Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222639 Renewal 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bathroom vanity in the main bathroom is peeling excessively, and there's a crack in the floor marble threshold plank.Floors, walls, ceilings and other surfaces shall be in good repair. The bathroom vanity in the main bathroom is peeling excessively, and there's a crack in the floor marble threshold plank.Floors, walls, ceilings and other surfaces shall be in good repair. Staff reported the needed repairs to the Leasing office on March 20th. A walkthrough with the Facilities Manager on March 30th, and he stated the office will reach out to schedule the repairs. All reported repairs were completed between April 3rd -April 17th.A picture was taken once completed and will be submitted in the supporting documentation email. House managers will check the condition of the sites appliances during site checks while completing environmental checks weekly for the site. House Managers will report any discovered needed repairs to the leasing office and schedule a repair appointment. Staff received additional on-site orientation training on regulation requirements regarding site conditions on 4/11/23. 04/18/2023 Implemented
6400.67(a)In Individual 1's room, the wall under the window is damaged from water and needs to be repaired, as the paint is chipping excessively.Floors, walls, ceilings and other surfaces shall be in good repair. In Individual 1's room, the wall under the window is damaged from water and needs to be repaired, as the paint is chipping excessively.Floors, walls, ceilings and other surfaces shall be in good repair. Staff reported the needed repairs to the Leasing office on March 20th. A walkthrough with the Facilities Manager on March 30th, and he stated the office will reach out to schedule the repairs. All reported repairs were completed between April 3rd -April 17th.A picture was taken once completed and will be submitted in the supporting documentation email. House managers will check the condition of the sites appliances during site checks while completing environmental checks weekly for the site. House Managers will report any discovered needed repairs to the leasing office and schedule a repair appointment. Staff received additional on-site orientation training on regulation requirements regarding site conditions on 4/11/23. 04/18/2023 Implemented
SIN-00203233 Renewal 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Food was stored with poisonous materials in closet, Lysol disinfectant spray, Febreeze, Palmolive dish detergent, iced tea, coffee, peanut butter, Sprite and Pepsi canned sodas.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Food was stored with poisonous materials in closet, Lysol disinfectant spray, Febreeze, Palmolive dish detergent, iced tea, coffee, peanut butter, Sprite and Pepsi canned sodas. The poisonous materials were removed from the closet and placed in the upstairs closet in the staff office with the other locked cleaning supplies. Staff received additional on-site orientation training to review regulation requirements for storing of poisonous material.House managers will check that poisonous materials are stored separately from food items during their site checks while completing environmental checks weekly. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected 04/06/2022 Implemented
6400.64(a)There was Debris on the ceiling in the full bathroom, which needs to be cleaned and possibly painted. The bathroom floor in Individual 1's bedroom had dirt and debris around the toilet and sink area, that needs to be cleaned.Clean and sanitary conditions shall be maintained in the home. lndividual1's bathroom was thoroughly cleaned removing dirt build up throughout the bathroom and around the toilet. The leasing office schedule to paint the entire home including the ceilings in June. Staff received an additional onsite orientation to review required cleaning standards per the regulations. Site checks will be completed twice weekly, and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. House managers will check the cleanliness of the entire home during site checks while completing weekly environmental checks of the site 04/07/2022 Implemented
6400.72(b)The screen in the full bathroom window has a whole in it the size of small ball and needs to be replaced to avoid the entry of insects. The window in the full bathroom was not in good repair and was being held up by a plastic instrument, when discarded the window would not remain open without being held. Screens, windows and doors shall be in good repair. The screen in the full bathroom window has a whole in it the size of small ball and needs to be replaced to avoid the entry of insects. The window in the full bathroom was not in good repair and was being held up by a plastic instrument, when discarded the window would not remain open without being held. Work orders were put in with the leasing company to fix both windows. The leasing company fixed both windows along with other noted physical issues within the site. It was reviewed with staff how to submit work orders in with the leasing company at the development, and the process for following up with the House Manager when the request takes longer then three days to be addressed by the leasing company per their 72 hour scheduling policy at the development. 04/22/2022 Implemented
