Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00203054 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill conducted on 12/30/2021 does not indicate if the smoke detector was operable. This section was left blank.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. The Site Supervisors were briefed on this regulation after the exit interviewed concluded. The DSPs at the site were trained on 4/27/22. A Supervisory meeting was held on 4/28/22 to review fire drill regulations again with formal training. The Assistant Directors will review all fire drill records on a quarterly basis, beginning with drills that were conducted in April 2022 and after. Results of the drills will be shared with the Residential Director. 04/28/2022 Implemented
6400.112(d)The fire drill conducted on 5/14/2021 had an evacuation time of three minutes and fifteen seconds. The fire drill conducted on 9/29/2021 had an evacuation time of two minutes and thirty-five seconds. The fire drill conducted on 1/23/2022 had an evacuation time of two minutes and fifty-five seconds. The home does not have an extended evacuation time. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The Site Supervisors were briefed on this regulation after the exit interviewed concluded. The DSPs at the site were trained on 4/27/22. A Supervisory meeting was held on 4/28/22 to review fire drill regulations again with formal training. In addition to training of all staffing levels, a Fire Safety Expert completed an onsite evaluation of the physical site on 5/12/22. An extended fire evacuation time of three minutes was recommended. Site Supervisors have been instructed to communicate with Assistant Directors in the event of a failed fire drill. 05/12/2022 Implemented
SIN-00104495 Renewal 12/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(g)The agency is utilizing video cameras to monitor and record in the hallways, living room, dining room and other common areas of the home. An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. The use of the cameras was discontinued and will not be utilized in the future. Residential staff are trained on Client Rights including the right to privacy at orientation and annually thereafter. 01/30/2017 Implemented
6400.112(f)The monthly fire drills completed between November 2015 and November 2016 used the front door to evacuate. The home has two means of egress.Alternate exit routes shall be used during fire drills. The staff members at the site were retrained on evacuation procedures on 1/7/17 and the document was submitted to BHSL on 1/10/17. All fire drill logs will be audited by 3/31/17 by the Asst. Res Director to ensure that alternate exits are being used. If a site is found not to be using alternate exits, the staff will be retrained on evacuation procedures immediately.[Within 30 days of receipt of the plan of correction, all staff persons responsible for conducting fire drills shall be trained in the requirements as per 6400.112(a)-(i).Immediately, CEO shall develop procedures for the Asst. IDD Directors to follow if upon review of fire drill records it is found fire drills are not being conducted as required and train the Asst IDD Directors on the procedures. Documentation of trainings, procedures and reviews shall be kept. (AS 2/3/17)] 01/30/2017 Implemented
6400.168(c)Documentation of Direct Service Worker #1's medication administration training, completed on 10/16/16, was not signed by a certified instructor. Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. The Res. Program Specialist is scheduled to attend Med. Admin train the trainer by the summer of 2017 and will be completing medication practicums upon completion of the training. The Res. P.S. will be oriented to these duties when trained. The Asst. Res Directors will review medication administration training records to ensure that they are completed in their entirety within the week of completion. [Direct Service Worker #1 will not administer medications until medication administration training is completed in its entirety. Immediately and prior to staff administering medications, the Asst. Res Directors will review all medication administration training records to ensure training is completed in its entity. Documentation of medication reviews shall be kept. (AS 2/3/17)] 01/30/2017 Implemented
SIN-00164652 Renewal 10/22/2019 Compliant - Finalized
SIN-00054193 Renewal 09/24/2013 Compliant - Finalized
SIN-00051529 Initial review 07/11/2013 Compliant - Finalized