Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222791 Renewal 04/11/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)The provider assisted Individual #1 with purchasing bedroom furniture for $1,333.22 on 1/21/2023, jewelry for $298.53 on 1/28/2023, clothing and miscellaneous items for $263.96, a chair for $395.89 on 1/28/2023 and shoes for $310.00 on 1/28/2023. These disbursements were not logged into Individual #1's financial ledger until 2/16/2023.(2) Disbursements made to or for the individual. I. By May 30, 2023, the Program Supervisor/ID Director/CEO will consult with the fiscal department for review of Money Management Procedure 218.1 and to obtain simple step-by-step instructions on use of Safe Transaction Ledger. II. By May 30, 2023, the Program Supervisor will train all staff (Including new ID Director) on Financial Transactions for Person Served Training will include but not limited to: ¿ Instructions for use of the Safe Transaction ledger and review of Intellectual Disability Programs ¿ Individual Money Management Procedure 218.1 ¿ Reinforcement of procedure for same day entries into ledger at time of purchases in addition to all other required entries III. All staff will be required to verify the learned process by completion of two (2) demonstrations of correct ledger entries in one-on-one review with the Program Supervisor. Completion will be documented by supervisor and staff with date of completion on Demonstration Verification Form that has been newly developed. 05/04/2023 Implemented
6400.74There is not a nonskid surface on the interior steps leading to the attic of the home.Interior stairs and outside steps shall have a nonskid surface. The nonskid surface on the steps to the attic was installed within one week of the inspection 05/04/2023 Implemented
6400.81(h)On 4/12/23 at 12:35PM, the only window in Individual #2's bedroom was completely covered with a frosted window film, preventing a view of the outside.Each bedroom shall have at least one exterior window that permits a view of the outside. The frosting on the window was removed within one week of the inspection. 05/04/2023 Implemented
6400.32(s)The individuals residing in the home do not have a key, access card, keypad code or other entry mechanism to lock and unlock the front and back entrance doors of the home.An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.Keys to the entrance doors were made and distributed to all Persons Served within one week of the inspection. 05/04/2023 Implemented
6400.46(a)Direct Services Worker #1 initial had fire safety training did not include did not include home specific evacuation procedures and the designated meeting place.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.By May 8, 2023, Direct Service #1 will receive site specific fire safety training from CEO and provide verification of completion with Staff Record of Training Session to HR for Record. 05/04/2023 Implemented
6400.51(b)(1)Direct Service Worker #1's orientation, completed 11/22/22, did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.I. By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. 05/04/2023 Not Implemented
6400.51(b)(3)Direct Service Worker #1's orientation, completed 11/22/2022, did not include individual rights.The orientation must encompass the following areas: Individual rights.I. By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. III. By May 8, 2023 a Site-Specific Temporary Staff orientation will be implemented to include: ¿ Transitional Services Policies and Procedure on Individual Rights; and Incident Management ¿ Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) ¿ Shift Activities/Responsibilities (Job Related Knowledge/Skills) ¿ On-call Procedures ¿ Keys, Phones, 05/04/2023 Not Implemented
6400.51(b)(4)Direct Service Worker #1's orientation, completed 11/22/22, did not include recognizing and reporting incidents. [Repeat Violation, 10/5/2022]The orientation must encompass the following areas: recognizing and reporting incidents.By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. III. By May 8, 2023 a Site-Specific Temporary Staff orientation will be implemented to include: ¿ Transitional Services Policies and Procedure on Individual Rights; and Incident Management ¿ Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) ¿ Shift Activities/Responsibilities (Job Related Knowledge/Skills) ¿ On-call Procedures ¿ Keys, Phones, 05/04/2023 Not Implemented
6400.51(b)(5)Direct Service Worker #1's orientation completed on 11/21/22 did not include job-related knowledge and skills training as part of orientation.The orientation must encompass the following areas: Job-related knowledge and skills.By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. III. By May 8, 2023 a Site-Specific Temporary Staff orientation will be implemented to include: ¿ Transitional Services Policies and Procedure on Individual Rights; and Incident Management ¿ Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) ¿ Shift Activities/Responsibilities (Job Related Knowledge/Skills) ¿ On-call Procedures ¿ Keys, Phones, 05/04/2023 Not Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 5/5/2022, to the plan team members on 12/6/2022 for an Individual plan meeting on 12/6/2022. [Repeat Violation, 10/5/2022]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.By May 26, 2023, ID team (Program Specialist/ID Director) will develop and implement an ISP/Assessment tracking system that will collect the following data by person served: ¿ ISP annual date ¿ 120 days prior to ISP date for completion of assessment ¿ Verification of submission of assessment and accompanying email to Supports Coordinator immediately upon completion. ¿ 60 days prior reminder email to Supports Coordinator for ISP meeting date. ¿ 30 days post verification of ISP attendance 05/04/2023 Not Implemented
SIN-00217896 Unannounced Monitoring 01/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The screen in the first floor bathroom window is bent and does not fit securely. Screens, windows and doors shall be in good repair. The screen in the first floor bathroom window was replaced with in 24 hours of inspection. Review with staff process to request maintenance order. 02/15/2023 Implemented
6400.144Individual #2's prescribed pro re nata medication, Atarax Hydroxyzline 50MG tablet was not available in the home at the time of inspection.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Medication was ordered and received with in 24 hours of inspection. Reviewed with staff the process to order and document delivery of all medications. Reviewed with staff regulation that all medications, including PRN must be maintained at all times in the home. 02/15/2023 Implemented
