Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216499 Renewal 12/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom curtain liner and shower mat were lightly stained with residue consistent with dirt or mildew.Clean and sanitary conditions shall be maintained in the home. The two areas of non-compliance were addressed by purchasing a new bathroom curtain liner and shower mat. Pictures (Attachment #10) of the areas in question will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/29/2022 Implemented
6400.67(a)The carpet in the formal dining area on the first floor was stained around the seating area and fraying at the seams behind the chair. The bathtubs on the second level were peeling at the surface and the glaze surface was worn. The furniture piece in individual #1s bedroom that held the TV was damaged.Floors, walls, ceilings and other surfaces shall be in good repair. These areas of non-compliance have not been remedied at this time, but steps have been taken to address the issues. It is still being discussed as to how the carpet in the formal dining area on the first floor will be replaced. A decision will be made to have it replaced with either a new carpet or wood floor will be made by Administration by the end of January 2023. Then, multiple estimates will need to be obtained before moving forward with the work. It is not clear as to when this will be completed at this time, but it is hoped to be done by the end of May 2023. In the meantime, the carpet was cleaned by professional cleaners to help ensure that the carpet was as clean as possible for the time being. All of the bathtubs will also be re-finished to repair the areas of non-compliance observed during the inspection. JCHAI will be having a professional contractor inspect the area and repair it as soon as he is able to. Due to the number of projects and repairs, this should be completed by the end of May 2023. The damaged furniture piece in Individual #1's bedroom that held the TV will be replaced by the end of February 2023. Her family was contacted about the need for a new piece of furniture, and that is the time frame that was given. Pictures and/or other documentation showing the corrections will be forwarded, along with all other necessary documentation, by May 2023. 05/31/2023 Implemented
6400.67(b)The outlet cover was missing on the outlet located in the eat-in dining area Floors, walls, ceilings and other surfaces shall be free of hazards.This area of non-compliance was remedied following inspection on December 28, 2022, by putting an outlet cover on the outlet in the eat-in dining area. Pictures (Attachment #11) showing the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/28/2022 Implemented
6400.112(d)The following monthly fire drills documented an evacuation time longer than 2 minutes and 30 seconds without a subsequent drill conducted in the same month: 12/13/2022 recorded 3 minutes and 8 seconds, 2/22/22 dated fire drill was timed 2 minutes and 52 seconds, 3/7/22 was timed 2 minutes and 44 seconds, 5/26/22 was timed 3 minutes and 33 seconds, 7/13/22 was timed 3 minutes and 51 seconds, 10/17/22 was timed 3 minutes and 00 seconds, 11/9/7/22 was timed 4 minutes and 7 seconds 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. 01/31/2023 Implemented
6400.141(c)(14)Individual #1's 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 1/5/2023. Documentation (Attachment #12) for the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 01/05/2023 Implemented
6400.144Individual #1's prescribed medications Aspirin 325mg tablets, Fluticasone spray and Mucinex tablets to be taken as needed were not located on site at the time of inspection but listed as active medications in the medication record. Individual #1's prescribed daily medication, mirtazapine 15mg tablet to be taken daily at 8pm was not in the home. This medication was ordered and received the night of the inspection, but too late to be taken for the 8pm dose.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. This area of non-compliance was remedied by having Individual #1¿s medications removed from being listed as active medications in the medication record. Her PCP was contacted, and approved of the change. Documentation (Attachment #13) for the corrections will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 12/23/2022 Implemented
6400.52(c)(1)Staff #2 (CEO) has over 12 annual hours of training, however these hours do not encompass application of person-centered practices, community integration, prevention, detection and reporting of abuse, individual rights, recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.This area of non-compliance was addressed by having the CEO, staff #2, complete additional trainings that included person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. Documentation (Attachment #14) of this area of non-compliance Rd will be forwarded, along with all other necessary documentation, by Friday, January 27, 2023. 01/16/2023 Implemented
6400.163(d)Individual #2 had two medications Clobetasol propionate topical solution and ala-scalp hydrocortisone lotion located by their bedroom nightstand. This individual does not self-medicate. This medication was not in a locked area or container.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.This area of non-compliance was remedied by having Individual #2¿s medications kept in the staff locked closet immediately following inspection on December 21, 2022. 12/21/2022 Implemented
