Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215530 Unannounced Monitoring 10/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)Hope Enterprises, Inc.'s Restrictive Procedures Policy and Procedure states that a PRN medication is permitted if the physician documents a very clear description of the explicit psychiatric symptoms of the mental illness. Individual #1's PRN Haloperidol increased from 2mg tab to 5mg tab on 9/22/2016. The prescribing physician wrote the reason for prescribing the medication to treat a psychiatric illness is agitation. "Agitation" is not a clear description of the explicit psychiatric symptoms related to the individual's mental illness.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Disclaimer: Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. Licensing Representative indicated that HOPE did not have a clear description of the explicit psychiatric symptoms for the use of Individual #1s PRN Haloperidol 5mg tab on 9/22/2016. On 9/22/2016, Individual #1 saw his prescribing physician while the PRN Haloperidol was increased from 2.5mg to 5mg. During the Licensing Representatives Investigation, Residential Regional Manager provided individual #1¿s original psychiatric appointment form dated 9/22/2016 with the physician prescription which indicated ¿Haldol 5mg every 8 hours PRN for agitation. On the same appointment form, Agitation was defined as property destruction, self-abuse, verbal threats". On 11/30/2022, Individual #1s prescribing physician signed a PRN MEDICATION USE FOR PSYCHATRIC BULLETIN #00-02-09 Form with instructions on when to administer the PRN. Program Specialist will review 100% of all individuals who are prescribed a PRN for psychiatric treatment to ensure there is a very clear description of the explicit psychiatric symptoms of the mental illness. Any findings of non-compliances, the Program Specialist will consult with the prescribing physician for further clarification during the next scheduled psychiatric visit. Documentation will be maintained and available for on-site review. On 12/7/2022, Residential Regional Manager reviewed the PRN MEDICATION USE FOR PSYCHIATRIC TREATMENT BULLETIN #00-02-09 Form to ensure all regulatory components were met. On 12/7/2022, The Policy Committee reviewed and revised Policy #6.2 Restrictive Procedure to ensure it is compliant with Bulletin #00-02-09 regarding PRO RE NATA MEDICATION USAGE FOR PSYCHIATRIC TREATMENT. The PRN MEDICATION USE FOR PSYCHIATRIC TREATMENT BULLETIN #00-02-09 Form will be completed by the Program Specialist based upon the prescribing physician¿s orders. Program Specialist will request the prescribing physician to sign the PRN MEDICATION USE FOR PSYCHIATRIC TREATMENT BULLETIN # 00-02-09 Form prior to administering the medication prescribed. The PRN MEDICATION USE FOR PSYCHIATRIC TREATMENT BULLETIN # 00-02-09 Form will become part of the individual¿s permanent record and revised when the medication changes. The Corporate Compliance Department will retrain Program Specialists on Regulation 6400.43(b)(1) and agency policies to ensure they maintain compliance with implementing agency policy and procedures. Program Specialist will be trained on the revision to Policy #6.2 to ensure they are compliant with the changes to the PRN process. Documentation will be maintained and available for on-site review. 03/31/2023 Implemented
6400.182(c)Individual #1's assessment dated 8/2/22 addresses the home being equipped with alarms on the exterior doors due to his history of elopement. The assessment has not been updated to reflect that the Individual currently has an alarm on their bedroom door.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Disclaimer: Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. On 12/6/2022, Program Specialist updated Individual #1s assessment to include the home being equipped with an alarm on his bedroom door to alert staff when individual #1 has exited the bedroom. Individual #1¿s assessment will be updated upon returning to residential services based upon current needs from hospital discharge instructions. Program Specialist will review 100% of all individual adaptive equipment lists to ensure that the individuals specific equipment used will be included within the assessment. Any findings of non-compliances, the Program Specialist will revise the individuals assessment. Documentation will be maintained and available for on-site review. The Corporate Compliance Department will retrain Program Specialists on Regulation 6400.182(c) and agency policies to ensure they update individual assessments as individual needs change. Program Specialist will continue to complete monthly home visits and review individual records monthly to ensure their assessments are kept current based upon their current needs. Documentation will be maintained and available for on-site review. 01/31/2023 Implemented
SIN-00173255 Unannounced Monitoring 06/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Individual #1 did not have a locking mechanism on the their bedroom door for privacy.An individual has the right to lock the individual's bedroom door.Hope will work with team to assess the situation. If the individual would like a lock then one will be provided. Hope will assess all individuals in their care to assure that individuals rights are provided. Hope will continue to follow the plan of correction submitted. 06/12/2020 Implemented
SIN-00172849 Unannounced Monitoring 04/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71At the time of inspection, there was no emergency phone numbers on the back of the cordless phone in the living room that was located on the TV stand. The sticker was replaced before the end of the inspection.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Hope will continue to follow the plan of correction submitted and assure that this issue as been corrected using those guidelines. 04/17/2020 Implemented
SIN-00160018 Unannounced Monitoring 07/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)All poisons, except personal hygiene items, are locked for safety in the home. The kitchen is small,l and cleaning supplies, etc., are kept locked under the kitchen sink. Directly across the kitchen sink hanging on the wall, about 4 feet from the ground, are all the keys to unlock the cabinets that contain all the poisonous materials. From what I learned, these keys have ALWAYS been located there. These keys should have never been accessible to the individual(s). The poisons are locked, yes; however, they are still made accessible to the individual(s) because the keys are available to anyone.Poisonous materials shall be kept locked or made inaccessible to individuals. Hope will correct this issue. It will then review this violation for every home in the agency. Hope will add a home inspection checklist monthly and then upper level management will sign off on it. Staff will be trained on the this violation and how it can lead to health and safety issues. 08/30/2019 Implemented