6400.165(b)The medication label for Fleet Mineral Oil Enema MG prescribed to Individual #1 reads, "Take one application rectally every 120 hours as needed for constipation. If no bowel movement in five days. If no results call as directed by physician." Individual #1's January 2023 Medication Administration Record reads, " One application rectally every 5 days as needed for constipation."A prescription order shall be kept current.Medication label and MAR were corrected to match exactly. Medication label MAR review procedures were reviewed with staff. 02/15/2023 Implemented
6400.166(a)(7)Individual #2's January 2023 Medication Administration Record does not include the dose for Acetaminophen. [Repeat Violation, 10/4/2022]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.MAR was corrected within 24 hours of inspection. 02/15/2023 Implemented
SIN-00215097 Unannounced Monitoring 11/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Fluvoxamine, Lorazepam, Quetiapine and Simvastatin prescribed to Individual #1 were not initialed as administered on 11/6/2022 at 7:00PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff person reviewed medication administration procedures with staff who have been trained and passed the approved medication administration training program. 11/14/2022 Implemented
SIN-00212597 Renewal 10/04/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills completed from February 2022 through September 2022 do not address problems encountered.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. [Immediately, the CEO or designee shall audit the written fire drill documentation to ensure all required information including problems encountered is included on the documentation and revised as needed. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff person on conducting fire drills and documenting as required to ensure all required information is included including if problems are encountered and their responsibility if problems are encountered. Documentation of the trainings shall be kept. Upon completion of fire drills, a designated management staff person shall audit all fire drills to ensure fire drills are conducted as required and documented as required to ensure the safety of the individuals and if problems are encountered, they are addressed, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/17/2022)] 11/01/2022 Implemented
6400.141(a)Individual #2 had a physical examination on 1/21/2021 and then again on 2/14/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. [Immediately, the CEO or designee shall develop and implement a tracking system of individual physical examinations, to include the scheduling process with a responsible person, to ensure timely completion of individual's physical examination and other medical appointments. Within 2 weeks of receipt of the plan of correction and continuing at least monthly, the CEO or designee audit the aforementioned tracking system to ensure timely completion of individuals' physical examinations to ensure individuals health services are arranged and provided. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.141(c)(9)Individual #2, date of birth 4/13/1944, has not had a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. [Immediately, the CEO or designee shall schedule and facilitate Individual #2's prostate testing. Immediately, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included including prostate examinations, as required. Immediately, the CEO or designee shall develop and implement a tracking system of individual physical examinations including prostate examination to include the scheduling process with a responsible person, to ensure timely completion of individual's physical examination and other medical appointments. Within 2 weeks of receipt of the plan of correction and continuing at least monthly, the CEO or designee audit the aforementioned tracking system to ensure timely completion of individuals' physical examinations to ensure individuals health services are arranged and provided. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.141(c)(14)Individual #1's physical examination, completed on 8/18/2022, does not include medical information pertinent to diagnosis and treatment in case of an emergency. [Repeat Violation, 2/28/2022]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. [Immediately, the CEO or designee shall facilitate completion of Individual #1's physical examination. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff persons responsible to supporting individuals with completion of physical examinations of the requirements of individuals physical examinations as per 6400.141c(a)-(14) and their responsibilities to ensure competition and to ensure individuals' health services are arranged and provided. Documentation of trainings shall be kept. Within 2 weeks of receipt of the plan of correction, upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and ensure individuals health services are arranged and provided. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 10/18/2022 Implemented
6400.142(g)Individual #2 has not had a dental hygiene plan completed.A dental hygiene plan shall be rewritten at least annually. [Immediately, the CEO or designee shall facilitate completion of Individual #1's dental hygiene plan. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff persons responsible to supporting individuals with completion of dental hygiene plans of their responsibilities to ensure dental hygiene plans are implemented and completed, timely. Documentation of trainings shall be kept. requirements of individuals physical examinations as per 6400.141c(a)-(14) and their responsibilities to ensure competition and to ensure individuals' health services are arranged and provided. Within 2 weeks of receipt of the plan of correction, upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' dental hygiene plans to ensure completion, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.181(d)Individual #1's assessment, dated 5/15/2022, was not signed by the program specialist.The program specialist shall sign and date the assessment. [Immediately, the program specialist shall review and sign Individual #1's assessment. Within 2 weeks, and upon completion for at least one year, the CEO or designee educated in the requirements of Individuals' assessments, shall audit all individuals' current assessments to ensure all required information is included and accurate. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 10/18/2022 Implemented
