Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00187421 Unannounced Monitoring 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)At the time of the inspection, Individual #1's ISP that is being kept in the home is dated 2/5/2021. The most recent updated ISP is dated 4/28/2021, per HCSIS.The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home.DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: Hope Enterprises immediately updated Individual #1s record to include the most current copy of her ISP on 5/14/2021. 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: Hope Enterprises reviewed 100% of the individuals records to ensure it included the most recent copy of their ISP by 5/17/2021. Hope Enterprises immediately updated any identified ISP that was not current with the most current ISP. Documentation will be maintained and available for on-site review. 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: Hope Enterprises will retrain all program specialists on the requirements of having the most current copy of the ISP within the individuals records to ensure immediate access of crucial information in the event that an individual is missing or experiences a medical or behavioral emergency requiring immediate treatment. Hope Enterprises will update policies to include specific requirements as mentioned above. 05/31/2021 Implemented
SIN-00155927 Unannounced Monitoring 05/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bedroom has 5 inches fluid residue stain on the wall opposite side of his bed. Also, there is 12 inches of cobwebs on the ceiling near the foot of the bed.Clean and sanitary conditions shall be maintained in the home. Hope will continue to implement the plan of correction submitted prior to this inspection. 06/05/2019 Implemented
SIN-00143585 Unannounced Monitoring 10/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light in the attic was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. 11/30/2018 Implemented
6400.80(b)A broken chair and a replacement dining table/chairs were stored on the back porch of the home since August 2018. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. 11/30/2018 Implemented
6400.110(e)The attic smoke detector was not checked monthly, as reported by a direct care staff.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. 11/30/2018 Implemented
SIN-00228378 Renewal 08/01/2023 Compliant - Finalized
SIN-00186248 Unannounced Monitoring 04/13/2021 Compliant - Finalized
SIN-00173250 Unannounced Monitoring 06/03/2020 Compliant - Finalized
SIN-00172414 Unannounced Monitoring 03/10/2020 Compliant - Finalized
SIN-00168066 Unannounced Monitoring 12/06/2019 Compliant - Finalized
SIN-00161775 Unannounced Monitoring 08/27/2019 Compliant - Finalized