6400.165(b)Individual #1's prescribed medication Propranolol 40mg tablet to be given daily was not current on either the blister pack or the medication record. The administration times were inconsistent with each other. The Blister pack ordered a 2pm administration time while the medication administration record indicated a 4pm administration time by staff.A prescription order shall be kept current.This area of non-compliance has not been remedied at this time, as we were waiting for the physician to contact the pharmacy in order for them to reissue the medication at 4pm, instead of 2pm. Now that this has finally happened earlier this week, the pharmacy will reissue the medication at 4pm for the next delivery cycle starting February 5, 2023. Documentation (Attachment #15) for the corrections will be forwarded, along with all other necessary documentation, by Friday, February 10, 2023. 02/05/2023 Implemented
6400.165(d)Individuall #1's prescribed medication Propranolol 40mg tablet to be given daily was not current on either the blister pack or the medication record. The administration times were inconsistent with each other. The Blister pack ordered a 2pm administration time while the medication administration record indicated a 4pm administration time by staff.A prescription medication shall be used only by the individual for whom the prescription was prescribed.This area of non-compliance was not previously identified as an issue, and the prescription medication was never used by any other individuals. 02/05/2023 Implemented
SIN-00198265 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Foods were found stored with poisons at various points around the property. A shelf in the garage held Germ-X and Boardroom Spirits hand sanitizer bottles alongside boxes of La Croix and generic seltzer waters and boxes of peanut butter crackers, and cans of green beans, corn, and fruit salad. Packets of seasoning and brown rice were found stored in a container in the dining room with Clorox wipes and Windex.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.This area of non-compliance was remedied by having the food items and poisonous materials moved to separate locations, in both the garage and dining room areas, immediately following the inspection on December 14, 2021. 12/14/2021 Implemented
6400.64(a)Clean and sanitary conditions were not maintained at various points around the property. Several refrigerators/storage freezers in the garage were observed to be coated in a brown/black material consistent with dirt or rust. The freezer side of the refrigerator on the right side of the garage had loose rice on a few shelves and along the bottom of the freezer that had fallen from a bag on a higher shelf. The floor of the garage had piles of loose pasta in a few spots around the room---some near the door, with much more in-between two shelves on the right side of the garage. Inside, the hallway on the first floor that leads toward the first floor bedrooms had a smell consistent with fecal or urine matter. The tub in the first bathroom to the right of the rear staircase did not drain after a test of its water temperature was taken; that tub's shower curtain was also partially caked, along its bottom, with a brown/black material consistent with mildew. A soiled rag was observed to be hanging from that bathroom's towel rack, stained with large brown patches consistent with fecal matter. In the second bathroom on the second floor, another soiled washcloth was observed hanging on a towel rack, also caked with clumpy brown material consistent with waste. The basement bathroom had a brown material caked around its floor consistent with dirt, and its sink was covered in spackled black material consistent with dirt and dead insects or other pest waste.Clean and sanitary conditions shall be maintained in the home. There were several areas of non-compliance that needed to be addressed. First, the refrigerators/storage freezers in the garage were completely cleaned out by staff immediately following the inspection on December 14, 2021. Next, the loose pasta that was observed on the floor of the garage, along with any other debris, was cleaned up by staff immediately following the inspection on December 14, 2021 as well. In order to remedy the smell of urine, observed in the first floor hallway leading to bedrooms, the house was cleaned thoroughly on December 16, 2021 by a cleaning professional. Additionally, JCHAI is continuing to work with the individual who has incontinence issues to make sure they do their laundry and clean up their room immediately following any issues. Air fresheners were also installed to help alleviate the odor. The first 2nd floor bathtub, to the right of the back staircase, that was observed to not drain was remedied by using a liquid plumbing solution immediately following the inspection on December 14, 2021. The shower liners in all of the bathrooms were replaced as well. The soiled rags observed in both upstairs bathrooms to the right of the back staircase were thrown out immediately following the inspection on December 14, 2021. They were replaced with fresh wash cloths. The basement bathroom was observed to have dirt around its floor and sink, and these were cleaned thoroughly on December 16, 2021 by a cleaning professional. 12/16/2021 Implemented
