Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227942 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The evacuation plan doesn't indicate what the individual's responsibilities are during an evacuation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The evacuation plan was revised and updated on 7.21.2023 to include the individual's responsibilities during an emergency evacuation. (Attachment # 1) 08/31/2023 Implemented
6400.112(d)At the time of the inspection, the record contained a letter from the local fire chief. The content of the letter did not state a specific recommended extended evacuation time for this home. (A sample fire drill was conducted but not all of the individuals were present during this drill. Then the letter stated that the time it took them to evacuate during this trial drill was an "acceptable time frame" and says its "still under the recommended 8-min evacuation window with the above stated times" --this isn't a letter approving them of an extended evacuation time because it did not contain a specific recommended 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. The fire chief was contacted and revised the letter dated 7.5.2023 to indicate the exact time permissible for evacuation in minutes and seconds. The fire chief updated and revised the letter to include the extended evacuation time of 4 minutes and 30 seconds on 7.18.2023. (Attachment # 5) 08/01/2023 Implemented
SIN-00204771 Unannounced Monitoring 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(f)Witness statements by Staff # 5 and Staff # 10 indicate that they both separately and face to face reported concerns of Staff # 11 holding hands with Individual # 2 to the home supervisor, Staff # 12. Staff # 12 indicated via email that she has no recollection of those face to face meetings happening, however, she reported that "appropriate boundaries" were discussed with all staff at a team meeting on 01/10/22. Notes from that staff meeting show that Staff # 11 was not in attendance at that meeting. Additionally, Staff # 11 provided a witness statement indicating that at no time was he spoken to about holding hands with Individual #2 by any supervisor or manager within the agency. The home did not take immediate action to protect the health, safety and well being of Individual # 2 following notice of an alleged incident or suspected incident.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.On 5.17.2022, the supervisor and staff at this program were retrained on the Incident Management policy and responsibilities when witnessing, being informed of allegations, or suspecting abuse and or neglect. On 5.19.2022, managers, program specialists and supervisors were retrained trained on their responsibility as a mandated reporter i.e. recognize, respond, and elevate upon initial knowledge or notice of an incident, alleged incident, or suspected incident per the Incident Management reporting bulletin. The managers and supervisors were retrained on ensuring that they review the minutes of the monthly staff meetings with the program staff who were not in attendance. After review, program staff will sign the minutes indicating they have read and understood the information. On 5.20.2022 the supervisor and staff at this program were retrained on the importance of reporting incidents and their role and responsibilities as a mandated reporter to ensure the health and safety of the individual is protected by recognizing, responding, and elevating. Staff #12 and all staff at the program will be retrained on healthy relationship and boundaries by 5/30/2022. 05/30/2022 Implemented
SIN-00174765 Renewal 08/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation procedures did not include an emergency shelter location at the time of inspection.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. This was corrected during the inspection on 8/19/2020. The Residential Director retrained the managers and supervisors on this regulation to ensure the emergency evacuation procedures include the list of the emergency shelter location on 8/31/2020. The Supervisors will check and ensure that the emergency shelter location list is attached to the evacuation procedures as they review the monthly fire drill and documented on the monthly monitoring form, the Supervisor will complete the initial review for each home by 9/30/2020 to ensure the emergency shelter location list is attached. Managers will randomly review the emergency evacuation procedures every quarter to ensure compliance. The quarterly internal audit teams will review the emergency evacuation procedures to ensure the list of emergency shelter is attached during the audits. 09/30/2020 Implemented
SIN-00125779 Unannounced Monitoring 11/22/2017 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 11/14/17 Individual # 1 was dropped off at day program. He/she was described by day program staff as wet with urine all the way through his/her pants and sling. A little urine was on the sleeve of his/her shirt. The brief was so saturated that it fell apart in staff hands. His/her colostomy bag was leaking onto his/her skin. On 11/09/17 individual # 1 was dropped of at his/her day program and described as being soaked in stale urine from bra down to legs through multiple layers of clothing. On 03/07/17, Individual # 1 was dropped off at day program without shoes. Agency plan of correction to create an out the door checklist was not created or implemented to ensure individuals are properly prepared for their day. On 02/19/17, individual # 1 was found by staff at his/her residence to be soiled in night gown as ostemy bag had lost seal and BM was everywhere. Agency plan of correction to create a form for staff to fill out to ensure that they are checking on individuals throughout their shift not implemented to prevent neglect of care.