6400.73(a)The handrail leading to the 2nd floor of the apartment was not secured and needs to be secured to the base of the stairwell. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The handrail leading to the 2nd floor of the apartment was not secured and needs to be secured to the base of the stairwell.Work orders were put in with the leasing company to fix the railing going up the stairway. The leasing company fixed the railing along with other noted physical issues within the site. It was reviewed with staff how to submit work orders in with the leasing company at the development, and the process for following up with the House Manager when the request takes longer then three days to be addressed by the leasing company per their 72 hour scheduling policy at the development. 04/22/2022 Implemented
6400.76(a)Sofa in living room area was worn in multiple areas and needs to be replaced. The light switch plate in the full bathroom was rusted and needs to be replaced to avoid a potential hazard. Furniture and equipment shall be nonhazardous, clean and sturdy. Sofa in living room area was worn in multiple areas and needs to be replaced. The light switch plate in the full bathroom was rusted and needs to be replaced to avoid a potential hazard. The damaged furniture was removed from the site by facilities. New furniture was purchased by the Program Director and was delivered to the home a week later.Managers will check the condition of the site¿s furniture during site checks while completing environmental checks. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. 04/18/2022 Implemented
6400.82(f)There was no soap, or a trash receptacle in the ½ bathroom in Individual 1's bedroom-the soap was replaced during the inspection.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. There was no soap, or a trash receptacle in the ½ bathroom in Individual 1's bedroom-the soap was replaced during the inspection. The trash can from the bathroom was placed in the bedroom area by Individual #1. A second trashcan was purchased and placed in 1/2 bathroom to avoid additional compliance issues with the changing in placement of the one trashcan.Managers will check the condition of the site¿s furniture during site checks while completing environmental checks. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. 04/06/2022 Implemented
6400.141(c)(14)Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the physical examination form dated 04/12/2021 for Ind. 1.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the physical examination form dated 04/12/2021 for Ind. 1.D. Duff's current annual physical examination was completed . His physical exam form was completed in its entirety to reflect medical information pertinent to diagnosis and treatment in case of an emergency. It was noted by the physician that "if seizure activity or change in mental status call 911 go to nearest ER." The annual physical form was also completed to reflect that D. Duff has allergies/sensitivity to medications of Dilantin and Tergretol . 04/22/2022 Implemented
SIN-00200515 Unannounced Monitoring 02/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The floor of the kitchen was sticky to the touch with dried spilled liquid staining throughout the floor. The bathroom tub, shower and ceiling, had residue consistent with dirt, staining and mildew. An odor consistent with body odor and dirty laundry came from both occupied bedrooms.Clean and sanitary conditions shall be maintained in the home. The floor of the kitchen was sticky to the touch with dried spilled liquid staining throughout the floor. The bathroom tub, shower and ceiling, had residue consistent with dirt, staining and mildew. An odor consistent with body odor and dirty laundry came from both occupied bedrooms. The kitchen floor was re-mopped by staff. It's an older bathroom with older tile their was no mold present in the home. The tub was recently re caulked by leasing office prior to the visit. The bathroom was thoroughly cleaned removing dirt build up throughout the bathroom. 02/18/2022 Implemented
SIN-00192836 Renewal 09/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The Shower/Tub knob was not in good repair, it fell off during inspection while worker was turning on the water.Floors, walls, ceilings and other surfaces shall be in good repair. The Shower/Tub knob was not in good repair, it fell off during inspection while worker was turning on the water, all Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted to the leasing office on 9/1/21 and was completed by the complex on 9/3/21. A picture was taken once completed and will be submitted in the supporting documentation email. 09/03/2021 Implemented
6400.104No notification letters to the fire department provided at the time of inspection for homes.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. No notification letters to the fire department provided at the time of inspection for homes, the home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. A letter was sent to the local fire department reintroducing the site since the last letter was sent when the site was originally opened prior to any of the current staff and individuals being present. A copy of the letter will be submitted in the supporting documentation email. 09/23/2021 Implemented
