedied at this point. Contact has been made with the physician's office to send prescriptions to the pharmacy for these over-the-counter medications, so that they can have pharmacy labels. Pictures of the pharmacy labels at the Actman House on City Ave will be forwarded to Licensing, along with all other necessary documentation, as soon as this occurs. Plan for Correction moving forward: The staff will inspect all medications on a daily basis, upon administration, to ensure that all medications are within regulatory compliance. If there are any errors, staff will report them immediately to the Program Director. The Program Director will then ensure any error is corrected by contacting the pharmacy and/or physician for their professional support. 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: December 7, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: Pending Ongoing Monitoring: The Program Director will be responsible for correcting any medication errors, in addition to 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. 12/22/2020 Implemented
6400.163(g)Hydrocortisone cream at 2.5% concentration to be applied twice daily to individual #1 was not stored with the rest of the medication and was unavailable at the time of inspection. The location of the medication was unknown.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Correction of this Non-Compliance: This area of non-compliance was remedied on 12/3/2020. The hydrocortisone cream had been all used and was discarded in the trash can. A refill of the hydrocortisone cream was then delivered, along with the individual's other medications, later that afternoon. This was then placed in his bin in the locked closet with his other medications. Pictures of the hydrocortisone cream at the Actman House on City Ave will be forwarded to Licensing, along with all other necessary documentation, by Friday, December 25, 2020. Plan for Correction moving forward: The staff will inspect all medications on a daily basis, upon administration, to ensure that all medications are stored together. If there are any errors, staff will report them immediately to the Program Director. The Program Director will then ensure any error is corrected and will contact the pharmacy and/or physician for their professional support, if needed. 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: December 3, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: December 3, 2020 Ongoing Monitoring: The Program Director will be responsible for correcting any medication errors, in addition to 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. 12/03/2020 Implemented
SIN-00153711 Renewal 03/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)In individual #1's bedroom, the dresser knobs were missing.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 dresser of Individual #1. Pictures of this area at the Actman House on City Ave will be forwarded to ODP, along with all other necessary documentation. 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. 04/05/2019 Implemented
6400.68(b)The water temperature in main level bathroom was measured at 126.2 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Correction of this Non-Compliance: This area of non-compliance was remedied on 3/29/2019 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 month of April 2019 to ensure that the hot water heater was functioning properly. A copy of the hot water temperature log sheet will be forwarded to ODP , along with all other necessary documentation. 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. 03/29/2019 Implemented
6400.72(b)The garage screen door was damaged. Screens, windows and doors shall be in good repair. Correction of this Non-Compliance: This area of non-compliance was addressed by the Program Director by having the screen door in the garage area removed. Pictures of this area at the Actman House on City Ave will be forwarded to ODP, along with all other necessary documentation. 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. 05/09/2019 Implemented
6400.82(e)There were no bathmats or nonslip surfaces in the bathroom showers. Bathtubs and showers shall have a nonslip surface or mat. Correction of this Non-Compliance: This area of non-compliance was addressed by the Program Director by purchasing, and placing, non-slip bathmats for the showers and bath tubs in all of the group homes. Pictures of these areas at the Actman House on City Ave will be forwarded to ODP, along with all other necessary documentation, by Friday, May 10, 2019. 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. 04/05/2019 Implemented
6400.142(f)Individual #2's record did not have a written plan for dental hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Correction of this Non-Compliance: This area of non-compliance was addressed by reviewing the individual's previous dental visit forms and creating a dental hygiene plan category on the individual's annual assessment. The information will be reviewed with the dentist at the next dental appointment to ensure accuracy. A copy of the dental hygiene plan will be forwarded to ODP, along with all other necessary documentation. 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 dental hygiene plans 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. 05/10/2019 Implemented
6400.164(a)PRN medication Melatonin and Immodium was not documented in the Medication log of individual #2..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 by reviewing the individual's medications and creating a separate Medication Administration Record for his PRN medications that will be kept in his medical book. A copy of the medication administration record will be forwarded to ODP, along with all other necessary documentation. 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 medications are properly documented and recorded 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. 04/01/2019 Implemented
6400.182(a)Individual #2 has no ISP documented in the record. Forms found in record and used were not department-designated(a) An individual shall have one ISP. (d)(3) The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) and also on the Department's web site.Correction of this Non-Compliance: This area of non-compliance was addressed by reviewing the individual's records and creating an ISP using an Annotated ISP form. A copy of the annotated ISP (Attachment 2) will be forwarded to ODP, along with all other necessary documentation. 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 individual's ISP's 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. 05/10/2019 Implemented
SIN-00120551 Renewal 12/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers listed by the telephone in the kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Non-Compliance Regulation Number: 6400.71 Correction of this Non-Compliance: This area of non-compliance was remedied on 12/4/2017 by the Program Director by placing a list of emergency numbers by the staff telephone in the kitchen area. Pictures of the list by the staff phone in the kitchen area at the Actman House on City Ave (Attachment 10) 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 inspect all group homes 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 4, 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. 12/04/2017 Implemented