6400.181(e)(4)Individual #1's assessment, dated 5/15/2022, states, "[Individual] can be without supervision in the home and the community." This does not include the actual length of time the individual can be unsupervised. The Individual Service Plan, last updated on 10/03/2022, states, "[Individual] needs a home with 24 hour staff present. He is able to be unsupervised in the community for up to 6 hours at a time. Since being diagnosed with dementia, he is required to check in more frequently to ensure his safety." The assessment must include the following information: The individual's need for supervision. [Immediately, the program specialist shall facilitate an accurate completion of Individual #1's assessment to include all required information. Within 2 weeks, and upon completion for at least one year, the CEO or designee educated in the requirements of Individuals' assessments, shall audit all individuals' current assessments to ensure all required information is included and accurate. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Not Implemented
6400.181(e)(12)Individual #1's assessment, dated 5/15/2022, does not include recommendations for specific areas of training, programming and services. This section only says, "N/A."The assessment must include the following information: Recommendations for specific areas of training, programming and services. [Immediately, the program specialist shall complete Individual #1's assessment to include all required information. Within 2 weeks, and upon completion for at least one year, the CEO or designee educated in the requirements of Individuals' assessments, shall audit all individuals' current assessments to ensure all required information is included and accurate. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Not Implemented
6400.52(c)(3)Chief Executive Officer #1's training for the annual training year 1/1/2021-12/31/2021 did not encompass individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.[Within 2 weeks of receipt of the plan of correction and continuing at least quarterly, the CEO or designee shall audit staff training records and/or staff training tracking documentation to ensure all staff persons including the CEO have completed all required trainings, timely. Documentation of audits shall be kept. (AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.52(c)(4)Chief Executive Officer #1's training for the annual training year 1/1/2021-12/31/2021 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.[Within 2 weeks of receipt of the plan of correction and continuing at least quarterly, the CEO or designee shall audit staff training records and/or staff training tracking documentation to ensure all staff persons including the CEO have completed all required trainings, timely. Documentation of audits shall be kept. (AES,HSLS on 10/18/2022)] 10/18/2022 Implemented
6400.166(a)(4)Individual #2's October 2022 Medication Administration Record lists, "Complete Advanced Formula Sun." The medication label states, "HM Complete 50+ Formula MG."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.[Within 2 weeks of receipt of the plan of correction, and continuing at least monthly and upon all individuals' medication changes, a designated staff person qualified to administer medications shall audit all individuals medications, current medications administration record and prescribed medications including over the counter medications to ensure all individual are administered medications as prescribed, current medication administration record is accurate and medication administrations are documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 10/18/2022 Not Implemented
6400.166(a)(9)Individual #2's October 2022 Medication Administration Record states, "Artificial Tears ophthalmic solution [ocular lubricant] Instill two drops into each eye once daily as needed." The medication label states, "Instill two drops into each eye every four hours as needed."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.[Within 2 weeks of receipt of the plan of correction, and continuing at least monthly and upon all individuals' medication changes, a designated staff person qualified to administer medications shall audit all individuals medications, current medications administration record and prescribed medications including over the counter medications to ensure all individual are administered medications as prescribed, current medication administration record is accurate and medication administrations are documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Not Implemented
6400.166(a)(11)Individual #2's October 2022 Medication Administration Record does not include the diagnosis or purpose for Polyethylene Glycol. [Repeat Violation, 2/28/2022]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.[Within 2 weeks of receipt of the plan of correction, and continuing at least monthly and upon all individuals' medication changes, a designated staff person qualified to administer medications shall audit all individuals medications, current medications administration record and prescribed medications including over the counter medications to ensure all individual are administered medications as prescribed, current medication administration record is accurate and medication administrations are documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 10/18/2022 Not Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment completed, 5/15/2022 assessment to the Individual #1's plan team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.[Immediately, the program specialist shall provide Individual #1's current assessment to Individual #1's plan team member and maintain documentation to be provided to the Department upon request. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure all individual's assessments are completed, timely, and provided to the plan team members, timely and to maintain documentation. At least monthly for one year and then continuing at least quarterly, the CEO or designee shall audit the aforementioned tracking system and related documentation to ensure assessments are completed with all required information, timely and provided to plan team members, timely. (DPOC by AEs,HSLS on 10/18/2022)] 11/01/2022 Not Implemented