6400.112(e)Sleep drills were not performed every six months.A fire drill shall be held during sleeping hours at least every 6 months. Sleep drills were not performed every six months, a fire drill shall be held during sleeping hours at least every 6 months.Each home received a yearly rotation department fire drill calendar. The calendar was posted in each sites office and in the front of each sites fire drill log book as an attention bulletin on what type of drill and what time of day the drill is required for the drill of the month. The sites lead direct support professional will complete the monthly fire drill by the 15th of each month, then will submit the drill for an accuracy review prior to being logged in the department spreadsheet as completed and uploaded to the agency's Sharepoint system. 09/14/2021 Implemented
6400.142(a)No dental record in the record for Individual #2 at the time of inspectionAn individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. No dental record in the record for Individual #2 at the time of inspectionAn individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #2 refused their annual dental appointment. Documentation of the Annual Dental appointment was upload to the state dropbox with Individual #2's annual appointment information during inspection on 9/1/21. 09/01/2021 Implemented
6400.183(c)There was no ISP team sign in sheet in the record for Individual #2.The list of persons who participated in the individual plan meeting shall be kept.There was no ISP team sign in sheet in the record for Individual #2, the list of persons who participated in the individual plan meeting shall be kept. Even though the ISP meeting was completed virtually the agency's Program Specialist should have included a confirmation email of everyone stating they were attending and scanning a sign in sheet foe each participant to sign and send back to the Program Specialist. Moving forward all virtual ISP will need a confirmation email from each participant that is attending. The Program Specialist will then scan a sign in sheet to each participant to sign and scan back to the Program Specialist following the completion of the virtual ISP meeting . 09/22/2021 Implemented
6400.213(1)(i)Individual #2's record did not indicate Religious Affiliation.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Individual #2's record did not indicate Religious Affiliation, Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. Individual #2's record indicated N/A due to Individual #2 not having a religious affiliation. This was stated during the inspection exit interview, and no directions on an alternative way of documenting having no religious affiliation was given. 09/01/2021 Implemented
SIN-00191148 Unannounced Monitoring 07/28/2021 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The Main bathroom shower was dirty and the tub was lined with a substance consistent with dirt and mildew and the shower mat was worn. Individual 1 and 2's bedroom was dirty with open food containers with food such as "cup of soup" and used plates stacked on the dressers and tv stands.Clean and sanitary conditions shall be maintained in the home. The Main bathroom shower was dirty and the tub was lined with a substance consistent with dirt and mildew and the shower mat was worn. Individual 1 and 2's bedroom was dirty with open food containers with food such as "cup of soup" and used plates stacked on the dressers and tv stands.The home was thoroughly cleaned. Individual 1's bathroom was thoroughly cleaned removing dirt build up throughout the bathroom and the bath mat was replaced. Staff received an additional onsite orientation to review required cleaning standards per the regulations. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. House managers will check the cleanliness of the entire home during site checks while completing weekly environmental checks of the site. Implemented
6400.166(b)The Following Medications prescribed to individual 1 were not logged immediately after use on 7/25/2021: Benydryl 50mg one tablet at 8pm, glucphage 750mg two tablets daily at dinner (8pm), ocusoft pads 8pm application, Tinactin 1% spray 8pm application to the feet, Trileptal 150mg tablet twice daily 8am and 8pm dose, and Zoloft 50mg tablet 8am daily dose.