6400.64(b)Mouse and glue traps were observed in closets and rooms throughout the basement. The glue traps were partially covered in dead insects.There may not be evidence of infestation of insects or rodents in the home. This area of non-compliance is continually being addressed through the use of a professional extermination agency. 12/14/2021 Implemented
6400.65Two bathrooms were observed to not have ventilation, neither windows nor mechanical vents: the basement half bath, and the full bath on the second floor, to the right of the rear staircase.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. This area of non-compliance has been addressed in the basement bathroom by plugging in the vent fan to the outlet. However, the upstairs bathroom vent fan will need to be inspected and repaired by our professional contractor. Due to the number of projects and repairs to the house, this should be completed by the end of May 2022. 12/15/2021 Implemented
6400.66Several spots around the property did not have adequate light. The back porch does not have a light, and the interior staircase that leads to the basement did not have a working light at its top. There is a light near the top of the stairs, but it's located around a bit of a corner, and its light is blocked by the wall of the stairway, preventing it from adequately lighting the top of the staircase. The top of the staircase looked to have its own light, but it was non-operational at time of inspection. The second floor hallway has no lights back toward the two bathrooms; the hallway light ends further up the hall in the other direction. The property's vacant room also did not have a light at point of inspection.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 are currently still being addressed at this time by having a professional contractor look at the areas in question. Due to the number of projects and repairs to the house, this should be completed by the end of May 2022. The light bulbs at the top of the staircase were replaced immediately following inspection on December 14, 2021, and it is working. Additionally, a spare lamp was placed in the vacant room for lighting on December 14, 2021. Push lights were also added in the hallway area outside of the two back bathrooms on December 14, 2021. 12/14/2021 Implemented
6400.67(a)Different features and surfaces around the property were found to not be in good repair. Of three garage doors in the garage, only the leftmost door could open; the other two could not. A closet door in the den near the kitchen is missing a knob. In the corner of the den near the desk, there is a divot missing from the wall---a small, but deep scratch into the wall near the corner. The first floor full bathroom was missing tiles from its floor; the tiles were stacked on the back of the toilet; similarly, there were also tiles missing from the middle of the basement hallway floor. The first full bathroom on the second floor has a cabinet under its sink that's missing a knob, and the wall next to the tub is peeling; the tub lining is also chipped or peeling near the drain and at points around its perimeter. The bathroom next to it, at the end of the hall, also has a wall and ceiling around the head of the bath that are peeling and falling, as well as a curtain rod thickly coated with rust; the shower curtain cannot be opened or closed without scraping rust material off of the rod, which then falls down onto the tub. Its tub's lining is also peeling/chipped at various spots around the drain. The cabinet under this bathroom's sink also has damage on its lower left front corner, where the cabinet meets the ground---the leg of the cabinet looks to be broken or splitting, and is stained a dark black/brown color. The tub in the staff bathroom also has chipping/peeling all around its non-slip mat. In individual #2 room, the blinds on her window were damaged, with many of its slats bent out of shape; similarly, the window going up the main staircase had several slats that were bent and hanging down in their middles; also, all windows in the garage that face the walkway that leads to the front door have broken blinds, with all three sets of blinds having many slats that were bent or broken. Near the rear of the basement hallway, the drop ceiling was observed to be peeling off the corner of a tile, and right next to it, the fluorescent light was seen to have a hole or crack in its casing about an inch long. The rear staircase has a sconce at its top with two lights, one of which was operational at point of inspection; when the door at the top of the stairs opens and closes, it hits the left-most light in the sconce, which makes the operational light flicker. In individual #1 room, the ceiling is peeling/falling in the corner between her closet and dresser; a pile of paint chips was observed on the ground under the spot where the ceiling is coming down.Floors, walls, ceilings and other surfaces shall be in good repair. Some of these areas of non-compliance have been remedied, but others are currently still being addressed at this time by having a professional contractor look at the areas in question. At the time of inspection, it was observed that only one of the three garage doors could open. Another garage door, the one in the middle, was able