Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222792 Renewal 04/11/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment on 3/20/23; however, the following 6400 regulations were left blank: 19a3, 25c, 141c10, 141c11, 141c12, 141c15, 141d, 142b, 142c, 142d, 142e, 142g, 145(2), 145(3), 165f, 165g, 166a11, 181e9, and 212.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. I. By May 26, 2023, CEO, Program Specialist and ID Director will obtain the necessary education/training on utilization and guidelines on the Self-assessment licensing inspection instrument that is featured in the ODP 6400 Regulatory Compliance Guide as appendix A. II. The Program Specialists and Program Director will be responsible for completing these self-assessments, including marking "NA" for any areas that do not apply to the house that they are assessing. III. Self-assessment forms will be submitted to the Director and/or CEO for their review. 05/04/2023 Not Implemented
6400.15(c)The agency completed a self-assessment on 3/23/23 and indicated violations of 181e(10) and 217; however, a written summary of the corrections was not kept by the agency.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. I. By 4.10.23, all individuals had updated Lifetime Medical History records. II. By 4.10.23, all individuals had current release of information in their chart. 05/04/2023 Not Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed on 9/28/22, to the plan team members on 10/12/22 for the individual plan team meeting on 10/12/22. [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
6400.182(c)Individual #1's 9/28/22 assessment indicates that he can be without supervision in the home and community. Individual #1's supervision care needs section of the individual plan that was last updated on 2/8/23, reads "[Individual #1] requires minimal supervision while at home with routine checks. At this time, he does require some assistance while cooking on the stove or using the oven." [Repeat Violation, 10/5/2022]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.By 5.4.23, the Assessment of Individual # 1 will be updated to reflect that he does require minimal assistance/supervision when cooking on stove or using the oven. Assessment will be provided to Supports Coordinator on 5.4.23 to properly update the ISP to be in alignment with the needs of the individual. 05/04/2023 Implemented
SIN-00221580 Unannounced Monitoring 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:20AM on 3/21/2023, there were sticky substances and crumbs on the shelves in Individual #2's refrigerator.Clean and sanitary conditions shall be maintained in the home. The Callowhill staff immediately on 3/21/23 corrected the violation by providing a thorough cleaning to address all the items listed in this violation by the end of business day. 04/13/2023 Implemented
6400.171At 10:15AM on 3/21/2023, two packages of lunch meat with expiration dates of 3/16/2023, 3/17/2023 and 3/18/2023 in Individual #1's refrigerator. [Repeat Violation, 1/19/2023]Food shall be protected from contamination while being stored, prepared, transported and served. The Callowhill staff immediately on 3/21/23 corrected the violation by providing a thorough cleaning to address all the items listed in this violation by the end of business day. 04/13/2023 Implemented
SIN-00215098 Unannounced Monitoring 11/08/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light outside back exit at the home is inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb was replaced immediately. 11/08/2022 Not Implemented
6400.163(g)On 11/8/2022 at 11:41AM, there were two loose Vitamin D3 capsules on the bottom of Individual #1's medication storage box.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Vitamin D3 Capsules were removed from box and disposed of per TSI medication disposal policy and procedures 11/08/2022 Not Implemented
SIN-00212598 Renewal 10/04/2022 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 10/18/2022)] 11/01/2022 Implemented
6400.141(c)(11)Individual #1's physical examination, completed on 8/22/2022, does not include the medication regimen.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. [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)] 11/01/2022 Implemented
6400.142(f)There was not a dental hygiene plan provided for individual #1.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. [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
6400.32(r)(1)There is a deadbolt lock on Individual #1's bedroom door. Individual #1 has not been provided a key to lock and unlock his door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.[Immediately, the CEO or designee shall ensure Individual #1 is provided the ability to exercise the right to lock the individual's bedroom door. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall ensure all individuals are provided the right to lock their bedroom doors unless the individual clearly expresses that they do not want the door to be equipped with a lock. Documentation shall be maintained. Within 2 weeks of receipt of the plan of correction, upon hire, at least annually and as needed, the CEO or designee shall educate all staff persons of the individual right to lock the individuals' bedroom doors and the agency's procedures to ensure staff persons have entry device to lock and unlock the doors which allows easy and immediate access in the event of an emergency. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.34(a)Individual #2, admitted on 9/6/2022, was informed and explained his individual rights on 9/10/2022.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.[Within 2 weeks of receipt of the plan of correction, the CEO or designee shall develop and implement an admission process to include that all Individuals are informed and explained individual rights and the process to report rights violation, upon admission. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate the staff persons responsible for the admission process on their responsibilities of the admission process. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.51(b)(4)The orientatin provided to Direct Service Worker #1, date of hire 8/22/2022 did not encompass recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.[Immediately, Direct Service Worker #1 shall be educated in 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 and orientation records and/or staff training tracking documentation to ensure all staff persons have completed all required orientation and trainings, timely. Documentation of audits shall be kept. (AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