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.DIRECTED PLAN The Agency Nurse will do a weekly audit of medications to ensure medications are given properly, that medications are available, and to dispose of expired or discontinued medications as specified in the November 24, 2020 Settlement Agreement, paragraph 14: Review of individual medication administration records to ensure that: · Individuals are receiving correct medications and dosages as listed on the pharmaceutical label · Medication errors are identified, reported, and the individual's physician was contacted and recommended next steps are documented. The initial weekly review will be sent to licensing by Thursday, December 23, 2021. VOA will update the IDS Site Med Checks form to be completed weekly by the agency nurse and submitted to the agency director. The form shall be modified to include a description of any issues noted and documentation of their resolution. The updated checklist will be sent to ODP by Thursday, December 23, 2021. VOA will develop a written procedure for reporting, categorizing and analyzing medication issues discovered by the nurse (beyond entering reportable incidents into EIM) which will include: · When staff will be retrained · Who will retrain staff Documentation of the information noted above will be maintained by VOA and will include how and when issues have been corrected/resolved. This procedure will be submitted to ODP by January 3, 2022 The agency director will review the weekly med check forms on a monthly basis and create a plan for managing any home or agency deficiencies and remediation actions if there are staff with multiple medication errors. This shall occur within 10 days, after the end of the month. This will be sent to ODP no later than the 10th day of the following month. 12/23/2021 Accepted
6400.169(a)The Medication course renewal requirements were not met for staffs 1, 2, 3 and 4. The staff did not have the required amount of observations to maintain compliance. Staff 1, 2, 3 and 4 had one observation and one MAR review while certified in 2020 with no additional observations prior to the expiration of their certification. Staff 1's certification expired 12/27/2020, staff 2's certification expired 12/10/2020, staff 3's certification expired 12/10/20 and staff 4 expired 11/22/2020.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).DIRECTED PLAN Volunteers of America will conduct a 100% review of medication trainings and practicum requirements for all staff at all homes to ensure medication training is current. If not, then only staff that have successfully completed the ODP approved medication training and meet the practicum requirements shall administer medication until medication training is completed for any remaining staff. Additionally, VOA will review staff schedules for each home and ensure at least one person is working each shift that is certified to pass medications. Review to be initiated immediately upon receipt of DPOC and completed within 24 hours. This review will be completed, documenting the medication training status of all staff who were administering medication as of 11/30/2021, and it will be submitted to licensing no later than December 23, 2021 VOA will assure that new staff do not administer medication until they have completed and passed the ODP approved medication training and practicum. 12/23/2021 Accepted
SIN-00176380 Unannounced Monitoring 08/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The shower knob located in the bathroom was broken and not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The shower knob located in the bathroom was broken and not in good repair. Apartment Complex completed the work order for the shower knob on 9/21/2020. Site checks will be completed twice weekly and the results will be turned in to the Program Director for review and follow up on items that need to be addressed and corrected. House managers will check all facility issues during site checks while completing environmental checks, and will submit work order request for the issues and will follow up until completion. 09/21/2020 Implemented
6400.163(h)For individual #02, the medication KETOCONAZOLE 2% Cream was located in the individual's medication container but not on the (MAR) Medicine Administration Record which is used for documenting administered medication(s).Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.For individual #02, the medication KETOCONAZOLE 2% Cream was located in the individual's medication container but not on the (MAR) Medicine Administration Record which is used for documenting administered medication. KETOCONAZOLE 2% Cream was a discontinued medication that staff did not dispose of after it was discontinued and removed from the MAR by the pharmacy. The medication was removed from the medication container and disposed of per the proper guidelines for disposing of medication. Site staff received a refresher on proper guidelines for implementing medication discontinuance and disposing of medication. The prescribing physician provided another discontinue script for the KETOCONAZOLE 2% Cream to confirm that the medication was in fact a discontinued medication. House Managers will complete medication checks twice weekly during the completion of site environmental checks. The medication check documentation will be submitted to the Program Director every Monday of the following week for review and confirmation that items requiring follow up were completed by the House Managers. 09/22/2020 Implemented
