Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00163439 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license for this chapter expired on 10/15/2019. A self-assessment wasn't completed until 10/10/2019.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. a. The provider¿s Operations Director will ensure that a self-assessment schedule is created, ensuring that all homes have a completed self-assessment at least 3 times per year. This schedule will be created and implemented by 11/15/19. b. As the self-assessments were completed for all of the homes in October 2019, the schedule will begin in January 2020. c. Self-assessments will be completed by Program Specialists, as well as the Operations Director when necessary. d. Any non-compliant findings will be addressed and remedied upon discovery. e. Self-assessments of all group homes will be made available to licensing representatives whenever necessary. 11/15/2019 Implemented
6400.77(b)There was no thermometer in the 1st Aid Kit at the time of this inspection. 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. The provider will ensure that residential program supervisors, as well as Program Specialists, check that all necessary first aid kit items are present and functioning throughout routine inspections of the home. b. The provider will also ensure that the first aid kits are checked for items being present, as well as for proper functionality, during each of the self-assessment inspections, at least three times annually. c. At any time an item runs out or is noted missing, the provider will ensure that management is notified within 24 hours, and that it is replaced within 48 hours. d. Thermometer replaced at Clark Avenue by Residential Program Supervisor TS on 10/24/19. 11/11/2019 Implemented
SIN-00149008 Unannounced Monitoring 12/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)On 12/5/2018 and 12/6/2018, Individual #1 refused all of his 7am medications (Colace, Invega, Synthroid, Lisinopril, and Vitamin D3). There is no documentation of attempts to train Individual #1 about the need for health care in his record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The provider will ensure there is documentation if individual refuses medication or medical appointments. Full immediate correction occurred as a desensitization plan was created and put in the home. This plan was put in place as a guide for staff to assist the individual when refusing medication and or appointments. To prevent this recurrence of this issue, staff will follow the steps outlined in this plan. If medication is refused staff will notify Site Supervisor and they will ensure that there is documentation stating the refusal and why. Site Supervisor will ask if the steps outlined in the desensitization plan were followed 01/31/2019 Implemented
SIN-00086731 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 10/29/2014 does not indicate an evacuation time. 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. 1. Provider will ensure that emergency evacuation drills are accurately and thoroughly documented including the date, time, the amount of time for evacuation, exit route used, and the verification that alarms and/or detectors are operative. 2. For the immediate citation, informal counseling with the site supervisor of the home occurred regarding the requirement that all elements of an evacuation drill be noted on the evacuation drill form prior to its filing in the fire drill log book. 3. To prevent further recurrence of the deficient practice, each site supervisor will review the monthly evacuation drill form to ensure that it contains all required information. As a second check, the Program Specialist will review the form each month after the evacuation drill is completed to ensure thorough completion. Any forms found to be lacking required information will be returned to the site supervisor for completion. Once all information has been documented, the Program Specialist will once again review the form and file it in the site fire drill log for review as required. 4. If information that is determined to be missing by the site supervisor or Program Specialist cannot be adequately verified, the evacuation drill will completed again and thorough documentation of the drill will be verified per #3 above. 02/17/2016 Implemented
SIN-00212359 Renewal 10/11/2022 Compliant - Finalized