Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237598 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.171On 12/20/23, the following expired food items were observed in the basement of the home at 10:40 AM: Navy beans with a best-buy date of 8/4/22; classic roast decaf coffee with a best-if-used by date of 3/3/23; Great Value pork seasoning mix with a best-if-used by date of 7/18/23; Premier Party cheesy tuna pasta and cheese sauce with a best-by date of 3/1/23; and Campbells vegetable soup with an expiration date of 9/2/22.Food shall be protected from contamination while being stored, prepared, transported and served. The food items which were found to be expired during the inspection on 12/20/23 were items which had been donated by family of the individuals and were not items generally used on the menus or in accordance with prescribed diets. The expired food items were immediately thrown out and all other items checked for expiration dates. 02/29/2024 Implemented
6400.181(e)(12)Individual #1's most recent assessment completed on 10/25/23, did not address or provide any 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. For this individual, the assessment has been reviewed again and recommendations included for areas of training, programming, and/or services for the upcoming year. 02/16/2024 Implemented
SIN-00217756 Renewal 01/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)The most recent dental examination for individual #1 was completed 6/16/21.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. At this point it is too late to bring the dental appointment into compliance. However, the issue was discovered prior to the survey and the earliest available appointment was scheduled. Individual #1 saw the dentist on 1/23/23. An appointment has already been scheduled for next year, 1/24/24 at 1PM. The records of all other individuals have been reviewed and any dental compliance issues were noted and appointments scheduled for the earliest available. 01/23/2023 Implemented
SIN-00199895 Renewal 02/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(1)Individual #1's assessment completed 1/4/2022 did not include functional strengths, needs, and preferences of the individual.The assessment must include the following information: Functional strengths, needs and preferences of the individual.For this individual, an updated list of her functional strengths, needs, and preferences has been included with her annual assessment. 03/04/2022 Implemented
6400.181(e)(2)Individual #1's assessment completed on 1/4/2022 did not include likes, dislikes, and interests of the individual.The assessment must include the following information: The likes, dislikes and interest of the individual. For this individual, an updated list of her likes, dislikes, and interests has been included with her annual assessment. 03/04/2022 Implemented
SIN-00185562 Renewal 03/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The evacuation time for the fire drill held 09/28/2020 was 8 minutes and 59 seconds. The home does not have extended evacuation time [Repeat violation 12/18/2019, et. al.] 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. During this particular fire drill, which was done as a sleep drill, one of the individuals was refusing to get out of bed and exit the residence. This individual also has ambulation difficulties which prevents her from walking quickly so by the time she did get out of bed and walk out of the house, the drill had far exceeded the allowed time. This individual uses a cane for ambulation during short distances and a wheelchair for long distances. For this particular individual, and any other individual who has ambulation concerns which may cause difficulty moving quickly and safely during a fire drill, staff have been directed to use a wheelchair to assist them to exit quickly. The fire drill procedure will be reviewed with the residential manager of the Arch Street residence, paying close attention to when the time is supposed to start and end during a drill. This will also be reviewed with the managers from the other sites. [Documentation of fire drill procedure review with residential manager shall be kept. The agency shall use assistive devices for ambulation (canes, walkers, wheelchairs) for individuals whom have a current written order from a physician for such devices. DPOC by HDKP, HSLS, on 5/4/2021]. 04/30/2021 Implemented
SIN-00168311 Renewal 12/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(6)Individual #1's assessment, dated 6/15/19, does not address the individual's ability to use or avoid poisonous materials. This section of the assessment was blank.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The assessment for this individual will be reviewed and the area concerning supervision around poisons will be completed with the level of supervision required by the individual. The assessments for all other individuals will be reviewed to ensure that they are completed thoroughly. A training will be completed with the staff by 1/31/2020 on how to properly complete an annual assessment. Once the assessments are complete the program specialist is to review the assessment for thoroughness and if any areas are incomplete, they¿re to be returned immediately to the staff to complete them correctly. The Program Specialist Supervisor will monitor 25% of the assessments monthly to ensure that they have been completed correctly and thoroughly. The program specialist and the Program Specialist Supervisor will be responsible for this plan of correction. 02/29/2020 Implemented
6400.181(e)(14)Individual #1's assessment, dated 6/15/19, does not address the individual's knowledge of water safety or ability to swim. This section of the assessment states "n/a."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. The assessment for this individual will be reviewed and the area concerning swimming will be completed with the level of supervision required by the individual. The assessments for all other individuals will be reviewed to ensure that they are completed thoroughly. A training will be completed with the staff by 1/31/2020 on how to properly complete an annual assessment. Once the assessments are complete the program specialist is to review the assessment for thoroughness and if any areas are incomplete, they¿re to be returned immediately to the staff to complete them correctly. The Program Specialist Supervisor will monitor 25% of the assessments monthly to ensure that they have been completed correctly and thoroughly. The program specialist and the Program Specialist Supervisor will be responsible for this plan of correction. 02/29/2020 Implemented
