Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227306 Renewal 07/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)The most recent gynecological examination for Individual #1 was completed 1/13/2022.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Dawn has a pap test exemption letter dated for August 17, 2016 from her primary care physician. Her current primary care physician wrote a new letter dated for July 7, 2023 continuing her exempt status. Dawn received a mammogram on August 25, 2021 and a breast ultrasound on August 26, 2022. As she is still currently in compliance with annual exams, she will not receive another ultrasound or mammogram until the end of August 2023. . 07/13/2023 Implemented
6400.165(g)the most recent psychiatric medication review for Individual #1 was completed 11/09/2022.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Dawn is scheduled to see her physician for her quarterly psychiatric medication review on August 10, 2023. Provider will have the physician document this review on a specific quarterly psychiatric medication review form and will keep this in her medical record. 08/10/2023 Implemented
SIN-00209142 Renewal 08/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1's most recent prostate examination was 6/7/21.The physical examination shall include: A prostate examination for men 40 years of age or older. Individual #1 has been scheduled to get his PSA bloodwork on 8/10/2022. 09/10/2022 Implemented
SIN-00192044 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #2's 6/1/21 physical examination did not include a review of previous medical history. The area was left blank.The physical examination shall include: A review of previous medical history. The medical forms will be updated by the Clinical Coordinator to include all necessary information. The form will be highlighted where an answer needs to be written in by a physician. A bright pink paper will also be attached to all medical forms explaining to the doctor office that the information highlighted is essential to our 6400 regulations to be in compliance with the state. This will include the previous medical history. 10/01/2021 Implemented
6400.141(c)(6)Individual #1's 7/30/20 Tuberculin skin testing by Mantoux method was read by a medical assistant.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. 6400.141d Immunizations, vision and hearing screening and tuberculin skin testing may be complted, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant.A bright pink paper will be attached to all orders for immunizations, including TB tests, that state our regulations and the authorized medical professionals Easterseals can have administering or reading any immunizations or TB tests. 10/01/2021 Implemented
6400.141(c)(14)Individual #2's 6/1/21 physical examination did not include medical information pertinent to diagnosis and treatment in case of an emergency. The area was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The medical forms will be updated by the Clinical Coordinator to include all necessary information. The form will be highlighted where an answer needs to be written in by a physician. A bright pink paper will also be attached to all medical forms explaining to the doctor office that the information highlighted is essential to our 6400 regulations to be in compliance with the state. This will include the medical information pertinent to diagnosis and treatment in case of emergency. 10/01/2021 Implemented
SIN-00177361 Renewal 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There were not fire drills held in November 2019 and April 2020. An unannounced fire drill shall be held at least once a month. The Program Specialist will review this regulation with Direct Care staff to ensure compliance and understanding. This item will also be added to the Residential Program Calendar to remind the Director and Program Specialist of the approaching due date at the end of each month. [Immediately, the CEO or designee shall educate all staff persons responsible for conducting fire drills of the requirements of fire drills as per 6400,112a-112i. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/30/20)] 10/30/2020 Implemented
6400.112(d)The most recent extended evacuation time of four minutes in writing by a fire safety expert was completed on 10-2-18. 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. This documentation was unable to be located. The Program Specialist will contact Cornplanter VFD to ensure compliance. This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are aware of approaching the due date moving forward. [Until an extended evacuation written documentation is provided to the agency from a fire safety expert evacuation time shall not exceed 2 1/2 minutes. Additional staffing or other changes shall be made as needed to ensure timely evacuation. As soon as feasible and safe, the CEO or designee shall coordinate a fire safety inspection with a fire safety expert. Immediately, the CEO or designee shall develop a tracking system to ensure timely completion of scheduling of fire safety experts to complete documentation of evacuation times and maintaining of the documentation. Immediately, the CEO or designee shall educate all staff persons responsible for conducting fire drills of the requirements of fire drills as per 6400,112a-112i. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/8/20)] 10/30/2020 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was held on 12-22-19 at 6:00AM.A fire drill shall be held during sleeping hours at least every 6 months. A Residential Program (shared) calendar was created to ensure that the Director and Program Specialist are aware of overnight fire drills approaching the due date. The Program Specialist will review this regulation with Direct Care staff to ensure compliance and understanding. [A fire drill was conducted during sleeping hours on 12/9/20. Immediately, the CEO or designee shall educate all staff persons responsible for conducting fire drills of the requirements of fire drills as per 6400,112a-112i. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/9/20)] 10/30/2020 Implemented