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.The Senior Director of Operations and the Program Manager completed the administrative review for the incident occurring on 11/21/17. It was agreed to complete a two hour toileting/Ostomy schedule as well as an out the door checklist. The Program Manager implemented these procedures on 11/28/2017. (Attachment # 12). The House Manager will monitor review the Toileting/Ostomy and Morning Routine checklist (Attachment #5 and #6) twice a week and the Program Manager will also check weekly. All staff were trained on these procedures 12/22/2017 (Attachment # 7). On 11/29/17 and 12/20/17, new staff were trained by the Nurse on Individual #¿1 Ostomy care (Attachment # 16). Additionally, staff were trained on the definitions of abuse and neglect and were debriefed on both incidents occurring on 11/9/2017 and 11/14/2017. Moving forward when corrective actions are identified as part of a critical incident it will be the Program Managers responsibility to ensure implementation of the corrective action occurs. The Program Manager is responsible for providing the Residential Division Director with supporting documents verifying the action have taken place. (ie. Training log, email for changes to the ISP, copy of disciplinary action, etc.). See Copy of corrective action for critical incident that occurred on 12/11/17 (attachment #14 and 15). UCP will conduct quarterly program audits by external audit teams to verify compliance with this regulation as well as all 6400 regulations. Audit team members will review corrective actions listed in EIM prior to conducting the review to determine what actions were developed along with their effective dates. Any identified non-compliances will be reported to the Residential Director who will complete an appropriate POC within 10 days of discovery of non-compliances to ensure timely correction of issues. Program Managers will review and sign off on the training documentation regarding the plan of corrections with House Managers and staff to ensure completion and compliance. Program Managers and House managers will utilize monthly Program Monitoring Tool to track the implementation of the plans of correction (Attachment#8). 11/28/2017 Not Implemented
6400.43(b)(3)On 11/14/17 Individual # 1 was dropped off at day program soaked in urine with a colostomy bag leaking onto skin. On 11/09/17, Individual # 1 was dropped off at program soaked in stale urine from bra down to legs and soaked with urine through multiple layers of clothing. On 02/19/17 Individual # 1 was found by relief staff in the AM to be soaked in BM due to ostomy bag losing it's seal. A founding of neglect of care was determined by agency. A plan of correction for regular checks of individual by staff was not implemented. On 03/07/17, Individual # 1 was dropped off at day program without shoes. A founding of neglect of care was determined by agency. A plan of correction for the creation of an Out the Door Checklist was not implemented nor monitored by house manager.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. The Chief Executive Officer will review the importance of ensuring the safety and protection of the individuals with the Senior Director of Operations and Residential Director by 01/15/2018. The Senior Director of Operations will review this regulation with the Program Managers and House Managers by 2/15/18. After the administrative review was held for the 11/21/2017 incident, an out the door checklist was created by the Program Manager and implemented for Individual #1 (Attachment #6). This checklist along with the toileting/Ostomy checklist will be checked twice a week by the house manager and weekly by the Program Manager for 3 months. The House manager will then check the toileting/ostomy checklist weekly and the Program Manager will review the checklist monthly to ensure compliance. All staff were trained on this procedure on 12/22/2017 (Attachment # 7) UCP will conduct quarterly program audits by external audit teams to verify compliance with this regulation as well as all 6400 regulations. Any identified non-compliances will be reported to the Residential Director who will complete an appropriate POC within 10 days of discovery of non-compliances to ensure timely correction of issues. The Residential Director reviewed this citation along with the plan of correction with the Program Managers on 01/02/2018 (Attachment #13). 02/15/2018 Not Implemented
6400.46(a)Staff # 1 did not review Individual Support Plan (No signature on ISP review sheet provided) prior to working with Individual # 1.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Program Manager trained staff #1 as well as all other staff on individual #1¿s ¿ ISP on 12/22/2017 (Attachment #3). UCP will conduct quarterly program audits by external audit teams to verify compliance with this regulation as well as all 6400 regulations. Any identified non-compliances will be reported to the Residential Director who will complete an appropriate POC within 10 days of discovery of non-compliances to ensure timely correction of issues. House Manager will maintain a training binder to ensure that all training forms are kept up to date. ISP changes will be reviewed at each monthly house meeting by the House Manager and Program Manager. Sign in sheets for the meetings and trainings will be completed each time a training takes place. The House manager will utilize the monthly monitoring tool (attachment# 8) to ensure that all staff have signed the ISP review sheet. The Program Manager completed and will utilize the Program Specialist tool to ensure that all staff have signed the ISP ( Attachment #4). The Residential Director trained Program Managers on this citation as well as the Plan of Correction on 01/02/2018 (attachment # 13). 01/02/2018 Not Implemented