to be opened manually on December 14, 2021, but the third garage door needs to be repaired. JCHAI will be having a professional contractor inspect the area and repair it as soon as he is able to. Due to the number of projects and repairs to the house, this should be completed by the end of May 2022. New knobs were purchased for the closet door in the den near the kitchen and the upstairs bathroom to remedy that area of non-compliance on December 14, 2021. The first floor bathroom tiles and basement tiles will be repaired as soon as the professional contractor is able to get to it. He was made aware of the issue and, due to the number of projects and repairs to the house, this should be completed by the end of May 2022. All of the bathrooms will also be re-finished to repair the areas of non-compliance observed during the inspection. JCHAI will be having a professional contractor inspect the area and repair it as soon as he is able to. Due to the number of projects and repairs to the house, this should be completed by the end of May 2022. The curtain rod and hooks were also replaced in the upstairs bathroom, at the end of the hallway, to avoid having rust material fall down. This was completed on December 14, 2021. Various blinds were observed to be in non-compliance during inspections, and they were either replaced, or are in the process of being replaced. The light bulb was replaced in the sconce at the top of the rear staircase to make it work, and the door at the top of the stairs was removed to avoid it hitting the sconce when being opened or closed. These were done immediately following inspection on December 14, 2021. In Individual #1¿s room, the peeling paint in the ceiling will be addressed by a professional contractor as soon as he is able to, and the pile of paint chips observed on the ground was cleaned up immediately following inspection on December 14, 2021. 12/14/2021 Implemented
6400.67(b)The house was not free of hazards. The den-type room that is also used as a staff office had a cable running from the phone jack at the front of the room to computers on the other side of the room, snaking along the wall and resting in front of a door that leads to the backyard, presenting a tripping hazard. The dryer lint trap was also observed to have a golf ball-sized collection of lint, but was cleared at point of inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.This area of non-compliance was remedied immediately following inspection on December 14, 2021, by removing the phone cable that runs in front of the door that leads to the back yard. 12/14/2021 Implemented
6400.68(b)All bathtubs in the property were found to have running hot water whose temperature exceeded 120 degrees. The first floor full bathroom was measured at 154.9 degrees; the first bathroom to the right of the rear staircase was measured at 153.5 degrees; the bathroom immediately next to that was measured at 140.3 degrees; and the staff bathroom shower was measured at 143.7 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 14, 2021, 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. 12/14/2021 Implemented
6400.74The stairs leading down into the basement did not have non-slip material on them.Interior stairs and outside steps shall have a nonskid surface. This area of non-compliance was remedied immediately following inspection on December 14, 2021, by purchasing a non-skid mat for the stairs leading down to the basement. 12/14/2021 Implemented
6400.80(a)The spot where the concrete walkway out front meets the driveway was cracked in several spots, making the concrete rise up slightly, creating a tripping hazard. The exterior stairs that lead into the basement were observed to have a thick layer of leaves at the bottom landing, and each step was also observed to have leaves on them, presenting a fall risk. Outside walkways shall be free from ice, snow, obstructions and other hazards. A professional contractor will be used to inspect and repair the concrete walkway out front of the house to reduce any tripping hazards. This repair will have to wait until the weather is more suitable for setting concrete, most likely by the end of May 2022. The leaves on the steps, and at the bottom, of the exterior stairs leading to the basement were cleaned up immediately following inspection on December 14, 2021. 12/14/2021 Implemented
6400.80(b)The fence alongside the left side of the house was observed to be broken. Its posts were standing, but the wooden planks between those posts had fallen to the ground. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.A professional contractor will be used to inspect and repair the broken fence along the left side of the house as soon as he is able to. Due to the number of projects and repairs to the house, this should be completed by the end of May 2022. 05/31/2022 Implemented
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
6400.110(b)The smoke detector immediately outside of the vacant room was non-operational at time of inspection.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. This area of non-compliance was remedied by replacing the battery in the smoke detector immediately outside of the vacant room. This was done following inspection on December 14, 2021. 12/14/2021 Implemented