6400.165(g)Individual #1's psychiatric medication reviews completed on, 2/1/2022, 5/3/2022 and 8/9/2022 do not include the necessary dosage for the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.[Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for supporting individuals in obtaining psychiatric medication reviews in the requirements as per 6400.165g and their responsibility to ensure completion and that all individuals are administered medications as prescribed. Documentation of the trainings shall be kept. Upon completion, a designated staff person educated in 6400.165g shall audit the medication reviews to ensure completion and that all individuals are administered medications as prescribed. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
SIN-00211954 Unannounced Monitoring 09/22/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:49AM, there were burnt substances on the bottom of the oven and thick, white residue throughout the inside of the oven. [Repeat Violation, 2/28/2022, 5/3/2022]Clean and sanitary conditions shall be maintained in the home. The oven was recleaned on 9/23/22 by staff. 09/23/2022 Not Implemented
SIN-00208225 Unannounced Monitoring 07/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71On 7/6/22, the telephone number of the nearest hospital, police department, fire department, ambulance and poison control center were not on or near the telephone in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. On 7/6/22 the emergency phone numbers were added to the phone in apartment 2. 07/06/2022 Implemented
6400.76(a)The springs under one side of the loveseat were bent and the material above the springs was ripped exposing the padding. In addition, that side of the loveseat was concaved and the cushion was approximately 5 inches lower than the other side of the loveseat. Furniture and equipment shall be nonhazardous, clean and sturdy. The damaged loveseat and chair were removed from the apartment. New furniture has been ordered and was delivered on 7/26/22. 07/26/2022 Implemented
SIN-00204507 Unannounced Monitoring 05/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70The telephone in the home did not have a dial tone and was not operable.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Verizon phone service has been contacted to determine if the phone line installed is currently active. An appointment with a technician has been scheduled for May 31, 2022 and June 2nd 2022. Until June 2, 2022 and cell phone is available for the individual living in the home along with a land phone line in the hallway outside of the apartment. 06/02/2022 Not Implemented
6400.110(b)The smoke detector located three feet eight inches from Individual #1's bedroom was not ioperable when tested at 10:12AM. The plastic strip to activate the smoke detector had not been removed.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. The smoke detector's plastic strip was removed, tested and found to be in working order at 10:15 am on the date of the inspection. 06/01/2022 Not Implemented
6400.171At 10:12AM, a carton of eggs that expired on 3/30/2022 was located on the top shelf of the refrigerator of the home.Food shall be protected from contamination while being stored, prepared, transported and served. All expired food was removed from the refrigerator and new, fresh food replaced. 06/01/2022 Not Implemented
6400.163(d)Individual #1's prescription medication, Fluticasone nasal spray, was observed inside of a baggie on the dresser in the bedroom. Individual #1 is not assessed to self-administer medication.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The over the counter medication was removed from the dresser and properly stored in the individual's medication box on 5/6/22. 05/27/2022 Not Implemented
SIN-00200931 Renewal 02/28/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom along the hallway did not have 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. A towel was immediately placed in the bathroom. 03/31/2022 Implemented
6400.110(b)The smoke detector in the hallway of the home was 18 feet and 4 inches from Individual #1's bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. A smoke detector was installed in Apartment 2 within 15 feet of each individual¿s bedroom door on 3/1/2022. Staff were trained on this regulation on 3/3/2022. 03/03/2022 Not Implemented
6400.151(c)(2)Direct Service Worker #1, date of hire 4/12/2021, had Tuberculin testing on 5/26/2021. 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. The following has been documented in the employee file for direct service worker #1. TB test for direct service worker #1, hired 4/12/2021, the employee had his first dose of the COVID vaccine on 3/22/2021 & second does on 4/19/2021. The doctor followed the CDC guidelines for TB testing & COVID vaccines that state: If COVID-19 mRNA vaccination has already occurred, defer TST or IGRA until 4 weeks after completion of 2-dose COVID-19 mRNA vaccination. This documentation provides evidence the employee was prevented from receiving the Tuberculin test due to medical advice. HR practice is compliant with the standards this was an exception due to medical recommendations. 03/09/2022 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 11/18/21. 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. 03/31/2022 Not Implemented
SIN-00164031 Renewal 10/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill held during sleeping hours was completed 10/15/18.A fire drill shall be held during sleeping hours at least every 6 months. Supervisor will plan and conduct monthly fire drill to ensure the appropriate drill is performed and documentation is completed correctly for each of the person served. The ID Fire Drill Schedule will continue to be used to ensure compliance. In an event the person served is awake for a sleeping fire drill the supervisor will conduct a separate sleeping fire drill for that individual and complete documentation. All fire drills documentation will be reviewed by the IDD Program Director and Safety committee for accuracy. All fire drills will be entered into the newly developed electronic system that will maintain compliance with all regulations for agency-wide fire drills. Attachment: ID Fire Drill Schedule [A fire drill during sleeping hours was held on 10/11/19 at 5:45AM. (DPOC by AES,HSLS on 10/21/19)] 10/18/2019 Implemented