6400.182(c)Individual #1's assessment, dated 5/15/2022, states, "[Individual #1] is able to evacuate in the event of a fire." Individual #1's Individual Plan, last updated 10/03/2022, states, "During overnight fire drills, [Individual #1] cannot hear the sounding alarm and needs to be physically tapped on the shoulder to wake up and signal evacuation."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.[Immediately, the program specialist shall audit Individual #1's current assessment and current Individual plan and coordinate with Individual#1's SC to ensure consistency and accuracy with both. Within 2 weeks of receipt of the plan of correction and continuing at least quarterly for 1 year and then at least annually, the program specialist shall audit all individuals' current assessments and individual plans and facilitate with the individuals' SCs to ensure consistent and accurate information between all individuals' current assessments. Documentation of audits and correspondence with SCs shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Not Implemented
SIN-00208271 Unannounced Monitoring 07/06/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)On 7/6/22 at 12:24PM, inordinate amount of dead bedbugs were in cobwebs and on the floor near in the radiator in the corner of Bedroom #6. There was also a multitude of dead bedbugs on the window sill in the laundry room and on the floors in hallways on the first and second floors of the home.There may not be evidence of infestation of insects or rodents in the home. On 7/6/22 staff completed initial cleaning of bedroom #6, laundry room windowsill, floors, and hallway. 07/21/2022 Not Implemented
6400.70On 7/6/22, the telephones in the home were not operable.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Phones in both the hallway and kitchen of the building were repaired by the phone company on 7/10/22. The phones are now in working order. 07/10/2022 Not Implemented
6400.101There is a padlock on the door to the closet, large enough for a person to be entrapped, in the laundry room on the second floor of the home posing a possible obstructed egress when in use.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 7/6/22 the padlock was removed from the closet door. 07/21/2022 Implemented
SIN-00204506 Unannounced Monitoring 05/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bedroom has strong odor of urine.Clean and sanitary conditions shall be maintained in the home. Due to ongoing incontinence the following will be completed 1) The floor in the bedroom will be replaced by June 24th . 2) A new mattress, box spring, bed frame and cover will be purchased to replace old bed by June 10th and assessed for replacement in one year. 3) Change in protocol for garbage removal from daily to each shift has begun immediately. 06/24/2022 Not Implemented
6400.66There is not an outside light at the exit on the second floor of the home. There is not another source of light in that area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Maintenance Department has arranged for installing a new emergency exit sign and light to be installed by an electrical contractor. This was completed on May 26, 2022. 06/17/2022 Not Implemented
6400.72(a)The screen on the window on the left in Individual #2's bedroom was three inches too small leaving an gap at the top of the window without a screen covering.Windows, including windows in doors, shall be securely screened when windows or doors are open. New window screens have been ordered and replaced on May 27,2022. Staff have been retrained on protocol to report and document maintenance work orders. 06/17/2022 Not Implemented
6400.32(r)There is not on a lock on Individual #1's bedroom door.An individual has the right to lock the individual's bedroom door.The individual expressed their desire to not have a lock on their bedroom door. The site supervisor obtained the signature of the individual on a lock declination form. The form has been filed in the individuals record as of 5,27,2022. 05/27/2022 Not Implemented
6400.32(s)The individuals residing in the home do not have a key, access card, keypad code or other entry mechanism to lock and unlock the front and back entrance doors of the home.An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.Copies of keys were made and provided to each individual living in the home by the site supervisor on 6/1/22. 06/01/2022 Not Implemented
SIN-00200930 Renewal 02/28/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 11/8/21, had Pennsylvania criminal history record checks completed 10/9/2020 and then again 12/9/2021.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Direct service worker #1 had a criminal history records check completed on 12/9/21. The hire date was11/8/21. Although the criminal history records check was not completed within 5 working days of the hire dated, the HR specialist did identify this violation during a regular review of new hire paperwork and informed the Director of the violation. Given the violation could not be corrected, a new practice was implemented immediately. The HR director/HR Recruiter will review all new hire paperwork including the criminal background records check, prior to approval of a scheduled start date for new hires. 03/25/2022 Implemented
6400.15(b)The agency did not use the current Department's licensing inspection instrument when completing a self-assessment of the home on 11/17/21. The self-assessment used was modified 6/2018 and did not included the current community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency did not use the Regulatory Compliance Guide Appendix A 55Pa.Code Chapter 6400 Community Homes for Individuals with an Intellectual Disability or Autism Self Assessment Licensing Inspection Instrument to complete the annual pre licensing inspection paperwork. The Department director discarded the outdated pre licensing inspection checklist immediately. The department director immediately created a pre licensing inspection folder which now included the Regulatory Compliance Guide Appendix A 55Pa.Code Chapter 6400 Community Homes for Individuals with an Intellectual disability or Autism. The file is in hard copy form in the director's office. An electronic version is found on the agency's U drive. The ID Director will complete the tool in the month of April. 03/31/2022 Not Implemented
6400.52(c)(2)Chief Executive Officer #2's annual training hours for training year 1/1/21 through 12/31/21 did not encompass prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The CEO will complete the required prevention, detection and reporting of abuse, suspected abuse and alleged abused in accordance with the Older Adults Protective Services Act immediately. 03/31/2022 Not Implemented