6400.144Individual # 1 is recommended to have his/her ostomy pouch burped every two hours as per nurse orders for ostomy care and which staff were trained on 08/27/17-09/21/17. Daily logs indicate that ostomy bag was not burped every two hours from 09/20/17-10/28/17.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. The Program Manager created a toileting/Ostomy Schedule to be completed daily effective 11/28/2017 and guidelines (Attachment # 12). This schedule includes checking of the ostomy bag every two hours for issues as well as burping and changing every 2-3 days. The House Manager will review this schedule 2 times a week to ensure its implementation for 3 months then weekly. The Program Manager will also review the schedule weekly for 3 months then monthly to ensure implementation. All Staff received training and education on this schedule as well as individual #1 ISP on 12/22/2017. (Attachment #5 and #7) The Residential Director reviewed the importance of ensuring that all recommendations made by health services are followed as written with the Program Managers on 1/2/2018. Beginning immediately, UCP will be conducting quarterly program audits by external audit teams to verify compliance with all 6400 regulations. Any identified non-compliances will be reported to the Residential Director who will complete an appropriate POC within 10 days of discovery of non-compliances to ensure timely correction of issues. 01/02/2018 Not Implemented
6400.213(11)Individual # 1's Individual Support Plan last updated 11/08/17 does not include information regarding the need for staff to check and change the ostomy bag every two hours as directed by Registered Nurse developed Ostomy Care protocol. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Program Manager for individual #1 contacted the Supports Coordinator on 12/20/17 to request an update to the ISP to include that Brooke¿s colostomy bag must be checked every two hours (Attachment#1). The ISP was corrected (Attachment#2). An additional email was sent on 12/26/17 to the SC for an update to include the burping of the Ostomy bag every two hours (Attachment#11). The Ostomy Care protocol calls for changing the bag ever 2-3 days (Attachment# 9). On 1/2/18 the Program Manager reviewed individual #1¿s ISP utilizing the ISP Checklist (Attachment #10). Residential Director retrained Program Managers on the importance of this regulation, as well as ensuring that all recommendations made by healthcare practitioners are communicated to the SC (via email) and reflected on the ISP on 1/2/18 (Attachment #13). The Residential Director will retrain and review this regulation with the House Managers by 1/31/18. The Program Manager will utilize the ISP checklist (Attachment # 10) when reviewing ISP¿s to ensure all information contained in the ISP is accurate and updated. Beginning immediately, UCP will be conducting quarterly program audits by external audit teams to verify compliance with all 6400 regulations. Any identified non-compliances will be reported to the Residential Director who will complete an appropriate POC within 10 days of discovery of non-compliances to ensure timely correction of issues. 01/31/2018 Not Implemented
SIN-00097312 Renewal 06/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 had a $15 Subway gift card and a $15 McDonalds gift card. Both gift cards were not logged or tracked on the financial log.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. Regulation 6400.22(d)(1) was reviewed with the Program Manager and House Managers on7/19/2016 by the Assistant Director (Attachment #50) Gift card ledgers are now being documented for any cards or gift certificates the individual may have. Gift card ledgers for individual #1 are attached (Attachment #51). Program Manager will do monthly reviews of all financial transactions. 07/19/2016 Implemented
6400.44(b)(1)Individual #1's 1/15/16 assessment was completed by Staff #1. Staff #1 is a house manager, not a program specialist.The program specialist shall be responsible for the following: Coordinating and completing assessments. Regulation 6400.(b)(1) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #49). Individual #1 was re-assessed on 7/15/2016 by the Program Manager (Program Specialist) (Attachment #15). The Program Manager will ensure that the assessments are completed by himself with input from the House Manager and DSP's involved. 07/19/2016 Implemented
6400.46(e)REPEATED VIOLATION - 2/17/15 Staff #2 was hired on 5/26/16 and was not trained in intellectual and developmental disabilities, normalization, and program planning.Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Regulation 6400.46(e) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #48). The Program Manager will ensure that all newly hired staff attend the full 3 day new hire orientation or complete the entire on-line training to include intellectual and developmental disabilities, normalization and program planning. The Assistant Director will review all training documentation with the first 30 days of employment to ensure compliance. The training sign off for staff #2 are included (Attachment #49). 07/19/2016 Implemented
