Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00179475 Renewal 11/17/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(c)The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. Direct Service Worker #1 was observed in the home wearing a mask under his/her chin that was not covering his/her nose and mouth at 9:04AM on 11/18/20. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Individuals shall be treated with dignity and respect by staff wearing masks properly during the entirety of service provision.As of November 19, 2020, Mainstay Life Services updated the COVID Guidelines in accordance with local government and CDC guidance. The COVID Guidance was emailed to all staff on November 19, 2020 stating masks must be worn correctly (over nose and mouth) indoors, regardless of social distancing. This applies to all staff, including administration working at the Roessler office. Masks may be briefly removed to drink or eat while maintaining social distancing. Disciplinary procedures must be followed if masks are not worn accordingly. Program coordinators and program managers were retrained on 11/24/2020, on the updated COVID Guidelines including staff wearing face coverings properly as required during the entirety of service provision. Training was conducted by Director of Quality and the Director of Residential Operations. Immediate disciplinary action was taken for all staff that were not properly wearing a mask. Going forward, COVID Guidelines will be reviewed again with all staff at the December site staff meetings. Any infractions of this policy may lead to disciplinary action up to and including termination of employment. Supporting documentation includes, COVID Guidelines as of November 19 2020, the training signature sheet for the guidelines, and the example of the disciplinary form that will continue to be utilize. 11/25/2020 Implemented
SIN-00086403 Renewal 08/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)An audio monitor was being used in Individual #1's bedroom.An individual has the right to privacy in bedrooms, bathrooms and during personal care. This monitor was NOT in the individuals bedroom, but in the hallway outside of her door. This monitor was removed. The managers were requested to check for the presence of monitors in the bedrooms throughout the organization. There were no monitors in any bedrooms in the agency. The quarterly home safety checklist was modified to include checking for the presence of audio monitors. A copy of the checklist will be submitted. The 6400 regulations were reviewed with all staff in August 2015. Documentation of this training will be submitted. Going forward, the individual rights statement will be reviewed with all staff during the January staff meetings. 12/08/2015 Implemented
6400.141(c)(7)The pre-admission physical examination for Individual #2 completed on 6/18/14 did not include a gynecological examination and a Pap test. The individual is 48 years old.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. This individuals caretaker was in a nursing home with terminal cancer when she came to live at Mainstay on 6/7/15. We obtained a gyne and pap test on 8/26/15, being the first available appointment. Documentation of appointment will be submitted. We will no longer make exceptions to this requirement. We had no other female new admissions. The new admission packet will be completed for all new admissions in the future. This process was reviewed with all residential program coordinators. Documentation of training will be submitted. We also Implemented a health record audit process to be used throughout the agency. Copies of this will also be submitted. All residential agency personnel were retrained on the 6400 regulations in June 2015. Documentation of this training will be submitted. 12/14/2015 Implemented
6400.141(c)(8)The pre-admission physical examination for Individual #2 dated 6/18/14 did not include a mammogram. The individual is 48 years old.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 individuals caretaker was in a nursing home with terminal cancer when she came to live at Mainstay on 6/7/15. We obtained a mammogram on 9/29/15, being the first available appointment. Documentation of appointment will be submitted. We will no longer make exceptions to this requirement. We had no other female new admissions. The new admission packet will be completed for all new admissions in the future. This process was reviewed with all residential program coordinators. Documentation of training will be submitted. We also Implemented a health record audit process to be used throughout the agency. Copies of this will also be submitted. All residential agency personnel were retrained on the 6400 regulations in June 2015. Documentation of this training will be submitted. 12/14/2015 Implemented
SIN-00230512 Renewal 09/06/2023 Compliant - Finalized
SIN-00139631 Renewal 08/07/2018 Compliant - Finalized
SIN-00049822 Renewal 06/03/2013 Compliant - Finalized