Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220097 Renewal 02/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)There is not a screen in Individual #1's bedroom window.Windows, including windows in doors, shall be securely screened when windows or doors are open. Replacement screens were ordered on 3/7/2023 from Byler's Superior Windows. (Attachment #4). The new screens will not be available for pickup until Monday, March 13, 2023. Once picked up, Touch-Stone maintenance will install the new screen. Program Specialist, conducted a site checklist on 3/8/2023 (Attachment #5) and verified that all screens with holes were repaired and that screens missing were ordered. 03/13/2023 Implemented
6400.72(b)There are two, two-inch holes in the screen in Individual #2's bedroom window. Screens, windows and doors shall be in good repair. Replacement screens were ordered on 3/7/2023 from Byler's Superior Windows. (Attachment #4). The new screens will not be available for pickup until Monday, March 13, 2023. Once picked up, Touch-Stone maintenance will install the new screen. Touch-Stone Solutions maintenance used screen repair tape to cover holes on 3/7/2023 as an immediate fix until new screens arrive. (Attachment 6). Program Specialist,conducted a site checklist on 3/8/2023 (Attachment #5) and verified that all screens with holes were repaired and that screens missing were ordered. 03/08/2023 Implemented
6400.214(b)Individual #1's most recent Individual Plan and dental examination were not present at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Program Specialist , immediately corrected this on 3/3/2023. The most recent ISP and dental examination were added to the client book that is kept at the home in the staff office. On 3/8/2023, Program Specialist Shelly Spanopoulos conducted an on-site inspection on 3/8/2023. She verified that the documentation was present in the home (Attachment #5). 03/08/2023 Implemented
SIN-00126913 Renewal 12/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)The smoke detector in the living room was 18 feet from the door of the bedroom off the kitchen on the first floor of the home.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. On 12/28/2017 the smoke alarm at Walnut Street was moved to the kitchen door area between the dining room and the individual's rooms on the first floor. This placement ensures that the smoke detector is no more than 15 feet from bedrooms on the first floor of the home. A site inspection was conducted on 12/28/2017 to ensure that the smoke detector was placed in the correct location in compliance with regulations and that it was operable (Attachment # 6). The Program Specialist photographed the smoke detector to assure that it had been relocated as requested (Attachment #7). At ongoing monthly site visits, the Program Specialist will ensure that the smoke detectors are no more than 15 feet from bedrooms. If new smoke detectors are placed in any homes in the future, documentation will be kept showing that measurements were obtained. Site visit logs will be provided to the Executive Director or designee for review within three business days of monthly site visits. 12/28/2017 Implemented
6400.164(a)Penicillin VK 500mg tablet take 1 tablet by mouth 4 times daily prescribed for Individual #1 was in the Individual #1's medication box and was not listed on the December medication administration record for Individual #1. Amox-clav 75-125mg tablet take 1 tablet by mouth 2 times daily prescribed for Individual #1 from 12/10/17 8:00PM to 12/21/17 8:00AM remained on the Individual #1's December 2017 medication administration record on 12/21/17 at 12:15PM.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. The medication, Penicillin VK 500 mg was immediately removed from the medication box and discontinued as instructed. This medication was discontinued by the doctor on the date it was prescribed (Attachment #3 & #4). The medication Amox-clav 75mg was discontinued (Attachment #4) on 12/21/2017. The Program Specialist conducted a site visit to ensure that the medication log was correct with medications in the med box on 12/26/2017 (Attachment #5). Program Specialist will check the Medication logs within seventy-two hours of a medication change to ensure accuracy and document this on a site visit form. Site visit forms are turned into the Executive Director or designee within 3 businesss days for review. Program Specialist will document that the medication log and box are checked for accuracy at monthly site visits. Staff involved in these medication errors will obtain training provided by the HCQU (T.R.A.M.P. Out Med Errors) on February 6, 2018 or October 9, 2018. 12/26/2017 Implemented
SIN-00087557 Renewal 12/11/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Violation withdrawn 12/31/15 The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. per conversation with Amy Scharpf violation has been withdrawn 12/31/2015 Implemented
SIN-00068568 Renewal 12/17/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74There are three steps leading from the driveway into the mudroom; the bottom step had a nonskid surface that was peeling in three places. The top step had a nonskid surface that was torn and lifting up off the step approximately 4 inches. Repeat violation-11/4/14 et al.Interior stairs and outside steps shall have a nonskid surface. Non skid tape has been placed on the steps leading to the side door by Direct Care Staff. From now on, Program Specialists will ensure that all steps in the residence have a non skid surface. Habilitation Specialist and/or Program Specialist will check the status of all steps during the course of their monthly site visits. Direct Care staff will be trained to notify their respective Program Specialist immediately should the non skid tape become loose from any stairs in the home so that it can be replaced immediately. Program Coordinator will train Program Specialists on ensuring that all interior and exterior stairs have a non skid surface. 12/22/2014 Implemented
6400.77(c)A first aid manual could not be located. A first aid manual shall be kept with the first aid kit.Program Specialist has placed a first aid manual in the first aid kit. Program Specialists will train the direct care staff on what items are required to be in the first aid kit and the proper procedure for when items are missing from the first aid kit, which is to notify Program Specialist immediately so that a replacement may be purchased and placed in the kit. In addition, this item has been added to the monthly site inspection list to ensure future compliance for all items being present in the first aid kit. 12/22/2014 Implemented
6400.112(e)Fire drill records were submitted for review for the period of 9/1/13 through 11/12/14. The fire drills during sleeping hours were conducted on 4/15/14 and 7/11/14; there were no fire drills during sleeping hours conducted between 9/1/13 through 4/15/14.A fire drill shall be held during sleeping hours at least every 6 months. ): From this point forward, agency protocol will be that sleep time fire drills be performed on a quarterly basis to ensure that we not only meet but exceed the guidelines set by the regulations. Program Coordinator will train Program Specialists on this protocol. In addition Overnight drills will be added to the internal tracking system to better assist with ensuring compliance. 12/22/2014 Implemented
SIN-00049695 Renewal 11/14/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Individual #1's record did not include the admission date, the next of kin, and a current, dated photograph. Each individual's record must include the following information: (1) Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Upon review of the Personal Data sheet for Individual #1, the admission date was listed. Program Specialist has updated the Personal Data Sheet to include the next of kin. Current photograph in the file has been dated accordingly by the Program Specialist. The Program Coordinator will train the Program Specialists on proper procedure for completing the Personal Data sheet and dating the photograph in the file. In addition, Management Staff completing internal compliance audits will verify that Personal Data sheets have been accurately completed as part of their audit and will notify Program Coordinator of any discrepancies so that they can be corrected immediately. 11/27/2013 Implemented
6400.213(9)Individual #1's record did not include a copy of the current ISP. The ISP in Individual #1's record has an annual review update date of 5/19/13.(9) A copy of the current ISP. Program Specialist has placed a copy of the current ISP in the individual¿s file. From this point forward, when the Fiscal Department completes their weekly check for alerts in HCSIS, they will print out any updated ISP¿s and forward them to the Program Secretary who will place them in the appropriate file. In addition, Management Staff completing internal compliance audits will verify that Personal Data sheets have been accurately completed as part of their audit and will notify Program Coordinator of any discrepancies so that they can be corrected immediately. 11/27/2013 Implemented
SIN-00201676 Renewal 03/03/2022 Compliant - Finalized
SIN-00166123 Renewal 11/14/2019 Compliant - Finalized