6400.112(c)REPEATED VIOLATION - 2/17/15 The fire drill logs from 11/16/15 to 6/2/16 did not include whether or not the smoke detectors were operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Regulation 6400.112(c) was reviewed with the Program Manager and House Managers by the Assistant Director on 7/19/2016 (Attachment #46). Fire Drill logs for July and August were completed correctly to include whether or not the smoke detectors were operative (Attachment #47). The Program Manager will monitor fire drill logs monthly to ensure compliance. The Assistant Director will review a random sampling of the fire drill logs throughout the year to ensure on-going compliance. 07/19/2016 Implemented
6400.144Individual #1 was prescribed 50mg of Zoloft to be administered at 8am. On 3/29/16, a Zoloft pill was found in Individual #1's dress. The pharmacist authorized an hour late administration of Zoloft. The medication was administered at 9:45am. On 8/16/15, Lactulose was not available at the home for Individual #1 to receive his/her 8AM dose. Individual #2 required a hospital bed. According to staff in the home, the bed has been broken for at least a month. There was a sign hung on the wall next to the bed that stated the bed shouldn't be plugged in because it could overheat and be a fire hazard. On 8/21/15, Individual #1's physician recommended position changes due to a decubitus ulcer on Individual #1's buttocks. Position changes have not occurred.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. Regulation 6400.144 was reviewed with the Program Manager and the House Managers on 7/19/2016 by the Assistant Director (Attachment #45). The Program Manager will ensure that all health services that are planned or prescribed for the individual shall be arranged for and provided. The Assistant Director will review a random sampling of planned/prescribed health services to ensure they are arranged and provided for to ensure on-going compliance. 07/19/2016 Implemented
6400.145(1)The emergency medical plan did not include the location of the hospital to be used in an emergency.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. Regulation 6400.145(1) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #43). The emergency medical plan was updated to include the hospital to be used in an emergency (Attachment #44). The CHS Program Manager is responsible for ensuring the plan is posted in the home and will monitor monthly to ensure on-going compliance. 07/19/2016 Implemented
6400.162(a)REPEATED VIOLATION - 2/17/15 Individual #1's Tylenol had two different medication labels. One label indicated the medication should be given every 6 hours for pain for up to 10 days. The other label indicated Tylenol should be administered every 4 hours. The medication label for Miralax stated to give every 2-3 days and the medication administration record indicated to administer Miralax every 2 days.The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Regulation 6400.162(a) was reviewed with the Program Manager and House Manager on 7/19/2016 by the Assistant Director (Attachment #40). House Manager had the doctor discontinue the prescription for Tylenol every 6 hours for pain for up to 10 days, now it is just the single prescription of Tylenol every 4 hours (Attachment #41). The MAR for the Miralax was updated by the pharmacy to match the prescription to give every 2-3 days (Attachment #42). 07/19/2016 Implemented
6400.163(c)Individual #1 had psychiatric medication reviews on 7/22/15, 11/4/15, 2/10/16, and 6/1/16. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Regulation 6400.163(c) was reviewed with the Program Manager and the House Managers on 7/12/2016 by the Assistant Director (Attachment #38). The appointments for individual #1 were made by the doctor's office in the timeframes that the doctor felt was necessary (Attachment #39) The Program Manager and House Manager will ensure that the appointments are every 3 months as long as the individual continues to take psychiatric medication. 07/12/2016 Implemented
6400.164(a)Hydrocodone 325mg was administered to Individual #1 on 5/23/16. The medication log did not include a time of administration. The administration time for Zoloft was not listed on the medication logs from January of 2015 to May of 2016. The administration time for Tylenol 325mg was not logged on the medication administration log from January of 2015 through May of 2016. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Regulation 6400.164(a) was reviewed with the Program Manager and the House Managers on 7/12/2016 by the Assistant Director (Attachment #36). The pre-printed MAR's were updated to include the administration time for Zoloft and Tylenol 325mg (Attachment #37). The Program Manager will do monitor MAR's monthly to ensure they are completed correctly. The Assistant Director will review a random sampling of MAR's throughout the year to ensure on-going compliance. 07/12/2016 Implemented
6400.181(e)(7)Individual #1's 1/15/16 assessment indicated he/she could move away from heat sources. Other sections of the assessment indicate he/she is not able to move limbs, was unable to walk, and was wheelchair bound. Individual #1 was not adequately assessed on his/her ability to sense and move away from heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Regulation 6400.181(7) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment # 12). Individual #1 was re-assessed on 7/15/2016 by the Program Manager and the assessment indicates she is able to sense, but not move away from heat sources due to mobility issues (Attachment #13) 07/15/2016 Implemented
