Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00223371 Renewal 04/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)For individual #1's financial ledger, on 1/03/2023 there was a ledger balance of $163.33. on 1/06/2023 there was a debit of $3.95 which should have put the new balance as $159.38, however the ledger incorrectly reads $156.21, and the error was not caught thus the ending balance the ledger records is $5.15 but it should be $8.32. Also, the cash balance at the home was $86.77 but the ledger states the ending balance was $5.15. The deposit of monies was not recorded with date.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. The violation reported that individual #1's financial ledger, on 1/3/2023, there was a ledger balance of $163.33. On 1/6/2023 there was a debit of $3.95 which should have put the new balance as $158.38, however the ledger incorrectly reads $156.21, and the error was not caught thus the ending balance the ledger records is $5.15, but it should be $8.32. Also, the cash balance at the home was $86.77, but the ledger states the ending balance was $5.15. The deposit of monies was not recorded with date. Individual #1's ISP states that the individual has a separate checking account in which she chooses to deposit her income she makes at her independent living program. The individual chooses to independently control her personal checking account and uses a debit card for personal expenses. Staff encourage individual #1 to keep her receipts and staff assist her in keeping a ledger, although individual #1 monitors her personal checking account by use of a mobile app in which she checks her balance prior to making purchases. The ledger with ending balance $5.15 is the ledger that staff use to assist individual #1 in independently tracking her personal checking account and does not reflect the amount of petty cash in the home. The petty cash balance in the home was $86.77 at the time of review. Petty cash ledgers and receipts from February, March, and April 2023 show that all receipts are accounted for and the balance is correct. In order to provide clarification, track changes were submitted to the SC to clearly state that individual #1 chooses to independently monitor her personal checking account. 04/27/2023 Implemented
SIN-00145092 Renewal 10/31/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Hand soup (poisonous material) was stored in a decorative container in the home, not in the original, labeled container. Individuals in the home were assessed to not be able to safely use avoid poisons.Poisonous materials shall be stored in their original, labeled containers. Direct Support Staff must have a clear understanding of the ablities of the people we support in order to keep them safe in their home. When materials are removed from their original labeled container they we are unable to clearly provide emergency treatment in the event it is injested. The indiviudals have never attempted to injest hand soap and staff made an assumption that it was safe. It appears they failed to view hand soap as a poison. this is a failure on our part to train on the issue. If the indiviudals are safe around hand soap then this is important information for the Program Specialist to assure that the information in the Assessment and ISP is accurate. On 12-2-2018, following licensing review the dispenser was removed by the Supervisor and all poisons are locked pending review of assessment / skill levels. By 1-31-19 the Program Specialist are responsible for updating the indiviudals Assessment and ISP to reflect their current ability in relation to the ability to safely use hand soap in a decorative container. Staff were educated on the need to keep poisons in their original labeled containers and understanding the assessed need of the people they support and how it relates their their enviroment. (Attachment: T-1 Supervisor Training; T-2 Program Specialist Training. The Program Specialist are responsible for assuring regulatory compliance. The new Program Specialist are also planning house meeting in order to better assess skill levels and they are responsible to reviewing all materials with staff. If any changes in assessed levels are needed a new assessment will be completed. The Program Specialist Supervisor is responsibe for monitoring regulatory requirements. 01/31/2019 Not Implemented
6400.77(b)The first aid kit did not contain tape or a thermometer. 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. Having an Emergency First Aid Kit properly stocked is important in order for the staff to provide appropriate care in the event of an injury. The supervisor reported that she keeps the thermomenter in each individuals personal care basket along with other supplies. On 12-14-2018 the missing items were replaced. (Attachment: # 40 Reciept of Purchase ) Supervisors were educated on the need to maintain a properly stocked first aid kit and provided with a Contents List label to affix to all first aid kits.( Attachment: # 41 First Aid Kit Content Labels) All homes first aid kit contents have been checked to assure compliance with the regulations. Training on the regulation will be provided on 1-9-19 and 1-16-19 (Attachement: T-1; T-2)The Program Specialist and House Supervisor are responsible for assuring compliance with first aid kit contents. 01/18/2019 Implemented