SIN-00171640 Unannounced Monitoring 02/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Water temperature measured at 129.2 degrees Fahrenheit in the main bathroom tub at the time of the monitoring. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature measured at 129.2 degrees Fahrenheit in the main bathroom tub at the time of the monitoring. Facilities installed temperature controllers on the faucets to help regulate the water within the required parameters. Site staff will check water temperatures everyday and record the water temperature on the tracking sheet located on the refrigerator. If staff record a water temperature higher than 120 degrees they will notify the House manager of the site that an adjustment is needed by facilities. House managers will check the water temperature during site checks weekly. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. 03/10/2020 Implemented
SIN-00169668 Unannounced Monitoring 01/17/2020 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the bathtub of the main bathroom measured at 130.8 degrees Fahrenheit at the time of the monitoring. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature in the bathtub of the main bathroom measured at 130.8 degrees Fahrenheit at the time of the monitoring. The water temperature was turned down on 1/23/2020 and read 120.3 degrees. The water was tested again on 1/31/2020 and read 120 degrees. House managers will check the water temperature during site checks weekly. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. (All referenced items will be labeled POC 4 for Wagner way.) 01/23/2020 Submitted
6400.81(k)(2)The Head post piece of Individual 1's bed was not attached to the bedframe.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. The Head post piece of Individual 1's bed was not attached to the bedframe. A new bed was purchased for individual # 1on 1/30/2020 and program is awaiting delivery date from furniture store, the estimated timeframe given was between 5- 7 days . Managers will check the condition of the site¿s furniture during site checks while completing environmental checks. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. ( All referenced items will be labeled POC 4 for Wagner way.) 01/30/2020 Submitted
SIN-00165362 Renewal 10/30/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The blinds in individual #1's left bedroom window were damaged and not in good repair at the time of physical site inspection.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds in individual #1's left bedroom window were damaged and not in good repair at the time of physical site inspection. A work order for the blinds in individual 1's bedroom was submitted with the leasing company to ensure their replacement on 11/5/2019. The leasing company as of 12/6/2019 still has not replaced the blinds in individual 1's room. A work order with VOA facilities was submitted to have the blinds replaced since the leasing office still has not replaced the blinds. VOA facilities will be replacing the blinds on 12/10/2019. Managers will check the condition of site blinds during sites checks while completing environmental checks weekly for the sites. 12/10/2019 Not Implemented
SIN-00150071 Renewal 02/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1's last signed copy of rights was on1/9/2018, which is more than a year.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. The Program Specialist will inform each individual, or the individual's parent, guardian or advocate individual's rights upon admission and annually thereafter. The Program Specialist will ensure statements are signed and dated by the individual, or the individual's parent, guardian or advocate; acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept in the clients file. The Program Director will monitor this process via monthly supervisions with the Program Specialist. Quality Assurance will conduct monthly audits to maintain continuity of this process. 03/31/2019 Implemented
6400.72(b)The Screen in the living room was damaged. Screens, windows and doors shall be in good repair. The windows, including windows in doors, shall be securely screened when windows or doors are open: a) Staff will ensure to check daily for damaged or missing screens via the chore list and report repairs or replacements needed. b) The Site Manager has an obligation to review the chore list weekly and evaluate the home. c) The Site Manager will ensure the completion of the environmental health and safety check list monthly for continuity. d) The Site Manager will ensure that work orders are entered to ensure the replacement or repairs of the screens timely via the chore list and the health and safety check list. e) The Program Director shall ensure to review site needs at the weekly core team meeting. 03/31/2019 Implemented
6400.111(f)The fire extinguisher in the home was not inspected annually, last inspection was dated December 2017 A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. a) A fire extinguisher shall be inspected and approve annually by a fire safety expert. The date of the inspection shall be on the extinguisher. b) VOADV maintenance will ensure that all fire extinguishers are maintained and in fully charged and operable condition and kept in their designated places at all times except during use. c) VOADV maintenance will retain a record of the annual inspection and maintenance date for each extinguisher for at least one year after the last entry or the life of the extinguisher. d) The IDS Program Director will monitor this process at the weekly core team meetings. 02/28/2019 Implemented