6400.181(e)(12)Individual #1's 1/15/16 assessment did not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Regulation 6400.181(12) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #14). Individual #1 was re-assessed on 7/15/2016 by the Program Manager, recommendations for specific areas for training, programming and services has been updated (Attachment #15) 07/15/2016 Implemented
6400.181(e)(13)(i)Individual #1's 1/15/16 assessment did not include progress over the past year in health. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (i) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #16) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in health has been updated as well (Attachment #17). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(ii)Individual #1's 1/15/16 assessment did not include progress over the past year in motor and communication skills. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (ii) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #18) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in motor and communication skills has been updated as well (Attachment #19). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(iii)Individual #1's 1/15/16 assessment did not include progress over the past year in residential living. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (ii) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #20) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in residential living has been updated as well (Attachment #21). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(iv)Individual #1's 1/15/16 assessment did not include progress over the past year in personal adjustment. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (iv) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #22) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in personal adjustment has been updated as well (Attachment #23). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(v)Individual #1's 1/15/16 assessment did not include progress over the past year in socialization. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (v) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #24) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in socialization has been updated as well (Attachment #25). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(vi)Individual #1's 1/15/16 assessment did not include progress over the past year in recreation. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (vi) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #26) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in recreation has been updated as well (Attachment #27). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(vii)Individual #1's 1/15/16 assessment did not include progress over the past year in financial independence. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (vi) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #28) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in financial independence has been updated as well (Attachment #29). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(viii)Individual #1's 1/15/16 assessment did not include progress over the past year in managing personal property. This section was verbatim the 1/9/15 assessment.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. Regulation 6400.181(13) (viii) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #30) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in managing personal property has been updated as well (Attachment #31). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(e)(13)(ix)Individual #1's 1/15/16 assessment did not include progress over the past year in community integration. This section was verbatim the 1/9/15 assessment.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.Regulation 6400.181(13) (ix) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #32) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in community integration has been updated as well (Attachment #33). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. 07/15/2016 Implemented
6400.181(f)Individual #1's 1/15/16 assessment was not sent to the day program.(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). Regulation 6400.181(f) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #34). The Program Manager will ensure that the assessment is sent out to all team members 30 calendar days prior to the ISP, the re-assessment for individual #1 was mailed to all team members, including day program (Attachment #35). 07/15/2016 Implemented
6400.183(5)Individual #1's Individual Support Plan (ISP) did not include the social, emotional, environmental needs 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. Regulation 6400.183(5) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #10). Individual #1's SEEN plan was emailed to the SC to be included in the next ISP update (Attachment #11) 09/01/2016 Implemented
6400.186(a)The program specialist did not write the 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan (ISP) reviews. 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. Regulation 6400.186(a) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #1). The CHS Program Manager (Program Specialist) will be responsible for completing all portions of the ISP review. The Assistant Director will review a random sampling of ISP reviews throughout the year to ensure on-going compliance. 07/12/2016 Implemented
