Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231158 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The home's kitchen fire extinguisher had an inspection tag dated October 2017. This extinguisher was not inspected and approved annually by a fire safety expert as required. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The expired fire extinguisher was removed from the program and replaced with an operable, inspected and tagged fire extinguisher. 10/19/2023 Implemented
6400.112(d)A "Fire Drill Log & Systems Check" form dated 10/09/2022 records the results of a fire drill occurring in the home on 10/09/2022. The log notes that the home's four residents evacuated in 5 minutes and 7 seconds, which exceeds the 2 minutes and 30 seconds evacuation time permitted. This home did not have record of an extended evacuation time approved by a fire safety expert in writing within the year prior to this fire drill. There is no record of an additional fire drill being conducted before the end of the October 2022 calendar month in order to meet the evacuation time requirement. 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. Our current fire drill log is being updated to include a statement about the amount of time permitted at each program of 2 1/2 min. or approved extended evacuation time. This will serve as a reminder of the regulated time upon completion of the form, and immediate action which may need to be taken. 10/26/2023 Implemented
SIN-00210820 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(g)At time of inspection, medications were stored on an open shelf in the bathroom off the office of the home. Manufacturer's storage instructions for multiple medications indicate that they should be stored away from or protected from moisture.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.The Community Services Administrator (CSA) informed all supervisors on 11/3/2022 to "Please relocate all medications to a locked area of the program if they are not already locked up. This is a temporary plan of correction for licensing as we work on the permanent solution. The medications must be locked regardless of the individual's safeness around poisonous substances. ((all staff will be trained on a procedure to check storage instructions of medication and how to properly store all medications -CH 11/15/2022)). 12/01/2022 Implemented
SIN-00130243 Renewal 02/28/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #3's annual assessment dated 12/18/2017 was not complete because the progress and growth over the last 365 calendar days for the following areas: Health, motor/communication skills, activities of residential living, personal adjustment, socialization, recreation, and community integration. 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 Annual Skills Assessment has been revised to include progress and growth in all areas required by regulation. The revised Annual Skills Assessment will be reviewed with management on March 27, 2018 and will be implemented April 1, 2018. 03/27/2018 Implemented
6400.181(e)(12)There were no recommendations for specific areas of training, programming and services in Individual #3's assessment dated 12/18/2017.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Annual Skills Assessment has been revised to include a section under skill areas that include recommendations for further programming, evaluation, training, services and/or outcomes.as required by regulation. The revised Annual Skills Assessment will be reviewed with management on March 27, 2018 and will be implemented April 1, 2018. 03/27/2018 Implemented
6400.181(f)Individual #3's ISP meeting was held on 1/11/2018. Her assessment was completed on 12/18/2017.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The Annual Skills Assessment will be distributed to all team members at the Second ISP Review Meeting which is held no more than 90 days before the ISP Annual Review. Supports Coordination Unit has been informed that if the SC is not present at this meeting the Annual Skills Assessment will be emailed to the SC. This procedure will be reviewed with Program Specialist on March 7, 2018 and with management personnel on March 27, 2018. Email with this new procedure has been sent to Director of Supports Coordination on March 6, 2018 03/27/2018 Implemented
6400.186(b)Individual #3 didn't sign her ISP Review dated 4/7/2017.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Residential Services Administrator reviewed with Program Specialist the requirement that program participants must sign the ISP review signature sheet. Review signature sheet has been revised so the program participant and specialist will easily be able to see if the program participant has not signed the sheet. This was reviewed with the Program Specialist on March 7, 2018 03/07/2018 Implemented
SIN-00117741 Unannounced Monitoring 05/24/2017 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 5/8/17, while on the Carnival Pride cruise ship, Individual #1 passed away due to choking on a bolus of food during dinner. During dinner on 5/8/17, Staff #2, who was assigned as the escort for Individual #1, requested that the ship's kitchen "cut up" the food for Individual #1. Individual #1 was on a mechanical soft diet. Staff #2 failed to check Individual #1's food to ensure it was served with the proper consistency. Staff #2 was not trained in the dietary needs of Individual #1. During staff interviews, Staff #2 was unable to describe the required consistency of food as detailed in the dietary protocol for Individual #1. Staff #2 admitted that he failed to read the training materials provided by Prospectus Berco which included the dietary protocol for Individual #1. The Carnival Pride Medical Center report states that there were large chunks of food appearing to be chicken obstructing the airway of Individual #1.