Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00204784 Renewal 05/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Repeat Violation 5/25/2021:Self-assessments for all homes within the agency were not completed within the required timeframe.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The CEO is responsible for completing self-assessments. Self-Assessments were completed between the dates of 1/31/22 and 2/11/22. The CEO incorrectly documented the start date of 1/31/22 with 1/31/21. All self-assessment dates have been corrected on the self-assessments completed between 1/31/22 and 2/11/2022 to reflect the correct date. 05/20/2022 Implemented
SIN-00188248 Renewal 05/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Evacuation time: The fire drill record from 1/11/2020 notated that one of the two individuals refused to evacuate during the fire drill. This individual did not evacuate under the 2.5 min requirement. The fire drill for that month was not repeated in order to meet compliance with regulation 112d. 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. All fire drills were reviewed for the 1001 Poplar Ave home since the 1/11/2020 fire drill and all fire drills since have been successful. All agency staff were retrained on the importance of fire drills and the need to repeat any unsuccessful fire drill (see attachment #3) . All fire drill records for 2021 were reviewed for each home to ensure compliance with this regulation. 06/30/2021 Implemented
6400.112(g)Fire drills shall be completed during all times of the day and night: For the past year, all fire drills were either conducted in the evening hours (between 1:00pm to 11pm) or during sleeping hours (11pm to 6am). There were no drills completed during the morning hours from 6:00am to 11:59am Fire drills shall be held on different days of the week and at different times of the day and night. A fire drill was completed at the home on 6/8/2021 at 9:09am. All fire drill records for 2021 were reviewed for each home to ensure compliance with this regulation. All supervisors were alerted of any times/days that fire drills have not yet been conducted. An excel spreadsheet was created for each home so that fire drills could be tracked each month and to help supervisors ensure that they are using different exits, days, times, etc. per regulatory requirements. The CEO will monitor fire drill records to ensure that they are in compliance for each home no less than once every six months and communicate/educate with supervisors of any non-compliance. All staff in the agency were trained on this regulation. (Please see Attachment # 3, 4, 5) 06/08/2021 Implemented
6400.46(a)Staff #1 2020 annual training hours did not include the following-- Program specialists and direct service workers shall be trained before working with individuals in: · General fire safety · Evacuation procedures · Responsibilities during fire drills · The designated meeting place outside the building or within the fire safe area in the event of an actual fire · Smoking safety procedures if individuals or staff persons smoke at the home · The use of fire extinguishers, smoke detectors and fire alarms, and · Notification of the local fire department as soon as possible after a fire is discoveredProgram specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff #1 completed fire safety training on 6/8/2021. 06/08/2021 Implemented
SIN-00166498 Unannounced Monitoring 11/13/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Most recent assessment dated 9/2/19 and initial assessment completed on 4/2/19 both indicate under section "functional/medical limitations" that individual #1 is diagnosed with a seizure disorder but the staff at individual's home did not receive a seizure protocol until 10/4/19 and it wasn't reviewed and signed off by staff until 10/7/19 and 10/14/19, which is more than 8 months after individuals admission (2/2/19).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. Staff need to be educated on the diagnosis of people they support. Failure to understand medical conditions and how to respond can cause serious health and safety concerns. Medical Support staff feel that multiple events contributed to the failure to identify this issue. The period time prior to admission is used to learn about the person and their support needs. In this particular instance the medical support staff did not have an opportunity to review medical histories and as a result failed to identify and train staff on the diagnosis. The people responsible for the intake at this time failed to identify the diagnosis on the Intake, Orientation and Training Plan. In order to avoid that oversight all future intake teams will include a representative from each department including medical coordinators and nursing. in addition, Upon initial admission the medical coordinators are responsible for gathering information, research conflicting information, and developing a comprehensive training plan for staff will work in conjunction with the Training Coordinators to plan trainings which help staff support people we provide services. All files will be reviewed to assure that staff are trained on individual diagnosis. Attachment: PA # 6 Intake Admission Team ; Attachment: PA # 7 Training for Admission Team members 11/26/2019 Not Implemented
6400.181(e)(10)Most current assessment dated 9/02/2019 for individual #1 states that the lifetime medical history is attached to the assessment, however at the time of inspection the lifetime medical history was not attached to the most current assessment. Staff stated it was sent as separate documentation and placed in the individual's folder, however the date on the lifetime medical history is 10/15/19, which indicates that it was not sent at the same time as the assessment that was dated and sent to the SC on 9/2/19.The assessment must include the following information: A lifetime medical history. The Lifetime Medical History is a vital component of the individual assessment because the of health and safey impact has on the person support needs. At the time of admission Individual #1 initial assessment completed on 9/2/2019 failed to included a lifetime medical history. Medical Coordiantor stated that she failed to realize that the LMH needed included in the indiviuda assessment which was due 60 days after admssion. She completed the Lifetime Medical History one month after the completion of the assessment. The Medical Coordinator has been educated to understand the admission process and components of the indiviudal assessment. A new process has been developed where the Lifetime Medical History is now available on a shared access location on the central server and both the Medical Coordinator and Program Specialist are responsible for updating the record as necessary. The Program Specialist will include the Lifetime Medical History in the assessment rather than as attachment to avoid the two documents becomming seperated. Indivudal #1 Assessment has been revised to include the full history, reviewed with the individual and shared with the team. All files have been reviewed to assure the presance of the Lifetime Medical History (Attchment : PA # 4 Assessment Cover Letter; Attachment: PA # 5 Individual #1 Assessment . 11/26/2019 Not Implemented
