Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218721 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The home had the following items in a state of disrepair: The handle on dryer was missing, there was a large dent in wall in room #20, and there was a crack in the toilet tank in room #6Floors, walls, ceilings and other surfaces shall be in good repair. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.68(b)The water temperature in the bathroom measured an approximate 129.7 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. A housekeeping checklist was developed that managers will ensure is used by all housekeeping staff; Implementation of this checklist will be checked minimally, once/month. 04/30/2023 Implemented
6400.72(b)There was a large crack in one of the windows in the common area of Hall A. Screens, windows and doors shall be in good repair. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.142(a)There were no dental examinations provided on file for individual Individual 1.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Starting on 2/17/23, Penn Dental agreed to upload dental examinations daily into the individual's electronic health record. A member of the individual's treatment team will track the individual's appointments to coordinate dental care. 05/01/2023 Implemented
6400.32(d)Room #31 had the door removed. Agency stated door removal was in the plan of one of the individuals as a restrictive plan, however documentation of this was not provided. And documentation about the roommate agreeing to the plan was not provided. The two individuals who reside in that room are individuals 2 and 3.An individual shall be treated with dignity and respect.Woods facilities' department ordered and installed new bedroom door. 03/10/2023 Implemented
SIN-00199982 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)-The bottom of the wall in room 33 is severely damaged and crumbling. - There is a broken drawer in room 35. - The sink in bathroom of room 24 is hanging off of the wall and the caulking has pulled away as well. There is cardboard and tape holding it in place. -There is a damaged and partially missing doorframe in individual #1's room. -There is a broken tile in the bathroom that is attached to the bedroom of individual #1 - In the bathroom attached to individual #1's room, the toilet is missing the lid. ** It is worth noting that individual #1 has behavioral concerns which include property destruction. The physical site issues in his room were also reported to the Woods maintenance team on 11/29/21**Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance requests submitted for the wall in room 33. On 3/2/22 Residential Manger completed a walkthrough of Brown Hall and all other walls are in good condition. Dresser handle was broken and fixed. On 3/2/22 Residential Manger completed a walk through of Brown Hall and all dressers in good condition. Sink repaired 2/11/2022. On 3/2/22 Residential Manger completed a walk through of Brown Hall and all sinks are in good repair. Doorframe repaired on 2/15/2022. On 3/2/22 Residential Manger completed a walkthrough of Brown Hall and all door frames are in good repair. Broken tile-Maintenance requests submitted and completed on 2/28/22. On 3/2/22, Residential Manger completed a walkthrough of Brown Hall and there are two tiles in need of repair. Toilet lid- maintenance request sent and completed on 2/28/2022.On 3/2/22 Abdullah Kanneh, Residential Manger completed a walkthrough of Brown Hall and all other toilet lids are in good repair. 03/02/2022 Implemented
6400.68(b)The water temperature was measured at 128.1 degrees. ** The provider reported that this was adjusted to 120.1 the following day** Hot water temperatures in bathtubs and showers may not exceed 120°F. Corrected on 2/11/2022. Monthly water temps continue to be taken and all have been under 120 degrees. 03/31/2022 Implemented
6400.72(b)There is a broken window out front of the facility with cardboard and duct tape holding it in place. Screens, windows and doors shall be in good repair. Maintenance request was sent and replacement glass has been ordered. Due to low supplies there is a significant delay. On 3/2/22 Residential Manger completed a walk through of Brown Hall and all windows are in good repair 03/31/2022 Implemented
6400.46(b)Staff #1, #2, #3 and #4 were not trained by the fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a)."Per the discussion for 46a&b in the RCG (page 48), ""The training does not need to be face-to-face. Videos and other training packages are acceptable if they are prepared by a fire safety expert and if the film or type contains up-to-date fire safety techniques.¿ The four referenced employees were trained in Fire Safety prior to the records review. These records were provided to the auditors during the visit. The Fire Safety Training completed was an online course prepared and approved by a Fire Safety Expert. This course was developed in 2014/2015. Additionally, all employee training staff have been trained by a fire safety expert to answer questions or provide clarification to employees. Course content was provided during the visit. Attached documentation: 1.Training records for the 4 employees mentioned w/ Fire Safety training highlighted on each record, 2.Course content for Fire Safety, 3.Credentials of fire safety expert, 4.Email from fire safety expert outlining Fire Safety course development and TTT completed". Records checked on 3/2/2022 by AVP, Employee Training & Development. All Brown Hall staff in compliance. 03/01/2022 Implemented