6400.112(e)There was only one sleep drill held from the period of 1/4/17 through 8/11/17.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 being February 9th, 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 1, 2018 Record Review Date: By February 28, 2018 Corrections Completed Date: February 9, 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. 02/09/2018 Implemented
6400.141(b)Individual #1's annual physical dated 1/4/17 was not signed and dated by the appropriate personnel.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Non-Compliance Regulation Number: 6400.141(b) Correction of this Non-Compliance: This area of non-compliance was addressed on 1/25/2018 at the individual¿s next appointment with his PCP, by having the individual¿s physician complete another physical form to ensure that all necessary information was filled in, including the signature and date of the appropriate personnel. A copy of the physical (Attachment 9) 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: January 25, 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. 01/25/2018 Implemented
6400.141(c)(10)Individual #1's annual physical dated 1/4/17 did not did not indicate if the individual was free of communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Non-Compliance Regulation Number: 6400.141(c)(10) Correction of this Non-Compliance: This area of non-compliance was addressed on 1/25/2018 at the individual¿s next appointment with his PCP, by having the individual¿s physician complete another physical form to ensure that all necessary information was filled in, including that the individual was free of communicable disease. A copy of the physical (Attachment 9) 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: January 25, 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. 01/25/2018 Implemented
6400.141(c)(14)Individual #1's annual physical dated 1/4/17 did not 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 1/25/2018 at the individual¿s next appointment with his 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 and treatment in case of an emergency. A copy of the physical (Attachment 9) 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: January 25, 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. 01/25/2018 Implemented
6400.141(c)(15)Individual #1's annual physical dated 1/4/17 did not did not indicate dietary instructions.The physical examination shall include: Special instructions for the individual's diet.Non-Compliance Regulation Number: 6400.141(c)(15) Correction of this Non-Compliance: This area of non-compliance was addressed on 1/25/2018 at the individual¿s next appointment with his PCP, by having the individual¿s physician complete another physical form to ensure that all necessary information was filled in, including dietary instructions. A copy of the physical (Attachment 9) 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: January 25, 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. 01/25/2018 Implemented
6400.164(c)Individual #1's med log did not list 2 PRN medications, Clobetasol and Centrum vitamins. A list of prescription medications, the prescribed dosage and the name of the prescribing physician shall be kept for each individual who self-administers medication.Non-Compliance Regulation Number: 6400.164(c) Correction of this Non-Compliance: This area of non-compliance was immediately fixed as the two medications, that were not on the MAR, but found with the individual¿s other medications, were not current medications. JCHAI staff had failed to remove these medications to prevent confusion with the other medications being provided, but the discontinued medications have been disposed of properly. Plan for Correction moving forward: The Program Director will do an initial inspection of all the individuals¿ medications at the group homes to ensure that all discontinued medications are disposed of properly. All JCHAI staff will be retrained by the Program Director to notify him and/or the Resident Care Supervisor of any discontinued medications and dispose of them properly. The Program Director will then do quarterly reviews no later than the end of February, May, August, and November to ensure that this protocol is being followed. 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: December 1, 2017 for this individual By December 8, 2017 for all other individuals By March 15, 2018 moving forward after quarterly reviews 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
6400.185(a)Individual #1's annual ISP date was 10/1/17 and there was a 90 day review completed from 9/4/16 through 12/13/16. Therefore this review crossed over two ISPs. 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 was addressed on 1/10/2018, by completing the individual¿s quarterly report based on the ISP¿s start date. The previous quarterly report start dates were from 9/14/2016 through 12/13/2016, but this has been changed to 10/1/2017 through 12/31/2017. A copy of the quarterly report (Attachment 8) 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 quarterly reports are updated on a regular basis to ensure compliance with 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: January 10, 2018 for this individual By March 15, 2018 for all other individuals 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. 01/10/2018 Implemented
6400.213(1)(i)Individual #1's record did not indicate 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 7) 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: December 1 and 4, 2017 for this individual By March 15, 2018 for all other individuals 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
SIN-00105687 Renewal 11/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(c)Individual #1's assessment dated 2/5/15 did not contain notation as to the basis of the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations. Correction of this Non-Compliance: This area of non-compliance was immediately fixed by the Program Director to indicate that the assessment was based on assessment instruments, interviews, progress notes, and observations for this individual. The Program Director is revising all other residents¿ Annual Assessments, as needed, to indicate the basis of assessment. A copy of the corrected Annual Assessment will be forwarded to Walter Szott, along with all other necessary documentation, by Friday, January 27th, 2017. 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 that they were based on assessment instruments, interviews, progress notes, and observations. 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 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. 11/21/2016 Implemented
SIN-00077062 Renewal 06/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1's physical examination, dated 05/19/2015, did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Non-Compliance Regulation Number: 6400.141(c)(4) 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 did contact the individual¿s PCP to review the area of non-compliance and address it. The Program Director is also reviewing all other residents¿ records, as needed, to ensure that all physical examinations include a hearing exam. Please see attached (attachment 10). 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 physical exams include a hearing exam. 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 7) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these resident records on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/27/2015 Implemented
