Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220098 Renewal 02/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)At 1:29PM on 2/28/2023, there was an inordinate amount of mouse droppings under the sink in the kitchen.There may not be evidence of infestation of insects or rodents in the home. On 3/3/2023, Touch-Stone Solutions' maintenance technician went to the home to clean the mouse droppings from under the sink (Attachment #12). The maintenance technician went to the home on 3/4/2023 and on 3/6/2023 and observed no mouse droppings present. Staff were informed to report any evidence of bug or rodent infestation immediately to the Program Specialist. The Program Specialists were trained on 3/6/2023 on 6400 regulations, to include 6400.64(b). They were also trained on what to do if they are aware of any evidence of bug or rodent infestation. (Attachment #1). Program Specialist, conducted a house meeting with staff to discuss how to handle any evidence of mouse droppings. (Attachment #13). On 3/8/2023, Program Specialist visited the home to conduct a full site inspection and noted that the mouse droppings were cleaned up and a mouse trap was set out of reach from the individual (Attachment #3). 03/08/2023 Implemented
6400.67(a)The ceiling in the kitchen had cracks and peeling paint.Floors, walls, ceilings and other surfaces shall be in good repair. Touch-Stone Solutions immediately contacted the landlord. The landord of the home scraped and painted the ceiling to ensure it had no peeling paint or cracks (Attachment #8). Program Specialist, conducted a site inspection on 3/8/2023 and verified that the repairs were completed. (Attachment #3) 03/08/2023 Implemented
6400.67(b)There is an electrical outlet on the floor of the kitchen with a screw protruding from the bottom posing a puncture and laceration hazard. The heating vent on the floor of the kitchen is warped with a sharp point of metal protruding upward posing a puncture and laceration hazard. There are numerous puddles of water on the floor of the basement posing a slipping and falling hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Touch-Stone Solutions maintenance removed the screw from the outlet to ensure client safety and eliminate this hazard. This was completed on 3/7/2023 (Attachment #9) Touch-Stone Solutions maintenance used a shop vaccuum and cleaned all the water from the basement to ensure there were no puddles of water. (Attachment #10). The heating vent was repaired to ensure there were no sharp or protruding edges. A new heating vent was ordered on 3/10/2023 (Attachment 11) due to it being bent and warped in places and to ensure ongoing compliance. Program Specialist, conducted a site inspection on 3/8/2023 to ensure the above noted issues were corrected (Attachment #3). 03/08/2023 Implemented
6400.171At 1:32PM on 2/28/2023 a carton of eggs with a "best by" date of 2/15/2023 was on the top shelf of the refrigerator in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. A staff meeting was help with all Program Specialists on 3/6/2023 to address compliance and 6400 regulations. (Attachment #1). Program Specialist, held a staff meeting to review 6400.171 with house staff and stress the importance of checking labels for best by, sell by and expired dates daily.(Attachment #12). Staff are expected to discard all food items that are past their best by, sell by, or expired dates. Program Specialist, conducted a site inspection on 3/8/2023 and noted no expired foods were present in the home. (Attachment #3). 03/08/2023 Implemented
SIN-00146340 Renewal 12/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(e)The full date of the medications administration training was not documented for Direct Service Worker #1. The date of the annual practicum was documented as 12/2018. In addition, the dates of the medication administration observations were not documented. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.The Direct Service Worker #1 will receive retraining in medication management by 12/21/2018 by a medication administration trainer. Documentation of the date, including month, day and year will be clearly identified on the training forms. Medication Administration trainers will work together to review documentation on a quarterly basis to ensure that documentation is clear and comprehensive for all trainings and annual practicums. The Executive Director or designee will review 25% of medication administration training records on a quarterly basis to ensure on-going compliance.[Within 30 days of receipt of the plan of correction, CEO shall educate all aforementioned staff persons on their aforementioned responsibilities to ensure documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept .Documentation of aforementioned audits shall be kept. (DPOC by AES,HSLS on 1/2/19)] 12/21/2018 Implemented
SIN-00126915 Renewal 12/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The staff office on the second floor of the home had a skeleton key locking mechanism that required a key to open the door preventing egress from the inside the office when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The skeleton key hole was filled in with caulking on 12/28/2017 and a new door lock that can be unlocked from the inside was installed (Attachment #8). The Program Specialist conducted a site visit on 12/28/2017 to ensure that the correction was made and is compliant with regulations (Attachment #9). At all future staff visits, door locks will be observed and checked to ensure that they can be unlocked from the inside. This will be documented on monthly site visits and provided to the Executive Director or designee within three business days of the site inspection for review. All future homes will have skeleton key locks replaced prior to the placement of an individual in the home. 12/28/2017 Implemented