SIN-00183414 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The House Keeping closet light was not operational.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Lightbulb was replaced on 2/8/2021. 05/31/2021 Implemented
6400.76(a)The dresser drawers located in Individual#4 bedroom #17 was damaged. The dresser drawers located in Individual#5 bedroom #23 was damaged. Furniture and equipment shall be nonhazardous, clean and sturdy. Damaged furniture was removed and replaced on 2/9/2021. 05/31/2021 Implemented
6400.81(e)The bathroom of Individual#2 attached to room #5 did not have a mat or nonslip surface. No more than two individuals may sleep in one bedroom. This subsection does not apply to bedrooms occupied by more than two individuals in homes licensed in accordance with this chapter prior to November 8, 1991. All bathrooms were provided with mats to avoid fall from nonslip surfaces on 2/9/2021. 05/31/2021 Implemented
6400.81(k)(3)The bedding for Individual#3 did not include linens appropriate for the season. There was no flat sheet present.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.All beds will be equipped with fitted and flat sheet at all times, this was fixed on 2/8/2021. 05/31/2021 Implemented
6400.81(k)(6)There was no mirror present at time of inspection in Individual#6 bedroom #24. There was no mirror present at time of inspection in Individual#7 bedroom.In bedrooms, each individual shall have the following: A mirror. All bedrooms will be equipped with mirrors on 3/4/2021. 05/31/2021 Implemented
6400.82(f)The bathroom of Individual#3 did not have individual clean paper or cloth towels.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. Work order was sent to maintenance and paper towel dispenser was replaced on 3/4/2021. Attachment #3 05/31/2021 Implemented
6400.141(c)(4)Individual#1's last vision exam was 10/2019. Assessment states that individual should see ophthalmologist annually.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Eye doctor visits on 9/27/20 and 3/4/21 were canceled due to COVID quarantine. Exam performed on 3/16/21. Attachment #1 03/16/2021 Implemented
6400.32(d)The syrup located in the kitchen cabinet was expired 10/16/2020. Food located in the refrigerator was expired including but not limited to fruit that expired on 2/7/21, dates on labels may not be used past the date on the labels.An individual shall be treated with dignity and respect.That label is not an expiration date but rather the date the fruit was packed in the FNC. Fruit was on the menu for Sunday, 2/7 (see attached menu) so it was packed on either 2/6 or 2/7 and sent to the homes. 02/15/2021 Implemented
6400.46(b)Annual fire safety training was not current and not completed in the 2019-2020 training year for staff#1. The most recent fire safety training was completed 1/28/2021, the previous fire safety training was completed 3/7/19. There was no annual fire safety training found in staff#2s record. Last completed training was 1/30/2021, there was no 2020 annual training locatedProgram specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Woods has revised their training plans to create a structured design related to training course completion dates. Training plans will include month by month requirements that specify what classes are to be completed each month and how many total hours each employee should have completed by the end of each month. 05/31/2021 Implemented
6400.46(d)Current and up to date CPR training was not located in staff#1's record.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.CPR training was completed on 1/27/2021. Attachment #2 05/31/2021 Implemented
SIN-00156308 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(a)Individual #24's medication Clonazepam .05mg 1&1/2 tablets at 8am and 8pm was changed to 1 tablet at 8am and 1&1/2 at 8pm, but the label was not changed.The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. All original containers and blister cards for prescription medications will be labeled and include individual's name, name of the medication, date the prescription was issued, the prescribed dose, and the name of the prescribing physician as indicated under the guidelines of Department of Public Welfare regarding Administering Medications the Right Way. Instructions regarding the Pharmacy Label reveiwed with nursing staff. Employee Training Documentation Form attached. (attachment 1) 06/30/2019 Implemented
6400.181(a)Individual #24's initial assessment was not completed within 60 days of admission date of 2/12/19. Date of initial assessment was 4/30/19 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. All Care Coordination 6400 staff will be retrained by Directors and AVP on the importance of maintaining deadlines and time management skills. 6400 Program Planning Guidelines will be reviewed. Managing time will be a regular agenda item for department meetings. 07/31/2019 Implemented
SIN-00135822 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The handle on the closet door in rooms #2 and #7 were loose and detached. The fabric on the chair in Individual #2's bedroom was torn and ripped of on the edge. The racks in the freezer the kitchen were rusted.Floors, walls, ceilings and other surfaces shall be in good repair. The knobs on closets have been replaced (attached picture #1). The Residential Manager will confirm these knobs stay on the closet during the monthly environment walks. If knobs are noticed to be missing they will be replaced. New chair has been purchased for Individual #2 (attached picture #2). The Residential Manager will conduct monthly environmental checks and during this check and issues that come up will be addressed with appropriate department. The Residential Director sent a request on 6/14/18 for Maintenance to replaced rusted racks in freezer(attachment #2). The Residential Manager will conduct monthly environmental walks to confirm in compliance. Any issues found during this walk will be addressed right away. 07/01/2018 Implemented