6400.166(b)Valproic Acid 250 mg/5 mL with the instructions "give 5 mL by mouth every 8 hours" prescribed to Individual #1 was not initialed as administered at 8:00 AM on 8/9/19, 8/13/19, 8/14/19, 8/15/19, 8/16/19, 8/23/19, and 8/27/19. Atorvastatin 40 mg with the instructions "take 1 tablet crushed in applesauce every morning" prescribed to Individual #1 was not initialed as administered at 8:00 AM on 10/31/19. [Repeat violation 1/7/19 et. al.]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff member responsible for administering the medication to this individual on the date of the missing documentation will be retrained on the proper medication administration procedure, including signing and initialing the medication administration record. This staff will then be monitored one time per month over the next three months to ensure that they are continuing to follow the correct medication administration procedure. In the future, any staff member who commits a medication error will be retrained and then monitored at least one time per month over the next three months. The medication coordinator, nursing staff, program specialists, and residential managers will complete the retraining and monitoring. The medication coordinator will be responsible for this corrective action and will review 25% of the medication administration records each month to ensure that the medication administration records are being documented correctly. 02/29/2020 Implemented
SIN-00148615 Renewal 01/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill conducted during sleeping hours was 3/7/18.A fire drill shall be held during sleeping hours at least every 6 months. The fire drill form has been revised to allow the person conducting the drill to mark if it was conducted while the individuals were awake or sleeping. A schedule has been developed for when the sleep drills will be conducted and this will be followed by all residential sites. All fire drills are to be completed by the 15th of each month, allowing for adequate time remaining in the month if a drill needs to be repeated. A copy of each fire drill will be sent to the main office and the administrative assistant will review the drill forms to determine that the schedule has been followed and the sleep drills have been conducted within the appropriate timeframe. If the administrative assistant finds that a sleep drill was not done by the 15th day of the scheduled month, the residential manager and the program director will be notified and the residential manager must conduct the sleep drill again. The administrative assistant will be responsible for monitoring this plan of correction and keeping a copy of all residential fire drills. [NOT ACCEPTABLE, unannounced fire drills must be completed throughout the each month, and not by the 15th of each month. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure unannounced fire drills are conducted monthly as required including during sleeping hours. Prior to conducting fire drills, the CEO or designee shall train all staff persons responsible for conducting fire drills of the requirements as per 6400.112(a)-(I) and the aforementioned policies and procedures to ensure fire drills are conducted and documented as required. Upon completion of all fire drills for at least one year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 2/4/19)] 02/22/2019 Implemented
6400.163(c)Individual #1's psychiatric medication reviews completed 1/29/18 and 8/6/18 did not include reason the medications were prescribed or the need continue the medications. 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.For this individual the psychiatrist will be contacted for a review of prescribed psychiatric medications and then complete in its entirety the psychiatric medication review form. For this and all individuals, the psychiatric medication review form has been revised to include the required components (medication, dose, reason for the medication, and the need to continue). The residential managers were trained on 1/9/19 on how to assist the medical professional in completing this form. The residential managers will review the form prior to leaving the appointment to ensure that all necessary information has been included on the psychiatric medication review form. The Waiver Supervisor will be responsible for overseeing this plan of correction and will keep copies of all psychiatric medication review forms in a binder and sign each form once she has reviewed it. 02/22/2019 Implemented
SIN-00107482 Renewal 01/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(5)The assessment completed 1/5/17 for Individual #1 did not include the ability to self-administer medications.The assessment must include the following information:  The individual's ability to self-administer medications.The Program Specialist added the required information to the assessment while the inspector was on-site. Each assessment will be reviewed by the Program Specialist to ensure that it is complete. The Program Specialist will utilize a listing of all required topics for assessment from the regulations to compare with a completed assessment. The review of all assessments will be conducted to ensure all are complete. The target date for the review is 2/28/2017. The Program Specialists will be trained by 2/28/2017. [At least quarterly for 1 year, the Director shall review a 25% sample of completed assessments to ensure individuals are assessed in all require areas. (AS 2/23/17)] 02/16/2017 Implemented
6400.181(e)(12)The assessment completed 1/5/17 for Individual #1 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. The Program Specialist added recommendations to the assessment regarding training, programming and services. Each new admission assessment as well as annual assessments will be reviewed by the Program Specialist and will include recommendations for the specific areas. All assessments will be reviewed to ensure the recommendations have been completed. The Acting Director will train the Program Specialists by 2/28/2017.[At least quarterly for 1 year, the Director shall review a 25% sample of completed assessments to ensure individuals are assessed in all require areas. (AS 2/23/17)] 02/16/2017 Implemented
SIN-00073437 Renewal 01/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1's record, admission date 11/5/14, did not include a gynecological examination. The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. A prior admission checklist has been developed and will be used for any new admissions (see attached). [Gynegological examination has been completed for Individual #1. (CHG 1/30/15)] 01/25/2015 Implemented
6400.213(3)Individual #1's most recent physical examination that was in his/her record was dated 9/12/13. Individual #1 had a physical examination on 9/15/14; however, documentation of the examination was not in the record.Each individual's record must include the following information: Physical examinations. A prior admission checklist has been developed and will be used for any new admissions (see attached). [Documentation of a timely physical examination has been obtained. The CEO or designee will check the content of all resident records to ensure they contain all required documentation including documentation of a timely physical examination within 30 days of receipt of the plan of correction. (CHG 1/30/15)] 01/25/2015 Implemented
SIN-00057495 Renewal 03/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(3)For the program specialist's job description form, the items regarding the ISP are missing. (b) The program specialist shall be responsible for the following: (3) Participating in the development of the ISP, ISP annual update and ISP revision. Program Specialists job description has been rewritten and program specialists have been trained. Quality Management Team will review job descriptions annually. 03/04/2014 Implemented
SIN-00128212 Renewal 01/23/2018 Compliant - Finalized
SIN-00107315 Unannounced Monitoring 11/03/2016 Compliant - Finalized
SIN-00104220 Unannounced Monitoring 11/03/2016 Compliant - Finalized