6400.112(e)A sleep drill was not conducted within the 6 months time frame. A sleep drill was conducted 12/2020 and the next one was completed in 8/2021.A fire drill shall be held during sleeping hours at least every 6 months. This area of non-compliance cannot be remedied at this time, since the sleep drill was not conducted within the 6 month time frame. The next sleep drill will be completed no later than February 2022. 02/28/2022 Implemented
6400.141(c)(8)The Mammogram for individual #1 was not completed annually, the last completion date was 2/5/2020.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. This area of non-compliance was remedied on January 12, 2022, by having Individual #1 get a mammogram. 01/12/2022 Implemented
6400.141(c)(14)Information pertinent to diagnoses in case of emergency was left blank on physical dated 7/9/2021 for individual #1.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 her physical dated 7/9/2021. 12/20/2021 Implemented
6400.144It cannot be determined that pharmaceutical services are being provided for individual #1 as many of the medications listed on a document provided by the agency were not seen in the home at point of inspection. Vitamin C OTC medication was not observed, nor were the prescribed Zyrtec, Chlorhexidine Oral rinse, Lac Hydrin 12%, metronidazole gel, and ketoconazole cream 2% medications. Vitamin D3 OTC was observed, but it was a bottle of 1000IU tablets, as opposed to the Vitamin D 2000IU tablets indicated on the agency document. The house did not have a list of the individual's medications at time of inspection, and agency staff indicated they did not know what medications the individual took.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. This area of non-compliance was remedied by having Individual #1 continue to use her brother's pharmacy for any medications that she needs. The medication list at the house was also updated to reflect her current medications. 12/15/2021 Implemented
6400.171Spoiled and old foods were found in various containers around the garage. A frozen tube of turkey meat had a white casing that had been stained with indeterminate brown and red material and was dated 4/28/20. A cabinet in the right side of the garage contained cans of potatoes, green beans, corn, evaporated milk, tomatoes, and other vegetables ranging in dates from 2014 to 2016, some of which had ruptured, coating the drawer around them in a viscous, sticky black material consistent with food rot. Boxes of cans of fruit salad on the opposite side of the garage had collected a dark black liquid in the rear corners of the box; the cans were partially submerged in the black liquid.Food shall be protected from contamination while being stored, prepared, transported and served. This area of non-compliance was remedied by having items observed during the inspection thrown out on December 14, 2021. 12/14/2021 Implemented
SIN-00179903 Renewal 12/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The outside light on the stairwell leading to the basement was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Correction of this Non-Compliance: This area of non-compliance was remedied on 12/7/2020 by the Program Director by replacing the light bulb with a new one. Pictures of this area at the Ominsky House on Welsh Rd 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 7, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: December 7, 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. 12/07/2020 Implemented
6400.77(b)Upon inspection, there was no tape in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Correction of this Non-Compliance: This area of non-compliance was remedied on 12/7/2020 by the Program Director by purchasing tape for the first aid kit. Pictures of the first aid kit at the Ominsky House on Welsh Rd 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 7, 2020 Record Review Date: By February 28, 2021 Corrections Completed Date: December 7, 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. 12/07/2020 Implemented
6400.151(b)Staff #2 did not have a physical completed since 1/31/18 which is 2 years 11 months from the date of this inspection. 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 was remedied on 12/3/2020 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, by Friday, December 25, 2020. 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: December 3, 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. 12/03/2020 Implemented
SIN-00153709 Renewal 03/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)There was a large amount of dryer lint behind the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. Correction of this Non-Compliance: This area of non-compliance was remedied on 4/1/2019 by the Program Director by ensuring the area surrounding the dryer, and the dryer itself, was clear of dryer lint. Additionally, the ducts were cleaned to ensure that there was no build-up of lint inside the duct and vent. Plan for Correction moving forward: A reminder note will be placed by the dryers in all group homes to remind staff and residents to ensure that the area is free from dirt, lint, and other debris. 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. 04/01/2019 Implemented