SIN-00138938 Unannounced Monitoring 07/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The baseboard in the upstairs hall was missing.Floors, walls, ceilings and other surfaces shall be in good repair. 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. 08/31/2018 Implemented
6400.110(a)The basement smoke detector was not operable at the time of the inspection. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. 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. 08/31/2018 Implemented
SIN-00137368 Unannounced Monitoring 06/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Hygiene products for the individuals in the home were unlocked. They contained the phrase contact poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. Staff shall be trained on this regulation and how to identify it and implement properly throughout the home. An ISP review and assessment review will be conducted for all the individuals to determine if there are certain poisons they can handle appropriately without having to lock them. Home will use a sign off sheet that home supervisor conducted a weekly inspection of the home for this issue. The home supervisor's direct supervisor will then conduct a walkthrough every month to show compliance. This will documented on the form created by hope. 08/01/2018 Implemented
6400.110(a)The basement fire alarm was not operable at the time of the inspection. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Staff shall be trained on this regulation and how to identify it and implement properly throughout the home. The Home will use a sign off sheet that home supervisor conducted a weekly inspection of the home for this issue. The home supervisor's direct supervisor will then conduct a walkthrough every month to show compliance. This will documented on the form created by hope. 08/01/2018 Implemented
SIN-00117296 Unannounced Monitoring 07/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Repeat 2/23/17: The recliner located in Individual #1's bedroom had fabric coming off of the head rest area on the recliner.Floors, walls, ceilings and other surfaces shall be in good repair. Individual #1 chose to replace his recliner in his bedroom (see Elmira Attachment #1). Residential Director checked all recliners in good repair in each home. Administrative Coordinator ensured all recliners are in good repair in each home (see Elwood Attachment #2). Vice President of Residential Services trained Assistant Vice President, Administrative Coordinator, Residential Coordinator, Residential Directors and Habilitation Managers on Regulation 6400.67(a) (See Elwood Attachment #3). Residential Directors and Habilitation Managers will train current Habilitation staff on Regulation 6400.67(a) by 8/18/2017 (Elwood Attachment #4). 08/18/2017 Implemented
SIN-00071784 Renewal 11/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling tiles in the kitchen were stained, one had a tear in the tile, and the metal frames surrounding the tiles were rusted. The oven hood in the kitchen was rusted and covered in grease under the hood. There were rubber bands holding two cabinents under the sink shut but the cabinents still do not shut properly. Floors, walls, ceilings and other surfaces shall be in good repair. Ceiling tile and metal frames will be replaced. The oven hood will be replaced. The cabinets under the sink will be repaired in order to properly close, Attachment #2. In conjunction with the LCN Region Directed Corrective Action Plan to assure continued compliance, Hope has hired a Residential Support Specialist that will oversee the maintenance department. The RSS will inspect each community home once a month, using a checklist of all physical site regulations to assure the homes are properly maintained. The checklist will be reviewed by the Residential Coordinator each month. The RSS will assign maintenance issues to be completed by maintenance staff within two weeks. Directors will also visit another Director's home once a month and will complete a physical site checklist. All issues will be referred to the RSS for assignment. CMSU Region currently has a process for repairs in place and will maintain the current practice. 12/24/2014 Implemented
6400.103There was no written emergency evacuation procedure for this location. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. An emergency evacuation procedure was written for 1113 Elmira which includes individual and staff responsibilities, means of transportation, and emergency shelter location. See attachment #1. Residential staff will review the evacuation plan with the program director at the bi-weekly staff meeting. the emergency evacuation procedure will be maintained in the control log in each home. The emergency evacuation procedure will be updated as changes occur and annually during fire safety by the program director and submitted to RSS for review. CMSU Region currently has an emergency evacuation procedure process in place and will maintain the current practice. 02/28/2015 Implemented
6400.112(c)The fire drill record for this location stated that on 7/30/14 a fire drill occurred between 8pm and 10pm, no specific time logged. 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. A fire drill was conducted on 11/15/14 indicating the specific time of the drill, Attachment #3. In conjunction with the LCN Directed Corrective Action Plan to assure continued compliance, the Director of the home will review fire drills for thoroughness and compliance. The Directors will implement a checklist for monthly oversight for each of their homes. This checklist will be reviewed monthly by the Residential Coordinators to assure compliance and thoroughness. Residential staff will be trained on the responsibilities of conducting monthly fire drills and completion of the fire drill form. Residential staff will be trained by the Residential Director at the bi-weekly staff meeting. CMSU Region currently has a process for documentation of fire drills and will maintain the current practice. 02/28/2015 Implemented
SIN-00186391 Unannounced Monitoring 04/13/2021 Compliant - Finalized
SIN-00177566 Unannounced Monitoring 10/08/2020 Compliant - Finalized
SIN-00170363 Unannounced Monitoring 01/16/2020 Compliant - Finalized
SIN-00160027 Unannounced Monitoring 07/15/2019 Compliant - Finalized