6400.52(c)(6)The Program Specialist #3's annual training hours for training year 1/1/21 through 12/31/21 did not encompass implementation of the individual plans.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Program specialist will review ISPs of all individuals served immediately and sign documentation attesting to completing a self-study of all individuals ISP's. immediately. 03/31/2022 Implemented
6400.166(a)(11)Individual #1's February 2022 Medication Administration Record did not include the diagnosis or purpose for the following medications: Lorazepam .5mg, Omeprazole Cap 20mg, Quetiapine 40 mg, Acetaminophen 500 mg. [Repeat Violation, 3/9/21]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Retraining of all direct workers and supervisors on the proper method to enter medication into the agency's precision care database was provided. Retraining focused on ensuring staff understand the requirement that each medication record shall include the diagnosis or purpose for the medication. All direct workers will sign a training slip to document have received the training. This document will be filed in their human resources employee file by the HR Specialist. 03/31/2022 Not Implemented
SIN-00183175 Renewal 02/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1's most recent physical examination was completed on 9/5/18. 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. Staff person was sent to medical facility 2/1021 to obtain an updated physical. Documentation of the physical was filed in the staff person's human resource file. On a semi annual basis all staff human resource files will be reviewed to ensure compliance. Staff will be provided with a written reminder of the due date for an updated physical to be completed. TSI administrator will document receipt of updated physical then submit documents to be filed in HR department staff record. [Staff received a physical examination on 2/10/21. Immediately, the CEO or designee shall audit all staff records to ensure a current physical examination is complete and present in the record. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/16/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 5/15/20. The rights document did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j to voice concerns and 6400.32k to participation in the development and implementation of the individual plan; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home.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.A revised Individual rights sign off form was created to included 6400.32 e-6400.32 g, 6400.32j, and 6400.32 s. Each individual will be provided a copy of the updated form which will be reviewed with them and a signature will be obtained. Annually the Individual Rights Sign Off Form will be reviewed with each individual and an update signature will be obtained.[Updated individual rights form was signed by individual on 2/15/21. Immediately, the CEO or designee shall develop policies and procedures for reviewing agency documents to ensure they meet the requirements of the regulations. (DPOC by RM, HSLS on 3/18/2021)] 03/16/2021 Implemented
6400.169(a)Program Specialist #2's medication administration training completed on 6/24/20 did not include two required medication administration record reviews. Program Specialist #2 administered Risperdal 2mg tablet, with instructions to take 1 tablet 3 times a day for psychosis and other psychotic symptoms, to Individual #1 on 2/03/21 and 2/04/21 at 12:00pm.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).Program specialist will complete two medication administration record reviews in accordance with requirements on 3/9/2021. A review of medication practicums agency wide occurred to ensure there were no systemic issues with TSI's medication administration training practices. The TSI medication training committee met twice to revise and update training best practices. Medication practicums will be held each year in October and March. A new system to monitor completion of practicums has been created to ensure compliance. [Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/20/21)] 03/16/2021 Implemented
SIN-00164030 Renewal 10/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)The bed shaker belonging to Individual #2 who has bilateral conductive hearing loss was inoperable when the smoke detector system was tested at 11:46AM. The maintenance staff person replaced the bed shaker which was operable when the smoke detector system was tested at 11:50AM. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Program specialist will observe the bed shaker during all scheduled monthly fire drills. In addition to observing the test, the program specialist will begin recording the result of his observation on the monthly fire drill documentation as proof that the test was completed Attached; Verification of Bed Shaker line on Fire Drill document [Immediately and continuing at least weekly for 1 month and then continuing at least monthly, a designated staff person trained in the process to check the smoke alarms and bed shakers and the repair or replacement procedures, shall test the smoke alarm system including bed shakers to ensure are working at all times. Documentation of the testing of the smoke alarms including bed shakers shall be kept and reviewed at least quarterly for 1 year to ensure they are in working order at all times. (DPOC by AES,HSL on 10/21/19)] 10/18/2019 Implemented
6400.141(c)(11)Individual #1's physical examination completed 2/11/19 did not include health maintenance needs. This section was left was blank.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. Perspective admissions to Transitional Services Intellectual Disabilities Program(s) will be required to have a pre-admission physical examination with the results being recorded on our (Transitional Services, Inc.) agency physical form and signed by the examining physician as a condition of admission. Moving forward, we will no longer accept physical examinations (for admission) that are not documented on our agency paperwork (physical form) and admission to the program will be put on hold until our form is completed. Attached Revised TSI IDD admission procedure. [Individual #1's current physical examination was updated to address health maintenance needs on 10/15/19. Immediately and upon completion, the CEO or designee educated in the requirements of individual's physical examinations to ensure all individuals have a current physical examination that includes all required information and health services are arranged and provided. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 10/21/19)] 10/18/2019 Implemented