6400.151(a)Direct Service Worker #1 had physical examination completed on 6/15/17 and then again on 7/11/19. 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. 6400.1515 (C) (2) Employee Physical will be completed within the established time frames outlined in 6400.1515 (C) (2) a) 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. (b) The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician¿s assistant. (c) The physical examination shall include: (1) A general physical examination. (2) 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. (3) A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. (4) Information of medical problems which might interfere with the health of the individuals. Transitional Services, Inc Policy/Procedure 1001.0 ¿ Employee Physical Examination, clearly outlines the above requirements cited in regulation 6400.1515. (policy/procedure attached) Tracking of Employee Physical Examinations ¿ A monthly tracking system has been incorporated in recent years to track all employee physicals/tests. This monthly employee physical tracking spreadsheet will now be monitored on a weekly basis to prohibit the possibility of staff working in an ID Residential facility with an expired physical. (TRACKING SPREADSHEET ATTACHED) ¿ Transitional Services, Inc. clearly outlines the following in Policy/Procedure 1001.0 ¿ Employee Physical Examination: V. Staff who do not have their required physical to the Human Resources Department prior to the due date, will be placed on unpaid leave immediately. Once the updated physical is received, staff then will be allowed to report to their designated work site. Failure to meet this requirement may result in disciplinary action up to and including termination. The Human Resources Department notifies all staff of impending physical due dates. Therefore, the Human Resources Department will now notify the supervisor immediately of any physical that is due within 5 business days. The site supervisor will remove the employee(s) from the site schedule for anytime worked after the physical due date. Attachments 1. Updated Policy/Procedure 1001.0 to include advanced notice of expiring physicals and removal from schedule 2. Physical tracking spreadsheet. 10/15/2019 Implemented
6400.151(c)(2)Direct Service Worker #1 had Tuberculin skin testing completed on 6/16/17 and then again on 7/13/19. 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. 6400.1515 (C) (2) Employee Physical will be completed within the established time frames outlined in 6400.1515 (C) (2) a) 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. (b) The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician¿s assistant. (c) The physical examination shall include: (1) A general physical examination. (2) 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. (3) A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. (4) Information of medical problems which might interfere with the health of the individuals. Transitional Services, Inc Policy/Procedure 1001.0 ¿ Employee Physical Examination, clearly outlines the above requirements cited in regulation 6400.1515. (policy/procedure attached) Tracking of Employee Physical Examinations A monthly tracking system has been incorporated in recent years to track all employee physicals/tests. This monthly employee physical tracking spreadsheet will now be monitored on a weekly basis to prohibit the possibility of staff working in an ID Residential facility with an expired physical. (TRACKING SPREADSHEET ATTACHED) ¿ Transitional Services, Inc. clearly outlines the following in Policy/Procedure 1001.0 ¿ Employee Physical Examination: V. Staff who do not have their required physical to the Human Resources Department prior to the due date, will be placed on unpaid leave immediately. Once the updated physical is received, staff then will be allowed to report to their designated work site. Failure to meet this requirement may result in disciplinary action up to and including termination. The Human Resources Department notifies all staff of impending physical due dates. Therefore, the Human Resources Department will now notify the supervisor immediately of any physical that is due within 5 business days. The site supervisor will remove the employee(s) from the site schedule for anytime worked after the physical due date. Attachments 1. Updated Policy/Procedure 1001.0 to include advanced notice of expiring physicals and removal from schedule 2. Physical tracking spreadsheet. 10/15/2019 Implemented
SIN-00143623 Renewal 10/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the nearest hospital was not on or by the telephone in the living room of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Stickers on all of the phones at the site were immediately updated to include all previous information PLUS the number of the nearest hospital - UPMC Shadyside (completed 10.19.18).Program Specialist sent an email to all program staff informing them that the hospital number had been added to the phone stickers. This was also addressed at the staff meeting on 10.24.18 as well as at the house meeting with all persons served on 10.25.18. To ensure that this violation does not occur again in the future, the program specialist will scan/email the phone/emergency number audit to the ID Director monthly. The document will be kept and filed in the on site safety binder at Callowhill. Furthermore, regulation 6400.71 will be reviewed and signed off on at the all staff ID training on 11.5.18. The training slips will be kept on file with Human Resources 11/05/2018 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 9/5/18, did not include the medical information pertinent to diagnosis in case of emergency; this section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, phone call was placed to