Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229722 Renewal 08/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 8/2/2/23, the hot water temperatures at the sink located in the hallway bathroom measured 124.1 Degrees Fahrenheit at 10:30 AM and 123.2 Degrees Fahrenheit at 10:33 AM at the kitchen sink.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The hot water tank was adjusted immediately. The water temperate was tested three times and did not exceed 120 Degrees Fahrenheit. 09/01/2023 Implemented
6400.112(d)The fire drill completed on 10/26/22 had an evacuation time of 3 minutes, and the fire drill conducted on 1/16/23 had an evacuation time of 3 minutes and 45 seconds. This home does not have an approved extended evacuation time. 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 are compliant currently. Fire drills will be conducted monthly, and individuals shall be able to evacuate within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. 09/01/2023 Implemented
6400.181(e)(4)Individual #1's assessment completed on 12/14/22 states the following contradictory information in the domain of supervision: they are unable to be left unsupervised for less than 4 hours but yet does not require 24-hour supervision. The assessment must include the following information: The individual's need for supervision. Individual assessment was corrected to reflect proper supervision guidelines. All other individual assessments were checked for accurate information in comparison to the Individual Support Plan. 09/01/2023 Implemented
6400.181(e)(14)Individual #1's assessment completed on 12/14/22 indicates the following contradictory information in the skill domain of water safety: they are independent with water safety, yet they do not know or follow basic water safety rules.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Individual assessment was corrected to eliminate conflicting information and reflect proper water safety guidelines. All other individual assessments were checked for accurate information in comparison to the Individual Support Plan. 09/01/2023 Implemented
6400.32(n)On 8/22/23, the only phone located in the home was located on the table in the locked kitchen and inaccessible to the individuals.An individual has the right to unrestricted and private access to telecommunications.The phone was immediately relocated to the common area of the home where it's easily accessible to all of the individuals in the home. 09/01/2023 Implemented
SIN-00178162 Renewal 10/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Benztropine MES 1 mg tablet, take 1 tablet by mouth twice a day and Buspirone HCL 15 mg tablet, take 1 tablet by mouth twice a day prescribed to Individual #1 were not recorded as administered on 10/18/20 at 8:00PMThe information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff responsible for not recording medication administration was immediately contacted and notified to document the administration of the medications. All other Medication Administration records for the individuals in the homes were check to ensure all records were properly documented. Staff was given a discipline for committing a documentation error and retrained as to the proper medication administration documentation procedure and notified that the medication administration must be recorded at the time of administration. All staff will receive a reminder that Medications administrations should be documented at the time of administration. Medication Administration records will be monitored weekly by MCAR LPN's to ensure all administration records are being properly documented and no medications are being missed. [Documentation of the aforementioned audits shall be kept. (DPOC by AES,HSLS on 10/30/20)] 11/03/2020 Implemented
SIN-00157702 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Direct Service Worker #1, date of hire 12/11/17, had fire safety training on 5/7/19. There was not a record of the previous training; therefore, compliance could not be measured.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). MCAR POC is Training supervisor will create an excel spread sheet with all staffs training dates and re certification dates. MCAR will hold fire safety training in March for ALL STAFF and NEW HIRES. Training Supervisor will review the spread sheet and compare to the sign in sheet at fire safety training. If any staff are not in attendance that need to be training supervisor will notify them via phone call and mailed letter. The scheduler will also be notified to not schedule this staff member until further notice. [Immediately and continuing at least quarterly, the CEO or designee shall audit all staff persons 2 most recent fire safety trainings documentation and/or tracking documentation to ensure all staff persons are trained before working with individuals/upon hire and annually as required. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/9/2019)] 07/11/2019 Implemented
6400.112(a)An unannounced fire drill was not held in August 2018, November 2018 and December 2018. An unannounced fire drill shall be held at least once a month. All fire drills for this home have been completed and are up to date. Supporting documentation was reviewed during the inspection for fire drills held on November 2018 - March 2019. Will resend fire drill documents if needed. MCAR residential group home fire drills will be scheduled by the case managers. The Case Managers will schedule a fire drill for each home they supervise for the entire year. Residential direct care worker who is working in the home on the scheduled fire drill day will e notified by the case manager that a fire drill is to be completed that day. Residential direct care worker will conduct the fire drill. After the drill is complete they will contact the case manager to inform of the completed drill. Case manager will complete the fire drill log based on the information provided by the direct care staff and save on file for inspection. Protech security monitors all MCAR group home fire alarms. Residential Director will receive quarterly reports from ProTech showing the dates and time fire drills were completed in each group home. [Prior to conducting fire drill or other aforementioned responsibilities regarding fire drills or within one month of receipt of the plan of correction/LIS, the CEO or designee shall educate all staff persons responsible for conducting and documenting fire drills and reviewing written fire drill records and aforementioned quarterly reports; of the requirements of conducting and documenting fire drills and their responsibilities to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 9/9/19)] 07/11/2019 Implemented
SIN-00096255 Renewal 06/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1, date of admission 8/29/15, was not informed of his/her rights upon admission.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. First day Packet was made to address this area. RPS will have all necessary 1st day information in the packet and will be responsible for ensuring it is completed, once Completed RPS will sign off on the packet and give to Administrator of residential to be reviewed prior to uploading information into THERAP. All RPS's to be trained on this at Residential Meeting on 7/5/2016, documentation will be kept and sent.[Individual #1 was informed of individual rights on 1/5/16. Within 30 days of receipt of the plan of correction, RPS or Administrator of residential services shall review all individuals' records to ensure all individuals have been informed on the individual's rights as required and will inform each individual as needed. Within 30 days of receipt of the plan of correction, the Administrator of residential services will develop and implement a tracking system for RPSs to follow to ensure individual are informed of individual rights within the required timeframes. Documentation of all reviews shall be kept. (AS 8/4/16)] 07/01/2016 Implemented
6400.112(f)Nine fire drills were held between 9/17/15 and 5/24/16. The front door was used as the exit route in eight of the nine fire drills.Alternate exit routes shall be used during fire drills. Staff will be retrained at In-service training in September 2016, dates have yet to be identified. A Rolodex has been created for each home to ensure all exits used are alternating with the month. Residential Program Specialist will ensure that the alternate exits are used by initialing and dating the houses fire drill once received and reviewed. 07/01/2016 Implemented
6400.112(g)Fire drills were held on 10/23/15, 1/6/16 and 4/17/16 at 12:10 AM, 12:03 AM and 12:30 AM, respectively. Fire drills shall be held on different days of the week and at different times of the day and night. Staff will be retrained at In-service training in September 2016, dates have yet to be identified. Residential Program Specialist will ensure that the alternate times are used by initialing and dating the houses fire drill once received and reviewed. If it is not completed correctly the house will complete another drill before the end of the month to ensure compliance. 07/01/2016 Implemented
6400.113(a)Individual #1, date of admission 8/29/15, was instructed in fire safety on 9/21/15. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. First day Packet was made to address this area. RPS will have all necessary 1st day information in the packet and will be responsible for ensuring it is completed, once Completed RPS will sign off on the packet and give to Administrator of residential to be reviewed prior to uploading information into THERAP. All RPS's to be trained on this at Residential Meeting on 7/5/2016, documentation will be kept and sent.[Documentation of reviews shall be kept. (AS 7/11/16)] 07/01/2016 Implemented