SIN-00123546 Renewal 10/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)The program specialist signed and dated Individual #1's ISP reviews dated 6/1/17, 3/1/17 and 12/1/16 on 1/22/17. Individual #1 signed and dated Individual #1's ISP reviews dated 6/1/17, 3/1/17 and 12/1/16 on 1/15/17. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. What specific change will be made-Program Specialist reviewed the updated documentation due date spreadsheet that ID director updated. Who will make the change-Program Specialist/Id Director When with the change be made- 11/02/2017/11/01/2017 How will the change be made-The Program Specialist and the Individual will sign and date the ISP 3 month review within 15 days of the due date together. What system have you implemented to make sure that the same violation will not occur again-Program Specialist will immediately review the documentation due date spreadsheet with Site Staff and continue to review it monthly during supervision. Upon completion of the ISP 3 month review, the Program Specialist will scan and email each Individual's ISP 3 month reviews to ID director. What training will be provided to your staff-Staff will be re-trained on regulation 6400.186 (b) within 30 days of receipt of the plan of correction. Documentation of training will be kept. [Immediately, the Director shall train the program specialist on the responsibilities of the program specialist position as per 6400.44(b)(1-(19) and the aforementioned tracking spreadsheet. Documentation of the training shall be kept. At least quarterly for 1 year, the Director shall audit the tracking system and individuals' ISP reviews to ensure the program specialist and the individual signed and date the ISP review upon review. Documentation of audits shall be kept. (AS 11/8/17)] 11/02/2017 Implemented
6400.213(1)(i)Individual #2's record did not include identifying marks.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.What specific change will be made- Program Specialist added the identifying marks to the Individual's record. Who will make the change-Program Specialist How will the change be made-Site staff will not leave any blanks on any documentation and will include all required personal information as per, regulation 6400.213 (1) (I) What system have you implemented to make sure that the same violation will not occur again-Immediately and at least quarterly, site staff will check and correct any blanks on their documentation and that all Individual's records have the required personal information of regulation 6400.213 (1) (ii). Program Specialist will also audit the documentation at least quarterly and report needed corrections to ID director during monthly supervisions. What training will be provided to your staff-Staff will be re-trained on regulation 6400.213 (1) (ii) within 30 days of receipt of the plan of correction. Documentation of the training will be kept. [Aforementioned training shall included all required personal information required in Individuals' records as per 6400.213(1)(i)-(vi). (AS 11/8/17)] 10/27/2017 Implemented
SIN-00103397 Renewal 11/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature at the bathtub measured 135.8°F at 9:41 AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. What specific change will be made. The water heater was turned down immediately. Different thermometers have been ordered. Who will make the change. Site staff. When will the change be made. 11-10-16 and 12-2016 (when new thermometers are received). How will the change be made. New thermometers. What system have you implemented to make sure that the same violation will not occur again. We reviewed our record of monthly water temperature checks for the past two years. All checks were between 108º and 117º and averaged 113º. Therefore it appears that there is a discrepancy between the thermometers used by staff and those used by the inspectors. We have ordered new thermometers of the same brand and model as used by the inspectors and will begin using these for water temperature checks as soon as they are received. What training will be provided to your staff. Staff will be re-trained on using the new thermometers and the requirements contained in 6400.31(a).[Immediately, the CEO shall develop and implement policies and procedures to include daily hot water temperature checks at all bathtubs and showers until the hot water temperature do not exceed 120°F for at least one week and then continuing at least monthly and procedures to follow if hot water temperature exceed 120°F. Within 30 days of receipt of the plan of correction, all staff persons shall be trained in aforementioned policy and procedures. Documentation of all checks and trainings shall be kept. (AS 11/29/16)] 12/01/2016 Implemented
6400.112(c)The written fire drill record for the fire drills conducted on 2/22/16, 4/27/16, and 6/6/16 did not include whether the fire alarm was operative. 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. What specific change will be made. Staff will use the most-current version of the fire drill report form (which contains all required information). Who will make the change. Site staff. When will the change be made. 11-28-16 (i.e., next fire drill) How will the change be made. The most-current version of the fire drill report form contains all required information. For the drills in question, the staff who documented the drill used an obsolete form. The site supervisor has already addressed the proper form with staff and the proper form will be used during the next fire drill in late November. What system have you implemented to make sure that the same violation will not occur again. The building supervisor and the Health and Safety Committee will check for this condition when reviewing fire drills. What training will be provided to your staff. Staff will be re-trained on conducting fire drills with emphasis on the requirements contained in 6400.112 (c).).[At least monthly for 6 months and at least quarterly thereafter, the CEO or designated management staff person will review the fire drill records to ensure all individuals participate in an unannounced drill at least once a month. Documentation of the review shall be kept. (AS 11/29/16)] 12/01/2016 Implemented