the doctors office to have the missing information filled out by the physician so that the document was complete with no missing information (completed 10.22.18). Moving forward, program staff will ensure that all sections of the physical examination form are completed prior to leaving the physicians office. During monthly chart audits, program specialist will review all new medical documentation to ensure it is completed in its entirety. Any missing information will be immediately reported to the physician/specialist so that it may be completed. To ensure that the violation does not occur in the future, the program specialist will scan and email the monthly chart audit (medical) form to the ID Director for review. The form(s) will be kept/filed in the on site chart review binder. In addition, regulation 6400.141 (c)(14) will be reviewed as a part of an all staff ID training that will take place (scheduled for 11.5.18), be signed off on, and kept on file. [Within 30 days of receipt of the plan of correction, the CEO or designee shall train all staff person responsible for ensuring individuals' physical examinations are completed as required of the requirements of individuals' physical examination as per 6400.141(c)(1)-(15) and that no required areas shall be left blank. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 10/30/18)] 11/05/2018 Implemented
SIN-00123548 Renewal 10/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70The home did not have an operable, noncoin-operated telephone with an outside line.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. What specific change will be made-Immediately, the Director of Operations ordered phone lines with Verizon and purchased phones for the homes that did not have a landline and cordless phones. Who will make the change-Director of Operations When will the change be made- 11/01/17/Installation 11/10/17 per Verizon How will the change be made- During November's House Meeting for the individuals, staff will review the importance of having an operable telephone for emergencies. What system have you implemented to make sure that same violation will not occur again- Immediately, then monthly site staff will complete an audit to make sure all the phones are operable. The program specialist will scan and email the Phone/Emergency Number's Audit to ID director monthly. These audits will be kept and in the on-site Safety Binder. What training will be provided to your staff-Staff will be re-trained on regulation 6400.70 and on the Phone/Emergency Numbers Audit within 30 days of receipt of the plan of correction. Documentation of the training shall be kept. 11/10/2017 Implemented
SIN-00103399 Renewal 11/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The individuals living in the home were not in the home when the monthly fire drills were held on 9/22/16, 6/6/16, 5/18/16, and 3/2/16. An unannounced fire drill shall be held at least once a month. What specific change will be made. Fire drills are conducted each month for the building as a whole. If no resident for a given apartment is present during a drill, another drill will be conducted for that apartment when at least one resident of that apartment is present. Who will make the change. Site staff. With the December 2016 fire drill. How will the change be made. As much as possible, fire drills will be conducted for the building when residents of all apartments are present. However, if no resident for a given apartment is present during the drill, another drill will be conducted for that apartment when at least one resident of that apartment is present. 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 (a).).[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
6400.186(d)The program specialist did not provide the ISP review dated 6/16/16 for Individual #1 to the entire plan team 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 06-16-16 Quarterly Review was sent to the family on 11-11-16. Who will make the change. Program Specialist. When will the change be made. On 11-11-16. How will the change be made. The Review 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 Quarterly 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
SIN-00069176 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 9/11/14.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 1/1/14, did 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
6400.213(1)(i)Individual #1's record does 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. The face sheet has been revised to capture this information. Who will make the change. ID Program Director. When will the change be made. 10-23-14. How will the change be made. This information will be indicated in the ¿Notes¿ section of the Face Sheet. What system have you implemented to make sure that the same violation will not occur again. The revised form has replaced the original form for use in the future. What training will be provided to your staff. Staff was trained on the revised face sheet and the requirements contained in this regulation. [Records will be audited to ensure identify marks are present for each individual. (AS 11/7/14)] 10/27/2014 Implemented
6400.217Individual #1's most recent release of information, signed 1/1/14, states that it expires after 6 months.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. What specific change will be made. Consents with a 6-month expiration date will be renewed before the expiration date. Who will make the change. Site staff. When will the change be made. 10-29-14. How will the change be made. All consents will be renewed. What system have you implemented to make sure that the same violation will not occur again. Renewal of consents will be scheduled for all individuals in April and October of each year. What training will be provided to your staff. Staff was trained on the consent cycle and the requirements contained in 6400.217. 10/27/2014 Implemented
SIN-00230021 Renewal 07/06/2023 Compliant - Finalized
SIN-00217838 Unannounced Monitoring 01/19/2023 Compliant - Finalized
SIN-00210601 Unannounced Monitoring 08/22/2022 Compliant - Finalized
SIN-00183176 Renewal 02/09/2021 Compliant - Finalized
SIN-00085619 Renewal 10/15/2015 Compliant - Finalized
SIN-00055046 Renewal 09/16/2013 Compliant - Finalized