6400.167(b)Vitamin A.D ointment that says 'apply to groin after each diaper change' prescribed for Individual #1 was being administered as prescribe (at each diaper change). Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Due to individuals inability to safely use prescribed medication it is stored in medical chart. A&D ointment is supplied and labeled by the pharmacy. Nursing will pursue an alternate cream that is part of Wood stock i.e. barrier cream. A new physician order will be obtained. This stock cream will be made available to staff to use with every diaper change. 07/01/2018 Implemented
6400.241(b)Frozen food was kept at 20 degree Fahrenheit.Food shall be kept at the proper temperature. Cold food shall be kept at OR below 45°F. Hot food shall be kept at OR above 140°F. Frozen food shall be kept at OR below 0°F. Thermometer was replaced. Frozen food is confirmed at being kept at zero degrees (attachment #1). The Residential Manager conducts monthly temperature checks. Any issues will be addressed with appropriate department. 03/01/2018 Implemented
SIN-00108176 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)In the kitchen drawer near the stove was three tubes of white petroleum found unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals.The Petroleum jelly was thrown away on the day of the walk through inspection. The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted poisonous materials will be immediately locked up and addressed accordingly with staff involved. If observed at any time, staff, including housekeepers and counselors are to remove and lock up any chemicals immediately upon discovery. 02/08/2017 Implemented
6400.67(a)The cabinet door under the counter near the dining room was loose. In room 31 there was approximately a 1 inch by 3 foot area of wood peeled on the door.Floors, walls, ceilings and other surfaces shall be in good repair. The cabinet was fixed at time of the walk through inspection on 2/8/17. A request has been submitted to Maintenance on 3/21/17 to repair door. The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed appropriate action will be taken to replace the item. The environmental checklist will then be submitted to the Residential Manager for review. If observed at any time, Program Supervisors are to report any issues to the Residential Manager so that immediate action can be taken. (See picture & Maintenance request) 03/21/2017 Implemented
6400.72(b)The window by the exit door in C hall was shattered. Screens, windows and doors shall be in good repair. The window has been repaired in Hallway C. The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed, appropriate action will be taken to replace the item. The environmental checklist will then be submitted to the Residential Manager for review. If observed at any time, Program Supervisors are to report any issues to the Residential Manager so that immediate action can be taken. (See pictures) 02/28/2017 Implemented
6400.76(a)In the living room of B hall a couch had a hole approximately 1 and ½ inches in diameter. Furniture and equipment shall be nonhazardous, clean and sturdy. The cover on the couch has been replaced. The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed, appropriate action will be taken to replace the item. The environmental checklist will then be submitted to the Residential Manager for review. If observed at any time, Program Supervisors are to report any issues to the Residential Manager so that immediate action can be taken. (See picture) 03/21/2017 Implemented
6400.141(c)(14) Individual #1's annual physical examination, dated 1/19/17, did not contain information pertinent to diagnosis in case of an emergency. Individual #2's annual physical examination, dated 6/11/15, did not contain information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (See attachment) 02/13/2017 Implemented
6400.142(e)Individual #2's dental examination, dated 4/7/15, recommended two additional fillings were necessary and this did not occur. Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Individual # 2 currently is no longer seen by the Woods Dental department. His mother does all the appointments and prefers for him to be seen off campus. Individual #1 is scheduled for Monday, April 17th. His mom will be taking him and will provide Woods with the results. Going forward, the Nurse/Program Specialist will follow up with mom if she has not made a schedule dental appointment to encourage her to make the appointment and the importance in staying in compliance with licensing regulations. They will also follow up if the appointment was conducted and Woods did not receive follow up in return. 04/17/2017 Implemented
6400.181(e)(14)Individual #1's assessment, dated 4/24/16, did not document the individual's 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 #1's assessment was updated to include his ability to swim. Going forward, swimming abilities will be clearly stated in the residential assessments to ensure compliance with the regulations. (see attachment) 02/28/2017 Implemented