SIN-00105685 Renewal 11/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual # 1 was reportedly able to handle finances but the assessment and and ISP documented that they were not capable. The home did not keep a financial record of funds deposited at the home.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Correction of this Non-Compliance: This area of non-compliance was fixed by the Program Director by having JCHAI staff keep a record of the money that the individual independently withdrawals from her bank and puts in her lock box that is kept in the staff locked closet. This money is then distributed to her by JCHAI staff on a daily basis to help her manage her spending habits, which is also being recorded on the same document. A copy of this documentation will be forwarded to Walter Szott by Friday, January 27th, 2017. Plan for Correction moving forward: JCHAI staff will keep a record of any spending money that individual¿s need help managing. This includes any money that an individual independently withdrawals from their bank and puts in their lock box, which is kept in the staff locked closet. This money will then be distributed to by JCHAI staff to the individual, based upon the agreed upon process by the support team, to help manage the individual¿s spending habits appropriately, which will also be recorded. 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 JCHAI staff is keeping current, and accurate, documentation of individual¿s spending monies if they require assistance. 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
6400.22(d)(2)Disbursements made to Individual # 1 were not available for review.(2) Disbursements made to or for the individual. Correction of this Non-Compliance: This area of non-compliance was fixed by the Program Director by having JCHAI staff keep a record of the money that is being distributed to the individual on a daily basis to help her manage her spending habits. A copy of this documentation will be forwarded to Walter Szott by Friday, January 27th, 2017. Plan for Correction moving forward: JCHAI staff will keep a record of any spending money that individual¿s need help managing. This includes the money that is distributed to the individual by JCHAI staff, based upon the agreed upon process by the support team, to help manage the individual¿s spending habits appropriately. 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 JCHAI staff is keeping current, and accurate, documentation of individual¿s spending monies if they require assistance. 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
6400.22(e)(3)No receipts were avaiable for review for purchases made for Individual # 1 If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Correction of this Non-Compliance: This area of non-compliance was addressed by the Program Director by communicating to the individual and to JCHAI staff about the need to keep receipts of single purchases in excess of $15. However, since JCHAI staff do not spend any of the individual¿s money on her behalf, it remains unclear as to whether the individual will retain and/or give the receipt to JCHAI staff for record keeping. JCHAI staff have been instructed to remind the individual when distributing her weekend money to keep any receipts of single purchases greater than $15. Plan for Correction moving forward: The Program Director has communicated with all JCHAI residential staff and individuals that receive support in managing their spending monies to retain and give receipts to JCHAI staff for single purchases greater than $15. JCHAI staff will continually remind individuals, when receiving spending money in excess of $15, to retain and turn in their receipts for single purchases in excess of $15. JCHAI staff will keep any receipts turned in by individuals who spend more than $15 on a single purchase in the individual¿s lock box, which will be available for BHSL review upon request. 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 JCHAI staff is keeping current, and accurate, documentation of individual¿s receipts if they require assistance and are making any single purchases in excess of $15. 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
6400.64(a)There was a film of sticky substance on the kitchen cabinets and the wall above and around the stove.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 having JCHAI staff use cleaning products to clean off the film of sticky substance on the kitchen cabinets, wall, and hood above the stove. Pictures of the cleaned surface 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, JCHAI staff and the cleaning service that JCHAI employs will make sure to pay more attention to the cleanliness of the kitchen cabinets, wall, and hood above the stove 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)The closet doors were off the track in individual # 1 bedroom. The second floor bedroom has a dresser that is missing knobs.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 the closet door in individual #1¿s room repaired by a handyman and by purchasing and installing new pulls for the dresser in individual #2¿s bedroom. Pictures of the fixed 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