6400.141(c)(10)Individual #1's physical examination, dated 05/19/2015, did not include a space for specific precautions that must be taken if the individual has a communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Non-Compliance Regulation Number: 6400.141(c)(10) 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 did contact the individual¿s PCP to review the area of non-compliance and address it. The Program Director is also reviewing all other residents¿ records, as needed, to ensure that all physical examinations include a space for specific precautions that must be taken if the individual has a communicable disease. Please see attached (attachment 10). 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 physical exams include a space for specific precautions that must be taken if the individual has a communicable disease. 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 7) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these resident records on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/27/2015 Implemented
6400.141(c)(11)Individual #1's physical examination, dated 05/19/2015, did not include a blank or space for health maintenance needs to be reviewed. 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. Non-Compliance Regulation Number: 6400.141(c)(11) 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 did contact the individual¿s PCP to review the area of non-compliance and address it. The Program Director is also reviewing all other residents¿ records, as needed, to ensure that all physical examinations include a blank or space for health maintenance needs to be reviewed. Please see attached (attachment 10). 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 physical exams include a blank or space for health maintenance needs to be reviewed. 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 7) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these resident records on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/27/2015 Implemented
6400.141(c)(13)Individual #1's physical examination, dated 05/19/2015, did not include a blank or space for allergies or contraindicated medications to be reviewed. The physical examination shall include: Allergies or contraindicated medications.Non-Compliance Regulation Number: 6400.141(c)(13) 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 did contact the individual¿s PCP to review the area of non-compliance and address it. The Program Director is also reviewing all other residents¿ records, as needed, to ensure that all physical examinations include a blank or space for allergies or contraindicated medications to be reviewed. Please see attached (attachment 10). 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 physical exams include a blank or space for allergies or contraindicated medications to be reviewed. 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 7) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these resident records on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/27/2015 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 05/19/2015, did not include a blank or space for medical information pertinent to diagnosis and treatment in case of an emergency to be reviewed. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Non-Compliance Regulation Number: 6400.141(c)(15) 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 did contact the individual¿s PCP to review the area of non-compliance and address it. The Program Director is also reviewing all other residents¿ records, as needed, to ensure that all physical examinations include a blank or space for medical information pertinent to diagnosis and treatment in case of an emergency to be reviewed. Please see attached (attachment 10). 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 physical exams include a blank or space for medical information pertinent to diagnosis and treatment in case of an emergency to be reviewed to be reviewed. 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 7) Corrections Completed Date: By December 15, 2015 Ongoing Monitoring: The Program Director will be responsible for examining these resident records on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 07/27/2015 Implemented
6400.151(a)Staff #1's previous physical examination was dated 05/12/2010. The most recent physical examination was dated 06/04/2015. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Non-Compliance Regulation Number: 6400.151(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 Office Manager is reviewing all other employees¿ records, as needed, to ensure that all physical examinations are completed within the allotted time frame. Plan for Correction moving forward: The Office Manager will review all employee records on a quarterly basis, no later than the 15th of every January, April, July, and October. The Office Manager will use the Annual Employee Information tracking form (Attachment 9) to ensure that all necessary physical examinations have taken place within the allowed time frame and all necessary forms have been received. All necessary forms will be kept by the Office Manager in the employee files. Plan Start Date: November 1, 2015 Record Review Date: January 1, 2016 (See attachment 7) Ongoing Monitoring: The Office Manager will be responsible for examining these employee records on a quarterly basis to ensure that all necessary actions are being taken to manage this compliance issue per BHSL licensing guidelines. 11/02/2015 Implemented
6400.181(e)(13)(ii)Individual #1's assessment, dated 02/05/2015, 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 8). 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 7) 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. 07/07/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment, dated 02/05/2015, 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 8). 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 socialization. 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 7) 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. 07/07/2015 Implemented
6400.181(e)(13)(vi)Individual #1's assessment, dated 02/05/2015, 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 8). 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 recreation. 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 7) 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. 07/07/2015 Implemented
6400.181(e)(13)(viii)Individual #1's assessment, dated 02/05/2015, 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 8). 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 managing personal property. 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 7) 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. 07/07/2015 Implemented
6400.181(e)(13)(ix)Individual #1's assessment, dated 02/05/2015, 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 8). 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 community-integration. 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 7) 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. 07/07/2015 Implemented
6400.186(a)Individual #1's Individual Support Plan (ISP) review ending on 01/31/2015 was completed by the program specialist on 02/17/2015.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 6). 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 7) 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. 07/28/2015 Implemented
SIN-00050726 Renewal 06/06/2013 Compliant - Finalized