6400.186(b)REPEATED VIOLATION - 2/17/15 Individual #1 did not date the 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan Review.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Regulation 6400.186(b) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #2). Individual #1 did attend her ISP review meetings and signed the sign off sheet but did not date. The Program Manager had the individual date the sign off sheets (Attachment #3). The CHS Program Manager will ensure that all team members date the ISP reviews and the Assistant Director will review a random sampling of ISP reviews throughout the year to ensure on-going compliance. 07/12/2016 Implemented
6400.186(c)(1)The 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan reviews did not include participation and progress toward the outcomes of daily living skills and telling time.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Regulation 6400.186(c)(1) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #4). The 7/27/16 quarterly review for individual 1 was revised to clearly show participation and progress toward the outcomes of daily living skills and telling time (Attachment #5). CHS Program Manager will ensure that all outcomes are noted on the ISP reviews. The Assistant Director will review a random sampling of ISP reviews throughout the year to ensure on-going compliance. 07/27/2016 Implemented
6400.186(c)(2)The 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan reviews did not review the dental plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Regulation 6400.186(c)(2) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #6). The Program Manager will ensure that each section of the ISP specific to the residential home is included in the ISP review. The ISP review dated 7/27/2016 includes a review of Individual #1's dental plan (Attachment #5) 07/27/2016 Implemented
6400.186(d)Individual #1's ISP reviews were not sent to the day program.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. Regulation 6400.186(d) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #7). The ISP review for individual #1 dated 7/27/2016 was sent to all team members, including day program (Attachment #8) 07/27/2016 Implemented
6400.186(e)An option to decline the Individual Support Plan Reviews was not sent to Individual #1's power of attorney. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Regulation 6400.186(e) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #9). The option to decline was added to the cover letter that is sent to all team members for each ISP review and annual assessment that is written by the Program Manager (Attachment 8a). The Assistant Director will review a random sampling of ISP reviews and correspondence throughout the year to ensure on-going compliance. 07/27/2016 Implemented
SIN-00077962 Renewal 02/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(i)The fire drill log for 4/10/2014 did not inlcude which alarm was set off.  A fire alarm or smoke detector shall be set off during each fire drill.The regulation was reviewed with the Program Manager and House Managers on 4/29/2015 by the Assistant Director (Attachment #1). Fire drill records for this house since licensing are included (Attachment 2a-2j). The Program Manager will also review fire drill records at each house and sign that the record is complete. 04/29/2015 Implemented
SIN-00046480 Renewal 02/06/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(iv)The assessment for Individual #1 did not include progress and growth in personal adjustment. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (iv) Personal adjustment. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/6/2013 Regulation 6400.181(13)(iv)was reviewed with Program Manager and House Managers on 3/12/2013 (Attachment #1) It is the responsibility of the Program Manager to ensure compliance with all 6400 regulations. The personal adjustment section of the assessment has been completed for individual #1 (Attachment #2). 03/12/2013 Implemented
6400.181(f)The assessment for Individual #1 was not sent to plan 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). PARTAILLY IMPLEMENTED, ADEQUATE PROGRESS. JW 5/6/2013 Regulation 6400.181(f) was reviewed with Program Manager and House Managers on 3/12/13 (Attachment #3). It is the responsibility of the Program Manager to ensure compliance with all 6400 regulations. A sample letter (Attachment #4) that will be mailed along with the assessment to all team members is included. The next assessment is due 4/15/2013, will forward that assessment letter when completed. 03/12/2013 Implemented
6400.187The ISP reviews for Individual #1 were not sent to plan team members.A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/12/2013 Regulation 6400.187 was reviewed with the Program Manager and House Managers on 3/12/13 (Attachment #5). It is the responsibility of the Program Manager to ensure compliance with all 6400 regulations. A quarterly review letter that was mailed 3/8/2013 is attached (Attachment #6). This is the only quarterly report that has been completed since the licensing inspection. 03/12/2013 Implemented
SIN-00190374 Renewal 08/03/2021 Compliant - Finalized
SIN-00156524 Renewal 06/24/2019 Compliant - Finalized
SIN-00136544 Unannounced Monitoring 06/12/2018 Compliant - Finalized
SIN-00114080 Renewal 06/28/2017 Compliant - Finalized