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. In order to ensure program participants are not neglected by not providing for their health and safety. Employees will be expected to be knowledgeable of services to be provided to the program participant. As some of their responsibilities require being familiar and understanding protocols that are established for a program participant the agency will develop knowledge based testing. The Residential Services Administrator will work with a task force to develop the testing. The manager responsible for overseeing the implementation of a protocol will be responsible to administer the knowledge based test. Knowledge based testing will be completed at least twice per year Protocols will be reviewed no less than annually or any time there is a revision to a protocol or an employee does not pass a knowledge based test. During the annual re-training on Incident Management (conducted during the months of November and December)the instructor will review the expectation regarding implementation of protocols and any other required program participant programs. Program Specialists and managers will be required to administer the knowledge based testing at minimum twice per year to ensure employees know the protocols. This test will be maintained with the Professional Development Attendance sheets The Health Care Coordinator will work with the Program Specialists in providing education to managers and Direct Support Professionals as it relates to implementation of the protocol. All health related Protocols are to be reviewed with employees who will be working with the program participant and an Acknowledgment of Responsibilities From completed no later than August 18, 2017. All completed forms are to be submitted to the Residential Services Administrator. Written Knowledge base tests for Protocols will be completed by 9/30/2017 08/18/2017 Not Implemented
6400.46(a)Prospectus Berco failed to ensure that Staff #2, who was assigned as the escort for Individual #1 during a cruise, was properly trained in Individual #1's needs which were relevant to Staff #2's responsibilities. Individual #1 was on a mechanical soft diet. Staff #2 did not read the training material provided to him by Prospectus Berco which included Individual #1's dietary protocol. On 5/8/17, while having dinner on a cruise ship, Individual #1 passed away due to choking on a bolus of food as his food was not prepared to a mechanical soft consistency.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. On Tuesday July 25, 2017 a meeting was held with management to review their responsibilities with providing Professional Development to the Direct Support Professionals. The Residential Services Administrator reminded the managers they are to complete Module 2, 3 and 4 with all employees as per the specified time frames. Module 2 includes a review of Individual Profiles/Individual Support Plans, SEEP¿s, Emergency Guidelines, On Call Procedures, Response to Medical Emergencies. Module 2 includes Incident Management, Supervision of Program Participants. Module 4 includes Program Planning and implementation. These modules are completed by the management personnel on site and have specific time frames for completion. A copy will be sent to ODP licensing representative. The Residential Services Administrator and Program Specialist will get reports monthly to ensure these time frames are being met. When employees are escorting program participants on any overnight or extended day trips the escort will be given instructions face to face regarding any protocols or safeguards. The instructor who will be management personnel will be responsible to ensure the escort understands the expectations. Travel Books will be prepared for any program participant who will be escorted on an overnight or extended day trip. The escort will sign Acknowledgement of Responsibility Form and training credit will be given to the employee Included in the Travel Book will be Face Sheet, Safe Guards, Protocols, Lifetime Medical History, OTC and MAR¿s, Safety Plan, SEEP and other agency required forms. 07/27/2017 Not Implemented
6400.167(b)Individual #1 was prescribed Ventolin HFA Inhaler, inhale 2 puffs into lungs 4 times a day. From 5/1/2017 to 5/8/2017, this medication was not administered to Individual #1. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.On Tuesday July 25, 2017 a meeting was held with mangers and direct support professionals working in the Residential Department. These employees were instructed on the importance of reviewing MAR¿s when administering medications. Any medications listed on the MAR are to be administered to a program participant. If a medication is not administered as noted on the MAR a medication error report form must be completed. The Health Care Coordinator will be providing training to employees in the Residential Department as it relates to documentation and review when it comes to medication administration. The Health Care Coordinator and Residential Services Administrator will periodically review MAR¿s to ensure medications are administered as prescribed. The Program Specialist and management of each facility will review MAR¿s at least monthly. All MAR¿s are to be reviewed by management personnel on site and a report is to be made to the Residential Services Administrator with the name of the program participant, date of review and whether or not there are any needed corrections. This is to be complete by August 11, 2017. The agency Medication Administration Instructors complete a review of Modules 5 and 8 annually with employees in the department. The next scheduled review is March/April 2018. There are two dates for Plan of Correction August 11th for review of all MAR's and August 22, 2017 for review of all required documentation. 08/22/2017 Implemented
SIN-00066526 Renewal 09/17/2014 Compliant - Finalized