6400.151(c)(2)Direct Service Worker #1 had a Tuberculin skin test completed on 11/8/13 and then again on 12/18/15. 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. What specific change will be made. The interval between Tuberculin skin tests for a given staff will not be more than two years. Who will make the change. Site staff. When will the change be made. 11-11-16. How will the change be made. The policy on Employee Physical Exams was amended on 11-11-16 to indicate that staff who fail to meet deadlines for physical exams will be placed on unpaid leave and are subject to disciplinary action. What system have you implemented to make sure that the same violation will not occur again. HR Manager will monitor the next three employee physical exams for timely completion and any resulting actions. What training will be provided to your staff. Staff will be trained on the revised policy and the requirements contained in 6400.151(c)(2). [Immediately, CEO shall develop and implement a tracking and notification system to ensure all staff are notified and complete physical examination including Tuberculin skin testing, timely. Documentation of trainings and reviews shall be kept. (AS 11/29/16)] 12/01/2016 Implemented
6400.181(f)The assessment dated 2/15/16 for Individual #1 was not provided to all plan team members including the family. (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). What specific change will be made. The 02-15-16 Assessment was sent to the family on 11-22-16. Who will make the change. Program Specialist. When will the change be made. On 11-22-16. How will the change be made. The Assessment in question was sent to the family. What system have you implemented to make sure that the same violation will not occur again. The Director will monitor the next two Assessments for this individual to ensure that they were also sent to the family. What training will be provided to your staff. Staff will be re-trained on distribution of Assessments and the requirements contained in 6400.181 (f).[Prior to the program specialist providing the assessments to the plan team members for all individuals, the program specialist shall review the individuals' records including invitation letters, ISP and other documentation to ensure all plan team members are included. Documentation of the correspondence to the plan team members shall be kept and reviewed by the director at least quarterly, for 1 year the Director to ensure all plan team are provided the assessments as required. (AS 11/29/16)] 12/01/2016 Implemented
6400.186(d)The program specialist did not provide the ISP reviews for Individual #1 dated 9/30/16, 6/30/16, and 3/30/16 to all plan team members including the family. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. What specific change will be made. The 03-30-16, 06-30-16 and 09-30-16 Quarterly Reviews were sent to the family on 11-22-16. Who will make the change. Program Specialist. When will the change be made. On 11-22-16. How will the change be made. The reviews in question were sent to the family. What system have you implemented to make sure that the same violation will not occur again. The Director will monitor the next two reviews for this individual to ensure that they were also sent to the family. What training will be provided to your staff. Staff will be re-trained on distribution of Quarterly Reviews and the requirements contained in 6400.186 (d).[Prior to the program specialist providing the ISP reviews to the plan team members for all individuals, the program specialist shall review the individuals' records including invitation letters, ISP and other documentation to ensure all plan team members are included. Documentation of the correspondence to the plan team members shall be kept and reviewed by the director at least quarterly, for 1 year the Director to ensure all plan team are provided the ISP reviews as required. (AS 11/29/16)] 12/01/2016 Implemented
6400.186(e)The program specialist did not notify the plan team members including the family for Individual #1 of the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. What specific change will be made. The Declination Notice was sent to the family on 11-22-16. Who will make the change. Program Specialist. When will the change be made. On 11-22-16. How will the change be made. The Declination Notice in question was sent to the family. What system have you implemented to make sure that the same violation will not occur again. The Director will monitor the next two situations requiring Declination Notices to ensure that they were also sent to families. What training will be provided to your staff. Staff will be re-trained on distribution of Declination Notices and the requirements contained in 6400.186 (e).[Prior to the program specialist notifying the plan team members for all individuals of the option to decline ISP review documentation, the program specialist shall review the individuals' records including invitation letters, ISP and other documentation to ensure all plan team members are included. Documentation of the correspondence to the plan team members shall be kept and reviewed by the director at least quarterly, for 1 year the Director to ensure all plan team are notified of the option to decline as required. (AS 11/29/16)] 12/01/2016 Implemented
SIN-00085617 Renewal 10/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1, date of admission 1/19/15, was not informed of individual's rights until 1/20/15.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. What specific change will be made. Individuals will be informed of the individual¿s rights on the day of admission. Who will make the change. Site staff. When will the change be made. On the next individual¿s admission. How will the change be made. Admissions will be scheduled early enough in the day to allow for time to review all required information on admission day. What system have you implemented to make sure that the same violation will not occur again. Scheduling of admissions to allow time for all required information to be reviewed on admission day. What training will be provided to your staff. Staff will be re-trained on admission scheduling and the requirements contained in 6400.31(a).[CEO or designee will review all new admission documentation for the next 3 newly admitted Individuals on the day of admission to ensure all required documentation is completed including the being informed of rights. (AS 12/3/15)] 10/16/2015 Implemented
6400.141(c)(3)Individual #2, date of admission 2/20/15, did not have a TDap immunization until 4/10/15.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. What specific change will be made. Staff will ensure that all physical exams, including preadmission exams, contain the date of the tetanus/diphtheria immunization. Who will make the change. Site staff. When will the change be made. 10-16-15 How will the change be made. Staff will review all physical exams to ensure that they contain the date of the tetanus/diphtheria immunization. What system have you implemented to make sure that the same violation will not occur again. The physical exam form has been revised to include a space to specify the date of the last tetanus/diphtheria immunization. What training will be provided to your staff. Staff will be re-trained on the physical exam form and the requirements contained in 6400.141(c)(3)).[CEO or designee will review all new admission documentation for the next 3 newly admitted Individuals on the day of admission to ensure all required documentation is completed including physcal examinations including immunizations is completed within required time frames. Documentation of the reviews will be kept by the CEO. (AS 12/3/15)] 10/16/2015 Implemented