6400.113(c)There was not a written record of fire safety training for Individual #1. There was not a written record of fire safety training for Individual #2. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.This documentation was unable to be located. 2020 Individual Fire Safety Training will be scheduled as soon as possible due to limited availability of the Fire Dept due to COVID-19.This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are aware of approaching the due date. [Individual #1 and Individual #2 were trained in fire safety on 11/10/20, documentation provided to the department on 12/8/20. Immediately and at least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure fire safety training has been completed, timely, and retraining shall occur as needed. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are educated in fire safety, timely, and documentation is kept as required. (DPOC by AES,HSLS on 12/8/20)] 10/30/2020 Implemented
6400.141(c)(6)Individual #2 had a Tuberculin skin test completed on 7-12-18 and then again on 7-30-20.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. A Residential Program (shared) calendar was created to ensure that the Director, Program Specialist and Residential Nurse are all made aware of upcoming due dates for individual Tuberculin skin tests. The Residential Program Specialist and Residential Nurse will be retrained on this requirement to ensure compliance moving forward. [At least quarterly for one year, the CEO or designee shall review the aforementioned tracking documentation and individuals' physical examinations including Tuberculin skin testing to ensure up to date tracking and all individuals have physical examinations with required information including tuberculin testing completed. timely. (DPOC by AES,HSLS on 12/8/20)] 10/30/2020 Implemented
6400.181(a)Individual #2 had an assessment completed on 5-10-19 and then again on 6-4-20. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The Director will retrain the Residential Program Manager on regulations pertaining to Individual Assessments. The Director will conduct an inspection prior to the Individual Assessments being sent out to the ISP team to ensure compliance. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of all individuals' assessments and educate the program specialist on the system. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 11/20/20)] 10/16/2020 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 1-26-18 and then again on 1-27-20. Individual #2 was informed and explained individual rights on 11-23-18 and then again on 1-29-20.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.All annual paperwork, including Individual Rights, will be sent out no later than December 31 annually. This paperwork will be due to be returned to the agency no later than January 15 annually. This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are reminded of approaching the due date. 12/31/2020 Implemented
6400.167(a)(4)Simvastatin, 10mg take 1 tablet by mouth at bedtime prescribed to Individual #2 was not administered from October 1, 2020 to October 3, 2020.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.Upon identifying the medication error, the Residential Program Nurse contacted the prescribing physician. The physician stated that the prescription was never sent to the pharmacy; the pharmacy verified that they had never received the prescription. A medication error was entered into HCSIS. The medication was received on 10/06/2020. Medical appointment forms are now due to the Residential Nurse the same day as the appointment to ensure continuity of care and compliance. Any medication changes will be documented on a medication change form, which will be emailed to house staff, Residential Program Manager and Director to ensure that all parties are immediately notified of the change. [At least monthly, a designee certified to administer medications shall audit all individuals medication administration records, medications and prescribers' orders to ensure all individuals are administered medications as prescribed and documented as required. (DPOC by AES,HSLS on 12/8/20)] 10/06/2020 Implemented
SIN-00157281 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1, had physical examinations completed on 4/22/15 and then again on 7/7/17. Direct Service Worker #2, had physical examinations completed on 8/18/15 and then again on 11/14/17. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. A "Master Calendar" has been developed for all staff requirements, to include physical/PPD, and will be maintained by the Administrative Program Assistant. Director will review a sample of physical/PPD's to assure ongoing compliance. [On 6/28/19, the administrative assistant and director reviewed the process regarding scheduling, notifications, reviewing, documentation and tracking of staff physical examinations and tuberculin testing to ensure timely competition of staff physical examinations and tuberculin testing. At least quarterly for 1 year, the Director shall audit staff physical examinations and tuberculin testing to ensure timely competition of staff physical examinations and tuberculin testing and the process, revision and retraining will be implemented as needed. (DPOC by AES,HSLS on 7/3/19)] 06/26/2019 Implemented
