Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230452 Renewal 11/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.169(a)A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. Staff #1's had an annual medication practicum completed on 1/19/21, then they had an annual medication practicum on 12/22/21, and their next annual medication practicum occurred on 3/27/23. The 3/27/23 annual medication practicum was late.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).All staff members who administer medication shall be properly trained in a Department approved medication administration course. This includes all required medication administration passes and annual practicum. 11/27/2023 Implemented
SIN-00163449 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There were several failed fire drills this past year. On 2/5/2019, Individual #2 evacuated in 2 minutes & 40 seconds, Individual #3 evacuated in 2 minutes & 35 seconds and Individual #4 evacuated in 2 minutes & 45 seconds. On 2/11/2019, Individual #3 evacuated in 4 minutes & 20 seconds and Individual #4 evacuated in 4 minutes & 22 seconds. On 5/25/2019, Individual #3 evacuated in 2 minutes & 50 seconds. On 6/3/2019, Individual #2 evacuated in 2 minutes and 57 seconds and Individual #3 evacuated in 3 minutes & 10 seconds. On 9/18/2019, Individual #3 evacuated in 4 minutes. On 9/21/2019, Individual #2 evacuated in 4 minutes & 19 seconds, Individual #3 evacuated in 15 minutes & 83 seconds and Individual #4 evacuated in 7 minutes & 30 seconds. An unannounced fire drill shall be held at least once a month. 1. Provider will ensure that monthly fire drills are completed and that all individuals are able to evacuate in under 2.5 minutes or the time specified by a fire safety expert. 2. The site is in the process of two changes to aid in fire safety and evacuation times. The site requested PCP approval for one consumer for use of a wheelchair for safety as her gait is unsteady and she expresses fear of walking, especially when it is necessary to move at a faster pace. The site requested caster wheels be installed on each client¿s recliner to eliminate the need to transfer back to a wheelchair. The site will continue to practice drills monthly and repeat fire drills, should they exceed 2.5 minutes. 3. To prevent recurrence of this issue, the house supervisor and Program Specialist will ensure timely implementation of areas listed in #2. Additionally, the site has invited the local fire chief to observe a fire drill, and to offer guidance to ensure timely evacuation. The provider will discuss extending the evacuation time with the fire chief, should he feel that is necessary. 4. The Program Specialist, Site Supervisor and Operations Director will implement this plan as written. The Operations Director and Program Specialist will monitor monthly fire drills and assign additional drills should the evacuation times exceed 2 ½ minutes. 12/15/2019 Implemented
SIN-00108521 Renewal 12/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Multiple fire drills were conducted in October 2016 which exceeded the 2 ½ minute regulated evacuation time for the home. The evacuation time for the sleep drills are as follows: 5 minutes and 17 seconds on 10/7/2016; 5 minutes and 37 seconds on 10/14/2016; 2 minutes and 40 seconds on 10/20/216; and 2 minutes and 36 seconds on 10/25/2016. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. 1. Provider will ensure that monthly fire drills are completed and that all individuals are able to evacuate in under 2.5 minutes or the time specified by a fire safety expert. 2. The site had a successful overnight fire drill on 10/29/16, at which time the longest evacuation time was 2.16 minutes. Another overnight fire drill was conducted on 12/21/16, at which time the longest evacuation time was 2.18 minutes. The provider has taken measures to increase success with the fire drill, including adding castor wheels to one client¿s recliner chair to allow for easier transport and having the local fire department evaluate the program on 10/29/16 to offer guidance and recommendations. 3. To prevent recurrence of this issue, the program specialist will continue to monitor fire drills at all sites. If this issue presents itself again, the program specialist and operations director will collaborate with the fire department and county SCO as needed to add additional support and/or training. 4. The Program Specialist will implement this plan of correction as written. The Operations Director will monitor implementation through on site observations of fire drills. Any further areas of non-compliance will be evaluated and additional support provided as needed. 03/08/2017 Implemented