6400.141(c)(7)A gynecological examination including breast examination and Pap test for Individual #1, date of birth 2/5/92 was completed on 4/17/15. Individual #1 was admitted on 1/19/15.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. What specific change will be made. Staff will ensure that all physical exams for women 18 years of age or older, including preadmission exams, include a gynecological examination. Who will make the change. Site staff. When will the change be made. 10-16-15 How will the change be made. Staff will review all physical exams for women 18 years of age or older to ensure that they include a gynecological examination. What system have you implemented to make sure that the same violation will not occur again. Staff will review all physical exams for women 18 years of age or older to ensure that they include a gynecological examination and, if not, the physician will be alerted to rectify this. What training will be provided to your staff. Staff will be re-trained on the physical exam form and the requirements contained in 6400.141(c)(7).)[CEO or designee will review all new admission documentation for the next 3 newly admitted Individuals on the day of admission to ensure all required documentation is completed including the gynological examination within the required time frames. Documentation of the reviews will be kept by the CEO(AS 12/3/15)] 10/16/2015 Implemented
SIN-00069174 Renewal 10/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance expired 10/22/14; however, the agency completed the self-assessment on 9/17/14.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. What specific change will be made. Self-Assessments will be scheduled between 04-22 and 07-22 of each year. Who will make the change. ID Program Director. When will the change be made. For the next self-assessment (i.e., between 04-22-15 and 07-22-15). How will the change be made. In planning when to do the self-assessment it will be scheduled to occur after 04-22-15 and before 07-22-15. What system have you implemented to make sure that the same violation will not occur again. This adjustment has been built into the inspection cycle. What training will be provided to your staff. Staff was re-trained on the inspection cycle and the requirements contained in 6400.15(a). 10/27/2014 Implemented
6400.31(b)The "Rights" form, signed by Individual #1 on 1/18/14, does not state the full rights per regulations 33(e) regarding the right to privacy and 33(m) regarding not being required to work in the home. Per 6400.33(e), "An individual has the right to privacy in bedrooms, bathrooms and during personal care." Individual #1's signed statement does not include this statement. Per 6400.33(m), "An individual may not be required to work at the home, except for the upkeep of the individual's personal living areas and the upkeep of common living areas and grounds." Individual #1's signed statement included "the right to be paid by the agency for any work at the residence that benefits the agency, other than upkeep of personal and community living areas related to shared responsibilities for regular household chores." 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. Our Rights document included the following statements: ¿The right to privacy regarding myself and my possessions.¿ and ¿The right to be paid by the agency for any work that I do that benefits the agency. (This does not include regular household chores that are part of the upkeep of my personal living areas or related to my shared responsibilities for community living areas.)¿ The Rights document was revised on 10-09-14 replacing these statements with the following: ¿The right to privacy in bedrooms, bathrooms, and during personal care. This includes honoring male or female staff preferences for assistance during personal care, if I have communicated a preference for purposes of privacy and dignity.¿ and ¿The right not to be required to work at the home, except for the upkeep of my personal living areas and the upkeep of common living areas and grounds.¿ What specific change will be made. Our Rights document was revised to incorporate the language in the regulations. The revised form was reviewed with and signed by all individuals and will be the version used in future reviews of rights. Who will make the change. ID Program Director. When will the change be made. 10-09-14. How will the change be made. Our Rights document was revised to incorporate the language in the regulations. What system have you implemented to make sure that the same violation will not occur again. The revised Rights document will be used in place of the previous version. What training will be provided to your staff. Staff was re-trained on the revised Rights document and the requirements contained in 6400.31-34. 10/27/2014 Implemented
6400.68(b)The bath tub hot water temperature in the bathroom near the telephone on the second floor was 122.9 degrees Fahrenheit at 11:30 a.m. Hot water temperatures in bathtubs and showers may not exceed 120°F. What specific change will be made. Property Management staff immediately turned down the setting on the hot water tank. Who will make the change. Property Management staff. When will the change be made. 10-10-14. How will the change be made. Property Management staff immediately turned down the setting on the hot water tank. What system have you implemented to make sure that the same violation will not occur again. This has been added to the weekly physical site checklist. What training will be provided to your staff. Staff was re-trained on the weekly physical site checklist and the requirements contained in 6400.68(b). 10/27/2014 Implemented
SIN-00230020 Renewal 07/06/2023 Compliant - Finalized
SIN-00210599 Unannounced Monitoring 08/22/2022 Compliant - Finalized
SIN-00143622 Renewal 10/18/2018 Compliant - Finalized
SIN-00086541 Unannounced Monitoring 10/15/2015 Compliant - Finalized
SIN-00085661 Unannounced Monitoring 07/27/2015 Compliant - Finalized