6400.151(c)(2)Direct Service Worker #1, most recent Tuberculin skin testing was completed 4/24/2015. Direct Service Worker #2, had Tuberculin skin testing completed on 8/20/15 and then again on 11/16/17. 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. A "Master Calendar" has been developed for all staff requirements, to include physical/PPD, and will be maintained by the Administrative Program Assistant. Director will review a sample of physical/PPD's to assure ongoing compliance.[On 6/28/19, the administrative assistant and director reviewed the process regarding scheduling, notifications, reviewing, documentation and tracking of staff physical examinations and tuberculin testing to ensure timely competition of staff physical examinations and tuberculin testing. At least quarterly for 1 year, the Director shall audit staff physical examinations and tuberculin testing to ensure timely competition of staff physical examinations and tuberculin testing and the process, revision and retraining will be implemented as needed. (DPOC by AES,HSLS on 7/3/19)] 06/26/2019 Implemented
6400.186(b)Individual #1 did not sign the ISP review for the review period from 12/1/18 to 2/28/19.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Director and Residential Program Manager will review regulation as re-training" to ensure a thorough understanding of this regulation. Director will review a sample of ISP reviews to assure ongoing compliance moving forward. [Individual #1 signed the ISP for the review period from 12/1/18 to 2/28/19. On 6/27/19, the Director audited all other individuals' current ISP review to ensure they were signed as required. On 6/26/19, the Director trained the residential program manager on the program specialist and individual signing and dating the ISP review upon review of the ISPs. At least quarterly for 1 year, the director shall audit all individuals' ISP review to ensure the program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. (DPOC by AES,HSLS on 7/3/19)] 06/26/2019 Implemented
SIN-00136998 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1 had a statement acknowledging receipt of the information on rights signed on 1/3/17 and then again 1/30/18.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Program Specialist will create and maintain an annual tracking spreadsheet with the dates listed from the previous year in order to maintain accuracy.[Immediately and continuing at least quarterly for 1 year, the CEO or designated management staff shall audit the aforementioned tracking system and a 25% sample of statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights to ensure timely completion. Documentation of audits shall be kept. (AS 7/12/18)] 07/09/2018 Implemented
6400.186(a)The program specialist completed ISP reviews for Individual #1 for the review period of 6/1/17 to 8/31/17 on 9/27/17 and for the review period of 9/1/17 to 11/30/17 on 12/18/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialist will schedule and hold meetings with the individual within the first week after the review period has ended. Program Specialist is aware that in order to complete the quarterly review, it must be reviewed with the individual within fifteen days after the review period has ended. Program Specialist will create and maintain an annual tracking spreadsheet in order to maintain accuracy.[Immediately and continuing at least quarterly for 1 year, the CEO or designated management staff shall audit the aforementioned tracking system and a 25% sample of ISP review to ensure timely completion. Documentation of audits shall be kept. (AS 7/12/18)] 07/09/2018 Implemented
SIN-00098383 Renewal 07/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The physcial examination, dated 5/26/16, for Individual #1 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The agency Annual Physical Form was not completed in its entirety by Easter Seals / Physician. The form will be updated for each individual enrolled in 6400 programming, to include "self populated" areas that are completed prior to the actual annual physical exam. The form will also include "highlighted" areas that the doctor must complete. Both changes will allow for assurance that the Annual Physical Form is completed in its entirety.[Individual #1's physical examination was updated on 9/7/16 to include health maintenance needs, medication regimen and the need for blood work. Within 2 weeks of receipt of the plan of correction, the division director shall review the "Annual Residential Physical Form" and revise to include all required information areas as specified in 6400.141.(c)(1)-(15) where the licensed physician, certified nurse practitioner or licensed physician's assistant are able to complete, sign and date as required. Within 30 days of receipt of the plan of correction, the division director shall review with the program specialist(s) what individual physical examinations are required to include as per 6400.141.(c)(1)-(15) and sign and date upon review. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program specialist(s) shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank and will obtain missing information from the completing licensed physician, certified nurse practitioner or licensed physician's assistant. At least quarterly, the division director shall review a 25% sample of individual physical examination to ensure all required information is included and completed by a licensed physician, certified nurse practitioner or licensed physician's assistant. Documentation of all reviews shall be kept. (AS 9/7/16)] 08/08/2016 Implemented