6400.165(c)For Individual #1's Medication Administration log for medication "Hydroxyz HCL Tab 25mg" (Atarax) has med label instructions to, "Take 1 Tablet by mouth Daily @ 12pm". This medication is given at the individuals day program. Staff "KrBe" notated on the MAR on 7/20/19 "Medication wasn't picked up from day program 7/19/19 (Friday) for weekend doses". Thus, the individual missed her 12 pm dose on 7/20/19 and medication was not given as prescribed. The medication error was documented in EIM and once discovered, and a request was submitted to the pharmacy for an emergency dose and that dose was given the next scheduled day on 7/21/2019. However, staff initials "ErNe" is notated as having given the medication the next day, but there were no follow up notations to explain how the medication was able to be given when the previous notation stated the staff was not in possession of the medication. (Details of what happened post discovery were explained to this licensing rep at time of inspection).A prescription medication shall be administered as prescribed.It is important that all medications be administered as prescribed in order for the to be effective. Medications are typically packaged in blister packs with a separate card for each location. Because this medication was needed urgently it was filled at a local pharmacy and was not prescribed in a split pack and therefore had to be transported between the home and the day program. On Saturday 7/20/19 DSP realized that the medication had not been obtained on 7/19/19 from the day program and contcted the nursing staff. The emergency number at the pharmacy was contacted and additional doses were obtained but not in time for the 7/20/19 noon administration. Medical support filed the medication error for the missed noon dose on 7/20/19 and administered the 7/21/19 dose as prescribed. We have two issues: To address the issue of transfer of medications between agencies we have contacted the Adult Day Programs and established an after hours emergency contact numbers in the event medication are left at the program. We also recommend that staff use reminders. We have developed a tips list for staff to set up reminders that make sense for them. The second concern is to assure that medical staff explain any atypical entries on the MAR. Any entry on the MAR that is outside the normal administration or whose action is not immediately clear to a reviewer requires the medical staff to document an explaination. All Medical Coordinators and Nursing staff were educated in the importance of documenting any unusual occurances on the ECP Observation link. Attachment: PA #1 List of Emergency Contacts; Attachment: PA # 2 Transfer List; Attachment # 3 Medical Staff Training 11/26/2019 Not Implemented
SIN-00117338 Renewal 08/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74No non skid surfaces on the small 2 boards ramp leading from the kitchen door into the garage. Interior stairs and outside steps shall have a nonskid surface. A work order was issued for the use of non skid surfaces in all homes. Maintnenace repaired / replaced the non skid strips and are checking all residences to assure compliance. Attachment: Photo steps PA-4 Maintenance staff were educated on the need to assure a safe home and will inspect all exits monthly. Attachment: Training PA-5 09/01/2017 Implemented
6400.103There was no emergency shelter location located in the written emergency evacuation procedures. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Chief Executive Officer has been educated on the need to assure that all Emergency Evacuation Procedures are specific to the individal living in the home. All records were reviewed and corrected. Attachment: Policy Poplar Ave. - PA-3 Training Log 3 09/25/2017 Implemented
6400.104The notification letter was last updated on 1/28/12. States individual does not require assistance from staff to evacuate. Individual uses a walker since 8/2016 and requires assistance. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The Chief Executive Officer is responsible to assure the safety of the persons we support. An updated notification to the fire company was completed and all agency files were reviewed to assure compliance. In the future the Program Specialist will provide the level of support needed in the home to the CEO if a change has occurred when the annual assessment occurs. . Attachment: Fire Co. Letter PP-2 Training Log #3. 09/25/2017 Implemented
6400.145(1)The location of the hospital is not located in the written emergency medical plan. The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. The Administrative Assistant has been educated on the need to include the full address of the hospital identified on the Emergency Evacuation Plan. The address has been added and all files have been reviewed and corrected. Attachment: Emergency Evac Plan PP - 1 Training Log 3 09/25/2017 Implemented
SIN-00083004 Renewal 07/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(c)Individual #1's assessment completed on 2/16/15 did not include the baises for assessment. The assessment shall be based on assessment instruments, interviews, progress notes and observations. The Program Specialist has updated Individual #1's 2/16/15 assessment to include the basis for assessment. Attachment 4 - copy of Ind # 1 assessment dated 2/16/2015. The Program Specialist has been retrained on the proper content and completion of the Individual assessment. Attachment 5: Program Specialist Training. 09/04/2015 Implemented