6400.103REPEAT from 8/29/17 renewal inspection: The written emergency evacuation procedure did not include the means of transportation and an emergency shelter location.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. It is important to have a clear process identified in the event of an emergency to assure that care is provided, staff know exactly where they are to go without having to get direction from a supervisor. The current policy was written without a specific emergency shelter location in order to allow administration flexibilty in deciding an appropriate emergnecy shelter on a person by person basis according to their current needs . On 12- 1-2019 the Mattern House emergency medical plan policy has been corrected to identify the specific emergency shelter location to be used. (Attachment # 39 EMergnecy Policy and Procedure Foot of Ten). Prevention through education. On 1-9-2019 and 1-16-2019 Program Specialist and Supervisors will be educated on the need to specify the specifice emergency shelter location to be used. Attachment: T-1 Supervisor Training; T-2 Program Specialist / Medical Support TrainingAll policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter. 01/18/2019 Implemented
6400.145(2)The written emergency medical plan did not include the method of transportation to be used in a medical emergency.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. It is important to have a clear process identified in the event of an emergency to assure that care is provided. The current policy was written without a specific mode of transportation (any available) because vehicles frequently change at the homes. On 12- 1-2019 the Mattern House emergency medical plan policy has been corrected to identify the specific vehicle to be used. Attachment: # 39 a- f Emergency Policy and Procedure for Foot of Ten. Prevention through education. On 1-9-2019 and 1-16-2019 Program Specialist and Supervisors will be educated on the need to specify the method of transportation to be used. Attachment: T-1 Supervisor Training; T-2 Program Specialist / Medical Support Training All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter. 01/18/2019 Implemented
SIN-00083006 Renewal 07/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was poisons unlocked under the kitchen sink(clorox bleach, clorox wipes, comet cleaner) and individual is to have all posions locked. Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials were removed from the under sink cabinet and placed in a locked storage closet on the first floor. The Training Supervisor met with all the staff on 9-3-15 to educate them on the need to lock all poisons. Attachment 14: FOT Training Record Attachment # 15 a under sink with cleaners, 15 b under sink empty, 15 c: Moved to locked cabinet. 09/09/2015 Implemented
6400.112(e)A fire drill during sleeping hours was held on 7/18/14 and then again on 2/28/15. A fire drill shall be held during sleeping hours at least every 6 months. The Supervisor of the home held a Sleep Fire Drill on 7-31-2015 to meet the 6 month sleep drill requirements. Attachment 11: Fire Drill 7-31-15. To assure that the Supervisor continues to meet the sleep drill requirements the Mattern House Secretary has been educated to understand our responsibilities and to assist the Supervisors in maintaining the required schedule. Attachment 12: Training Record. We have also changed the Fire Drill Form to better assist staff in completing fire drills and identifying any problems that occur during a drill. Attachment 13: 8-31-15 Fire Drill with updated format. 09/09/2015 Implemented
6400.181(e)(13)(i)Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The Program Specialist has updated Individual #2's assessment to include the progress over the last 365 days and current days and current levels in health. Attachment 9: Ind #2 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 10: Ind. #2 Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5: Training Log 09/09/2015 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 #2's assessment to include the progress over the last 365 days and current days and current levels in socialization. Attachment 9: Ind #2 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 10: Ind. #2 Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5: Training Log 09/08/2015 Implemented
6400.183(5)Individual #1's ISP did not include a SEEN Plan. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. Individual #2 has a SEEN plan, the support coordinator was provided a copy of the SEEN Plan but did not enter the information on the ISP. The Program Specialist has notified the Support Coordinator of the presence of the SEEN Plan and requested an addition / correction of the ISP. Attachment 8: Letter to SC requesting addition of info to ISP 09/09/2015 Implemented
SIN-00050364 Renewal 07/29/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Staff person #1's physical did not include if they were free of a communicable disease. (3) A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Partially Implemented/Adequate Progress CSS 9/10/13 The Training Coordinator is responsible for assuring that all staff physicals are complete. To assure it does not happen in the future a employment file cover sheet has been developed. Attachment: D Training Log TM ; T: Cover Sheet ; U: Completed Staff Physical 08/08/2013 Implemented
SIN-00204791 Renewal 05/10/2022 Compliant - Finalized
SIN-00173071 Unannounced Monitoring 04/28/2020 Compliant - Finalized
SIN-00101835 Renewal 07/20/2016 Compliant - Finalized
SIN-00084570 Renewal 09/30/2015 Compliant - Finalized
SIN-00038532 Renewal 07/23/2012 Compliant - Finalized