6400.186(d)The 3 month ISP reviews for Individual #1 were not sent to the supports coordinator.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Correction of this Non-Compliance: This area of non-compliance was fixed by the Program Director, by sending the individual¿s Supports Coordinator a copy of the individual¿s quarterly reports for the 2015-16 ISP plan year. Documentation of this information being sent to the Supports Coordinator will be forwarded to Walter Szott by Friday, January 27th, 2017. Plan for Correction moving forward: The Program Director will send all individual¿s quarterly reports to their respective Supports Coordinators upon within 30 days of the individual¿s ISP meeting. Documentation of these reports being sent will be maintained by the Program Director for BHSL review upon request. Additionally, 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 individual¿s quarterly reports have been sent to their respective Supports Coordinators and documentation will be kept by the Program Director for BHSL review upon request. 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. 01/27/2017 Implemented
6400.213(9)A current updated copy of the ISP for individual #1 was not available in the file for review.The ISP meeting was held on 6/01/16 Each individual's record must include the following information: A copy of the current ISP. Correction of this Non-Compliance: This area of non-compliance was fixed by the Program Director by contacting the individual¿s Supports Coordinator to gain a copy of her 2015-2016 ISP. The Program Director is reviewing all other residents¿ records to ensure that current copies of their ISPs are in our records. A copy of the 2015-2016 ISP 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 JCHAI has current copies of all individual¿s ISPs. 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. 12/01/2016 Implemented
SIN-00077060 Renewal 06/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1's previous physical examination was dated 02/06/2013.The most recent physical examination was dated 03/30/2015. Staff #2 was hired on 08/17/2014. The physical examination was dated 08/30/2014. 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. JCHAI will make sure to receive all potential staff physical examinations prior to being trained, and will also make sure to receive future physical examinations every 2 years thereafter. The JCHAI Program Director and Office Manager will review these records during self-inspection and will make corrections as needed. 07/01/2015 Implemented
6400.181(e)(13)(ii)Individual #1's assessment, dated 09/08/2014, 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. 08/06/2015 Implemented
6400.181(e)(13)(iii)Individual #1's assessment, dated 09/08/2014, 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 and residential living 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 activities and residential living. 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. 08/06/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment, dated 09/08/2014, 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 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 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. 08/06/2015 Implemented
6400.181(e)(13)(vi)Individual #1's assessment, dated 09/08/2014, did not include progress and growth in the area of 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 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 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. 08/06/2015 Implemented
6400.181(e)(13)(vii)Individual #1's assessment, dated 09/08/2014, 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 financial independence. 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. 08/06/2015 Implemented
6400.181(e)(13)(viii)Individual #1's assessment, dated 09/08/2014, 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 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 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. 08/06/2015 Implemented
6400.181(e)(13)(ix)Individual #1's assessment, dated 09/08/2014, 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 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 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. 08/06/2015 Implemented
6400.181(f)Individual #1's assessment, dated 09/08/2014, was not sent to 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 of 12/01/14 to 02/28/15 was not implemented by the ISP start date of 12/17/14. 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. 09/18/2015 Implemented
6400.186(a)Individual #1's Individual Support Plan (ISP) review ending on 08/31/2014 was completed by the program specialist on 09/17/2014. Individual #1's ISP review ending on 02/28/15 was completed by the program specialist on 03/16/2015. 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. 09/18/2015 Implemented
6400.213(9)Individual #1's record did not included the current ISP. Each individual's record must include the following information: A copy of the current ISP. A copy of each resident's most current ISP will be kept in their individual records. In order to receive the most current ISP, the JCHAI Program Director will request from the Supports Coordinators that the resident's current ISP be sent to the JCHAI office in addition to the individual. This will also be the case if there are any corrections/updates to the ISP. The JCHAI Program Director will make sure that a current ISP is in the resident's records during the self-inspection process, and will request one if necessary. 07/01/2015 Implemented
SIN-00120549 Renewal 12/01/2017 Compliant - Finalized
SIN-00061321 Renewal 05/29/2014 Compliant - Finalized
SIN-00050724 Renewal 06/06/2013 Compliant - Finalized