6400.141(a)Individual #1's current physical examination dated 11/6/18 is more than a year from the previous physical examination dated 10/12/17.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individuals shall have a physical examination every 12 months. The Site Manager will maintain a calendar of appointments to ensure the annual physical is complete 2 weeks prior to on the anniversary date of the annual physical appointment. All scheduling of medical appointments including but not limited to the annual physicals shall be reviewed at the weekly core team meeting. The Program Specialist will include the completion of the annual physical by documenting the occurrence in the monthly and quarterly ISP review summary. Quality Assurance will complete monthly audits to maintain continuity of the required medical appointments. 03/31/2019 Implemented
6400.186(a)Individual #1's record did not contain three month ISP reviews for calendar year 2018.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. ISP's shall be reviewed every 3 months or more with the consumer: a) Program Specialist will ensure the completion of a documented quarterly review of the individual' progress. b) Quality Assurance will complete quarterly audits to ensure the documentation in each client file meets the regulatory requirements. c) The Program Director will meet with the Program Specialist monthly to evaluate the completion of the required documentation 04/06/2019 Implemented
6400.213(1)(i)Individual #1's record did not document their religious affiliation.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. The Client's face sheet will possess all of the required information listed under 6400.213(1) (i). The Program Specialist will update the client face sheet & emergency packet including the following information: a. Client name b. sex c. date of birth d. social security number e. language or means of communication f. race/ethnicity g. height h. weight i. eye color j.hair color k. religious affiliation l. any scars or marks m. next of kin n. dated photograph o. list of physicians and contact information p. current list of medication Quality Assurance will complete quarterly audits to ensure the documentation in each client file meets the regulatory requirements The Program Director will meet with the Program Specialist monthly to evaluate the completion of the required documentation. 03/05/2019 Implemented
SIN-00096490 Renewal 07/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Th self-assessmennt was completed on 7/5/16 after the expiration of the license on 3/18/16.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. In an effort to measure and record compliance, Volunteers of America will complete a self assessment of each home, within 3 to 6 months of the expiration date of our certificate of compliance. A copy of our self assessment results with a written summary of corrections made will be kept on record for at least one year. Volunteers of America Delaware Valley Intellectual Disabilities Services¿ self assessments are complete to date, and are in compliance with the 3 to 6 months requirement. 11/21/2016 Implemented
6400.64(a)Individual # 1's bedroom has an overhead ceiling fan with dirt on each of its 5 blades.Clean and sanitary conditions shall be maintained in the home. Volunteers of America Delaware Valley, Intellectual Disabilities Services (IDS) Program will ensure all sites are clean, sanitary, and free of infestations of insects and rodents at all times. Since our inspection in July of 2016 the ceiling fan has been cleaned thoroughly. Staff has continued to maintain the cleanliness of the overhead ceiling fan in Individual¿s #1 bedroom.( Please see attachment: 3901 Wagner Way Fan) 08/01/2016 Implemented
6400.113(a)Individual #1's record did not have documentation of fire safety training. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Volunteers of America Delaware Valley, Intellectual Disabilities Services, is dedicated to ensuring all individuals are equipped with the necessary general fire safety and emergency evacuation training. Our organization partners with the Graham Company to ensure our consumers receive fire safety training by a certified expert and Senior Safety Consultant. Individual # 1 has completed the Fire Safety training on (September 22, 2016). Moving forward Volunteers of America Delaware Valley will ensure all individuals are up to date and current with fire safety training. In the event an individual in medically or functionally unable to attend the training, documentation will be kept in the individual¿s file identifying the reason for non participation. Per regulations, a written record of fire safety training, including the content of the training and a list of the individuals attending, will be kept on file. ( Please see attachment: Fire Safety Training for Consumers 09222016, VOADV 2016 Fire Safety Training, and Sign In Sheet Fire Safety) 09/22/2016 Implemented