6400.213(1)(i)Individual #1's record did not document hair color, eye color or identifying marks. Individual #2's record did not document hair color or eye color.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1's assessment was updated to include hair color, eye color and identifying marks. Individual #2's assessment was updated to include hair color and eye color. (see attachments) Going forward, this information will be included in all residential assessments. 02/28/2017 Implemented
SIN-00063867 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Bathroom #38 had a strong smelled of urine.Clean and sanitary conditions shall be maintained in the home. The housekeeper cleans the bathrooms in the units on a daily basis and when accidents occur. The housekeeper will continue to clean and monitor the unit on a daily basis and report any needed repairs not in their ability to clean/fix to their immediate supervisor who will contact the needed person for any repairs needed. George Jallah, Residential Manager, will do random inspections to ensure that the bathrooms are cleaned as expected. In addition, the unit supervisor or manager completes a monthly environmental checklist of the unit and reports any needed duties and/or repairs to the necessary person. i.e. housekeeper, maintenance, housekeeping, Residential Director, etc. 08/01/2014 Implemented
6400.65The ventilation attached to all the bathrooms was inoperable. Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Woods Services' maintenance department inspected the ventilation in Brown Hall. While there, the maintenance workers replaced motors in the fans in the laundry room and in the front left wing. All other ventilation units were working. (See attachment K) Woods Services' maintenance department will do a regular inspection of the heating and ventilation system. In addition, the unit supervisor or manager completes a monthly environmental checklist of the unit and reports any needed duties and/or repairs to the necessary person. i.e. housekeeper, maintenance, housekeeping, Residential Director, etc. Daily, it is the expectation of staff, to report any maintenance issues they may see to their immediate supervisor. 10/02/2014 Implemented
6400.76(a)There was lint found in the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. The housekeeper cleaned the lint out of the dryer during the BHSL building walk thru inspection. A reminder sign was also hung in the laundry room as a reminder to clean out the lint filter after each load of laundry. (See attachment J) After each cycle, the housekeeper/staff/ shift leader is to inspect the dryer for any lint and clean it out after each dry. The housekeeper will continue to clean and monitor the unit on a daily basis and report any needed repairs not in their ability to clean/fix to their immediate supervisor who will contact the necessary person for any repairs needed. In addition, the unit supervisor or manager completes a monthly environmental checklist of the unit and reports any needed duties and/or repairs to the necessary person. i.e. housekeeper, maintenance, housekeeping, Residential Director, etc. 08/01/2014 Implemented
6400.163(c)Individual #1 had a medication review on 9/5/13, and the next review was on 12/26/13.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Effective immediately, all individuals prescribed psychotropic medication will be scheduled and reviewed by the psychiatrist every month as routine to ensure that the reviews with documentation are conducted within the required 90 day period. The Mollie Woods' Clinical Administrator sent written notification of this to personnel in Nursing and Psychology, who collaborate in conducting these monthly medication reviews. (See attachment H) Training for Psychology staff is in progress with sign-offs to be completed by 10/31/14. (See attachment I) 10/31/2014 Implemented
6400.186(c)(4)(ii)The program Specialist added outcomes to Individual #2's ISP dated 12/25/13, but did not send the recommendation to the Supports coordinator.The program specialist shall make a recommendation regarding the following, if applicable: The addition of an outcome or service to support the achievement of an outcome. Program Specialists will submit the attachments to the Director, Program Coordination or Program Planning Coordinator within 10 days following the ISP who will then log the information and pass it on to the Residential Support Specialist. ISP outcomes and additional attachments will then be mailed by the Residential Support Specialist to the Supports Coordinator following the ISP meeting date and prior to the ISP effective date. This agreement was made between the Director, Program Coordination and the Records Services Director on 10/7/14. Program Specialists were reminded by email on 10/7/14. (See attachment D) 10/07/2014 Implemented
6400.195(c)Individual #1's restrictive review committee reviewed on 12/5/13 and the next review was on 6/26/14. The restrictive procedure plan shall be reviewed, and revised, if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months. All clinical and program specialist staff were issued written notification that BMRC reviews of restrictive procedures must not exceed 6 months to the date of the last review.(clarifying "every 6 months" as it appears in the regulations). (See attachment B) This particular case for D.G. was cited but was reviewed by the BMRC six times between 12/5/13 and 6/24/14: 12/19/13, 1/30/14, 2/27/14, 3/26/14, 4/24/14, and 5/15/14. (See attachments C) 10/13/2014 Implemented
SIN-00091281 Renewal 10/26/2015 Compliant - Finalized