6400.141(c)(12)The physical examination, dated 5/26/16, for Individual #1 did not include the physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. The agency Annual Physical Form was not completed in its entirety by Easter Seals / Physician. The form will be updated for each individual enrolled in 6400 programming, to include "self populated" areas that are completed prior to the actual annual physical exam. The form will also include "highlighted" areas that the doctor must complete. Both changes will allow for assurance that the Annual Physical Form is completed in its entirety.[Individual #1's physical examination was updated on 9/7/16 to include limitations. Within 2 weeks of receipt of the plan of correction, the division director shall review the "Annual Residential Physical Form" and revise to include all required information areas as specified in 6400.141.(c)(1)-(15) where the licensed physician, certified nurse practitioner or licensed physician's assistant are able to complete, sign and date as required. Within 30 days of receipt of the plan of correction, the division director shall review with the program specialist(s) what individual physical examinations are required to include as per 6400.141.(c)(1)-(15) and sign and date upon review. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program specialist(s) shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank and will obtain missing information from the completing licensed physician, certified nurse practitioner or licensed physician's assistant. At least quarterly, the division director shall review a 25% sample of individual physical examination to ensure all required information is included and completed by a licensed physician, certified nurse practitioner or licensed physician's assistant. Documentation of all reviews shall be kept. (AS 9/7/16)] 08/08/2016 Implemented
6400.141(c)(14)The physical examination, dated 5/26/16, for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The agency Annual Physical Form was not completed in its entirety by Easter Seals / Physician. The form will be updated for each individual enrolled in 6400 programming, to include "self populated" areas that are completed prior to the actual annual physical exam. The form will also include "highlighted" areas that the doctor must complete. Both changes will allow for assurance that the Annual Physical Form is completed in its entirety.[Individual #1's physical examination was updated on 9/7/16 to include "emergency medical information." Within 2 weeks of receipt of the plan of correction, the division director shall review the "Annual Residential Physical Form" and revise to include all required information areas as specified in 6400.141.(c)(1)-(15) where the licensed physician, certified nurse practitioner or licensed physician's assistant are able to complete, sign and date as required. Within 30 days of receipt of the plan of correction, the division director shall review with the program specialist(s) what individual physical examinations are required to include as per 6400.141.(c)(1)-(15) and sign and date upon review. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program specialist(s) shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank and will obtain missing information from the completing licensed physician, certified nurse practitioner or licensed physician's assistant. At least quarterly, the division director shall review a 25% sample of individual physical examination to ensure all required information is included and completed by a licensed physician, certified nurse practitioner or licensed physician's assistant. Documentation of all reviews shall be kept. (AS 9/7/16)] 08/08/2016 Implemented
6400.141(c)(15)The physical examination, dated 5/26/16, for Individual #1 did not include special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. The agency Annual Physical Form was not completed in its entirety by Easter Seals / Physician. The form will be updated for each individual enrolled in 6400 programming, to include "self populated" areas that are completed prior to the actual annual physical exam. The form will also include "highlighted" areas that the doctor must complete. Both changes will allow for assurance that the Annual Physical Form is completed in its entirety.[Individual's physical examination was updated on 9/7/16 to include diet. Within 2 weeks of receipt of the plan of correction, the division director shall review the "Annual Residential Physical Form" and revise to include all required information areas as specified in 6400.141.(c)(1)-(15) where the licensed physician, certified nurse practitioner or licensed physician's assistant are able to complete, sign and date as required. Within 30 days of receipt of the plan of correction, the division director shall review with the program specialist(s) what individual physical examinations are required to include as per 6400.141.(c)(1)-(15) and sign and date upon review. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program specialist(s) shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank and will obtain missing information from the completing licensed physician, certified nurse practitioner or licensed physician's assistant. At least quarterly, the division director shall review a 25% sample of individual physical examination to ensure all required information is included and completed by a licensed physician, certified nurse practitioner or licensed physician's assistant. Documentation of all reviews shall be kept. (AS 9/7/16)] 08/08/2016 Implemented