6400.181(e)(13)(i)Individual #1's assessment dated 1/21/16 did not documennt progress in the area of health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. General health and safety are addressed on page 10-11 on the individual assessment for Individual #1. To guarantee future compliance with regulations, Volunteers of America will ensure to review progress for the individual in the specific area of health. This will include general and personal health for the individual. Please see attachment: Individual Assessment J. Madesky 12/30/2016 Implemented
6400.181(e)(13)(ii)Individual # 1's assessment dated 1/21/16 did not document progress in the area of motor and communicaion skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Motor skills are addressed on page 8 and 9 of the individual assessment. While the program specialist has reviewed his motor skills in the specified areas, there is no outline to specify progress of motor skills over the last 365 days. The assessment only addresses strengths and skills needed and reviews functionality over the last 365 days. Volunteers of America will revise the individual assessment form to ensure that motors skills and communication skills are reviewed and addressed over the last 365 calendar days in summary form. Please see attachment: Individual Assessment J. Madesky 12/30/2016 Implemented
6400.181(e)(13)(iii)Individual #1's assessment dated 1/21/16 did not document progress in residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. The program specialist did not include a summary of Individual #1 progress over the last 365 calendar days in the area of residential living. Moving forward, to ensure compliance, Volunteers of America will guarantee that all summaries for progress over the last 365 calendar days are documented, especially in the area of residential living. Please see attachment: Individual Assessment J. Madesky 12/30/2016 Implemented
6400.181(e)(13)(ix)Individual #1's assessment dated 1/21/16 did not document progress in community inegration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.Community integration is addressed on page 7 of the assessment but is bulked into the category of social integration. Volunteers of America will revise the assessment to include a specific review of community integration over the last 365 calendar days to remain complaint with regulations. Please see attachment: Individual Assessment J. Madesky 12/30/2016 Implemented
6400.181(f)Individual # 1's assessment dated 1/21/16 was not sent to he SC.(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). Summary: The individual assessment is provided to the Supports Coordinator yearly. To ensure future compliance, Volunteers of America will email the individual assessment to the supports coordinator 30 days prior to an ISP meeting and print out documentation as proof of the submission. 12/30/2016 Implemented
6400.186(a)Individual # 1's record did not have any 3 month ISP reviews.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A change in staff caused the monthly documentation for Individual #1 to go missing. A thorough review of current files and documentation for the site was completed; however this document was not located. Moving forward, Volunteers of America will ensure that all documentation is saved on a shared server to guarantee document retention and accessibility by all staff at Volunteers of America. Please see attachment: Individual Assessment Individual #1 12/30/2016 Implemented
6400.186(c)(1)Individual #1 record did not have monthly documentationfrom 6/15 through 3/16.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Due to a turn over in staff monthly documentation for Individual #1 was not available upon review. Review of current files and documentation for the site were completed however this document was not found. Moving forward, Volunteers of America will ensure that all documentation is saved on a shared server to guarantee document retention and provide for document accessibility for all authorized staff at Volunteer of America. This will prevent documentation from becoming missing when staff choose to end employment with Volunteers of America. Please see attachment: Individual Assessment Individual #1 12/30/2016 Implemented
SIN-00047355 Renewal 03/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff #1 received fire safety training on 12/12/12, but was not trained by a fire safety expert. (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Provider will ensure that all staff are trained annually by a fire safety expert in the training areas specified in subsection (f). Training was completed by Phila Fire Dept. on 4/15/13. The QE Director will minitor the training system. 04/15/2013 Implemented
6400.161(a)Individual #1's medication was removed from the medication blister packs at the home on 3/21/13 to 3/24/13 and accompanied the individual during a home visit. (a)  Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers.The provider will ensure that all medications will be kept in its original containers. When an individual will be outside their residence (vacation, visiting family, etc.) medication will be ordered from the pharmacy 2-3 days in advance, to ensure that they are in medical vials and labeled properly. The house supervisor will minitor this system. 04/01/2013 Implemented
SIN-00123364 Renewal 10/03/2017 Compliant - Finalized
SIN-00061830 Renewal 03/03/2014 Compliant - Finalized
SIN-00061991 Renewal 03/03/2014 Compliant - Finalized