6400.181(e)(13)(iii)Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in 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. The Program Specialist has updated Individual #1's assessment to include the progress over the last 365 days and current days and current levels in activities of residential living.. Attachment 6: Ind # 1 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 7: Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5: Program Specialist Training 09/08/2015 Implemented
6400.181(e)(13)(iv)Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The Program Specialist has updated Individual #1's assessment to include the progress over the last 365 days and current days and current levels in Personal Adjustment. Attachment 6: Ind # 1 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 7: Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5 09/08/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in 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. The Program Specialist has updated Individual #1's assessment to include the progress over the last 365 days and current days and current levels in socialization. Attachment 6: Ind # 1 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 7: Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5 Program Specialist Training 09/08/2015 Implemented
6400.181(e)(13)(viii)Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in 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. The Program Specialist has updated Individual #1's assessment to include the progress over the last 365 days and current days and current levels managing personal property. Attachment 6: Ind. # 1 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 7: Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5 Program Specialist Training 09/08/2015 Implemented
6400.181(e)(13)(ix)Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in 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.The Program Specialist has updated Individual #1's assessment to include the progress over the last 365 days and current days and current levels in community -integration.. Attachment 6: Ind # 1 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 7: Assessment to Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5 09/08/2015 Implemented
6400.186(c)(2)Individual #1's ISP reviewed a new outcome "relationships" was to start on 3/1/15 but was not being reviewed on documentation until 6/25/15. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. The updated ISP 3 month review for Individual # 1 is completed and attached. The outcome "Relationships" is directed at events occurring only at day program and not residentially. A request to the Support Coordinator asking for Mattern Houses removal as a responsible party has been submitted, showing Mattern House as not responsible and a copy of the Quarterly Review to team showing the summary of the issue. Attachment 1: ISP 3 month Review Attachment 2: Letter to SC providing review and right to decline. Attachment 3: Notice to Support Coordinator requesting change. 09/09/2015 Implemented
6400.186(e)Individual #1's record did not include an option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The option to decline the ISP review documentation has been added to the cover letter for the 3 month review by the Program Specialist and has been sent with Individual #1's 3 month review. Attachment # 2: Letter to SC offering right to decline. The Program Specialist will assure that all team members are afforded the opportunity to decline at each 3 month review using the attached template.. 09/09/2015 Implemented
SIN-00050362 Renewal 07/29/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)On 2/19/12 Individuals #2 & #3 did not evacuate for a fire drill within the 2 1/2 minutes. The evacuation time was 2.51 minutes. (d) 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 employee 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. Partially Implemented/Adequate Progress CSS 9/10/13 The House Supervisor is responsible for completing Fire Drills. They have completed training to understand their responsibility. The form has been changed to include a reminder to repeat any drill over 2.5 minutes. Attachments: N-1/N-2 Supervisors Training R: Completed Fire Drill. 08/08/2013 Implemented
SIN-00038530 Renewal 07/23/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165On March 30, 2012, the 8am medications were not indicated as being administered on the medication log for Individual #1.Documentation of medication errors and follow-up action taken shall be kept. Medications are in blister packs sorted by time,day and date. Because of this we were able to determine that the medication was administered and that the staff person failed to log the administration on the MAR. The Staff person was retrained in Medication Administration protocols. To assure that this does not happen again we provided staff with a Medication Administration Process Reminder. Attachment Q: Retraining of Staff Attachment R: Med Administration Process reminder Partially implemented, adequate progress. JW 08/22/2012 Implemented
6400.181(e)(10)6400.181(e)(10) - Repeat - The assessment for Individual #1 did not contain a lifetime medical history.(10) A lifetime medical history. The individual was a new admission and the Medical Support staff had not completed the Medical History at the time the Assessment was completed. Medical Supports will be responsible for having a medical history completed within 60 days of admission. Individual #1 medical history was forwarded to the team members. Attachment S: Letter to Team Partially implemented, adequate progress. JW 08/22/2012 Implemented
6400.213(11)The ISP for Individual #1 stated that she was to be given a multi-vitamin; however, this was not followed up on and never given. There was no documentation to support that her physician recommended taking a vitamin. (11) Content discrepancy in the ISP, The annual update or revision under § 6400.186. Medical Support staff checked with Individual #1's PCP who clarified the issue. The Program Specialist notified the SC of the change. Attachment T: Notice from PCP Attachment U: Notice to SC of ISP Change dated 8-22-12. In order to assure that there are no future content discrepancies all staff will have a mechanism to inform the Program Specialist of issues with the content of the ISP. The Program Specialist will contact the Support Coordinator to make the changes. See Attachment: Notice of Discrepancy Partially implemented, adequate progress. JW 08/22/2012 Implemented
SIN-00084568 Renewal 09/30/2015 Compliant - Finalized