6400.111(e)The fire extinguisher on the second floor of the home was kept in the locked staff office. A fire extinguisher shall be accessible to staff persons and individuals. The fire extinguisher was moved to the hallway on the second floor to ensure that all staff and individuals have access to it. This was corrected on 12/21/2017. The Program Specialist conducted a site visit on 12/28/2017 to ensure that this was moved to an accessible location and documented this on a site checklist (Attachment #9). During monthly site inspections, the Program Specialist will ensure that fire extinguishers are observed to be in accessible locations and will document this on the site visit checklist. [Within 30 days of the receipt of the plan of correction and annually, staff persons and individuals shall be educated as to the location of the fire extinguishers. (AS 1/26/18)] 12/28/2017 Implemented
SIN-00087559 Renewal 12/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)A black substance which appeared to be mold was on the outside of the door and along the rubber seal of the door of the upright freezer located in the garage of the home. Clean and sanitary conditions shall be maintained in the home. The freezer in question has been cleaned both inside and out and all traces of the mold-like substance has been removed. The freezer belongs to the landlord and was in an area of the basement that is for his use, but due to the buildup on the surface, a request has been made to remove it from the premises. It will be monitored as part of the monthly site visits to ensure it remains buildup free until the point in time it can be removed by the landlord. A copy of the site visit form along with photographs of the cleaned freezer will be sent to BHSL for review.[Activity Coordinator will complete site visit checklist and submit to Program Coordinator for review. Program Coordinator will assign needed work to the Program Specialists to be completed or coordinate with maintenance department within one week and then report back to Program Coordinator. (AS 12/31/15)] 12/23/2015 Implemented
6400.105A blanket and a cardboard box containing furnace filters were against the furnace. In addition, ten cans of paint and a bottle of "Ortho" bug spray were less than 3 feet from the furnace and the hot water tank.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. All items in question have been removed from the area around the furnace. Program Specialist will review the importance of keeping flammable and combustible supplies and materials stored away from heat sources. In addition, all staff will watch the Fire Safety DVD and sign off that they have watched the video and understand the importance of keeping flammable and combustible materials away from heat sources. This item will be placed on the list to monitor for compliance on a monthly basis. A copy of the site visit form along with the sign off sheet from staff will be sent to BHSL for review along with a picture of the furnace area.[Activity Coordinator will complete site visit checklist and submit to Program Coordinator for review. Program Coordinator will assign needed work to the Program Specialists to be completed or coordinate with maintenance department within one week and then report back to Program Coordinator. (AS 12/31/15)] 12/31/2015 Implemented
6400.151(c)(2)withdrawn 12/31/15 AS 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.   12/31/2015 Implemented
SIN-00068572 Renewal 12/17/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)A stream of water, approximately 1/4 inch wide, was coming into the basement near the steps where the wall was recently dry-walled.Floors, walls, ceilings and other surfaces shall be in good repair. Executive Director, Program Coordinator and Program Specialist visited the site and did not find any evidence of water on the floor or a possible source for the water. Program Specialist will instruct Direct Care staff to monitor the area and report any new water that they may see in the area. In addition, they will be trained to clean up any water that is present on the floor as soon as it is noticed. [Area will be monitored during every shift by direct care staff. If problem persists, then the CEO or program specialist will be responsible to make any necessary improvements to prevent further problems including problems with mold or repairs to floors, walls and ceilings. (CHG 12/31/14)] 12/23/2014 Implemented
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer has been purchased and placed into the first aid kit. Program Specialists will train Direct care staff on proper procedure when items are missing from the first aid kit, which is to notify Program Specialist immediately so that a replacement can be purchased and placed in the kit. In addition, staff will check as a part of the monthly site inspections to ensure compliance. 12/19/2014 Implemented
SIN-00184995 Renewal 03/18/2021 Compliant - Finalized
SIN-00066672 Initial review 08/06/2014 Compliant - Finalized