SIN-00081765 Renewal 07/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(14)The assessment for Individual #1 completed on 8/11/2014 did not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Individual assessment was revised on 7/9/15 to include that the individual needed supervision around all bodies of water. A copy was snet to the supports coordinator and the individuals day programs (LSHP and TracyJo's ADC).[As per conversation with PS on 9/16/15, PS will be responsible for immediately reviewing all individuals' assessments including Individual #1 and ensuring all individuals are assessed in the required areas including individual's knowledge of water safety and ability to swim and will complete all assessments as required. (AS 9/16/15)] 07/09/2015 Implemented
6400.186(a)The most recent assessment for Individual #1 was completed on 8/11/2014. The previous assessment was completed on 7/19/2013.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialist has established a chart with ISP date and other required assessments to ensure that all time frames are met. 08/08/2015 Implemented
6400.186(b)The ISP review completed on 12/15/2014 for Individual #1 was not signed and dated by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. All attempts will be made to obtain individual signature. If individual refuses or is unable to sign, program specialist will provide documentation on the review signature sheet that explain why it was not signed. [As per conversation with PS on 9/16/15, the program specialist will review immediately review all ISP reviews to ensure they are signed and date by the individual upon review and will continue to monitor all individuals' records on at least every other month to ensure ISP reviews are signed and dated upon review. (AS 9/16/15)] 08/08/2015 Implemented
SIN-00065678 Renewal 07/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(10)The monthly documentation for Individual #1 from November, 2012 to June, 2014 is not reviewed, signed and dated by the program specialist.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.The Residential Program Manager (Program Specialist) has consistently reviewed cosumer monthly reports but was not aware of regulatory requirement requiring her signature. The Residential Program Manager is now aware of this requirement and will be responsible for signing all future reports. Existing reports have been signed as of 7/11/14 and future reports will be signed at time of review. Informal training was provided at the time of the inspection and ongoing compliance will be assured by both the Residential Program Manager and Division Director. 07/11/2014 Implemented
6400.82(f)The bathrooms in the home did not have soap.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Hand soap has been placed at this location's bathrooms utilized by program participants. This area of non-compliance was related to mis-interpretation of regulation related to danger awareness with program particpants at this site. This non-compliance was addressed immediately (7/9/14) and moving forward all direct care & supervisory personnel are aware of this requirement. This was achieved through informal training. 07/09/2014 Implemented
6400.112(d)The most recent written evacuation time specified by a fire safety expert was completed on March 22, 2013. The evacuation times on 3/25/14, 5/20/14 and 6/21/14 were 3 minutes 51 seconds, 3 minutes 34 seconds and 3 minutes 40 seconds; respectively. 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 employee 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. Easter Seals management was aware of this requirement and had made requests to the Cornplanter Twp. Volunteer Fire Department for the "extension letter". This was again requested from Cornplanter VFD on 7/9/14. On 7/24/14, Cornplanter Twp. VFD completed an inspection of this location and felt that a 4 minute evacauation time was approrpriate based on the composition of the home and that a fire supression system exists. Future requests & receipt of this required information will be assured by the Residential Program Manager and Division Director. Documentation from this inspection will be forwarded. A "form letter" has been generated and will be used for future "4 minute extension letters" per the recommendation of licensing agent, which Cornplanter VFD felt was very helpful. 07/24/2014 Implemented
6400.171On 7/9/14, 6oz. container of yogurt was unsealed and a container of French Onion Dip with an expiration date of 6/14/14 were in the refrigerator in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. Easter Seals Direct Care Staff (RPW's) were aware of this requirement and are routinely reminded of this need through reminder from supervisory personel and during monthly moniroting by the AE. A checklist has been established and will be posted at this location where RPW's will need to "sign off" that they have examined "expirationdates" to assure there is no expired food kept. This documentation will continue for 6 months, further if needed based on their ongoing compliance. Staff have also been re-trained that once food is opened it must be used or kept in a sealed container. The Residential Program Manager will be repsonbile for assuring this location remains compliant with this requirement. 07/18/2014 Implemented
6400.186(b)The quarterly review dated 2/19/14 for Individual #1 is not signed by the Individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The signature that was missing from this quarterly report involved a program particpant who was physically unable to sign the report due to health related issues at the time of the review. Although an attempt was made at this review it did not occur and the Residential Program Manager failed to document this attempt. The Residential Program Manager and Division Director are aware of this requirement and will be responsible for assuring future compliance of this regulation. If the program participant is unable to sign, this will be documented on the report. 07/09/2014 Implemented
SIN-00117869 Renewal 07/19/2017 Compliant - Finalized