Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232240 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)Individual #1 has a hearing impairment and uses a hearing aid.  The fire alarms in the Individual #1's bedroom and near the front door in the living room are equipped with strobe lighting. There is not strobe lighting in the bathroom and kitchen of the home to alert Individual #1 in the event of a fire. In addition, Individual #1 does not have a bed alarm to be alerted in the event of a fire while sleeping. 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. KVOU ordered Sonic Alert HomeAware Alerting system , transmitter, bed shaker, blink receiver on 10/18/2023. The items were picked up from the post office on 10/24/2023 and will be taken to the residential location no later than 10/25/2023 by the RPS, Program Specialist or Program Director. The transmitter picks up the sound of a smoke alarm and transmits a signal to the alerting system, bed shaker, and blink receiver. The Alerting system and bed shaker will be placed in this person's bedroom and the blink receiver will be placed in the bathroom. 10/25/2023 Implemented
SIN-00180240 Renewal 12/17/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1 had a physical examination completed on 7/3/18 and then again on 8/3/20. 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. What specific change was made: A ¿Procedure for Staff Physical Examinations/Communicable Diseases¿ was written in compliance with 6400.151 and 6400.152 per RCG to increase the notification to staff 60 days prior to the 2 year anniversary of the last physical examination. Staff are notified to schedule the physical examination/TB test by a due date at least 14 days prior to the last anniversary 2 year date. The Administrative Officer will utilize interoffice e-mail to closely monitor the progress of scheduling the examination/TB test and the completion of both to comply with 6400.151a. Who will make the change: The procedure was written by the Executive Director and Program Director will be responsible for training all staff. Administrative Officer will be responsible for the implementation of the procedure to ensure compliance with 6400.151a. When will the change be made: Below is from the procedure written on 12/22/2020: Effective Date and Implementation The Administrative Officer will immediately notify all staff with physical examination/TB tests that are due in January and February 2021 following the applicable areas of this procedure. The Administrative Officer will closely monitor the staff¿s scheduled appointment and completion of the physical examination/TB test to include confirmation with the health care provider to ensure compliance with the Regulations. The 60 day staff notification shall be provided according to procedure for all physical examination/TB tests due March 2021 and thereafter. How will the change be made: The procedure effective 12/22/2020 will be electronically sent to all agency staff with an acknowledgement of training implemented by Program Director beginning 12/23/2020. What system have you implemented to make sure that the same violation will not occur again: The following is from the procedure: For Staff Biennial Physicals 1. The Administrative Officer will send the staff an interoffice e-mail with the following notifications: 1) Delivery Receipt 2) Read Receipt 3) High Importance at least 60 days prior to the biennial (2 year) anniversary of the last physical examination/TB Test. The email will include the date the physical examination is due, the health care provider contact information, the instructions for scheduling the examination, notifications required to update the Administrative Officer, disciplinary action for non-compliance and all required paperwork for completion. 2. The staff will be given a due date for completion of the physical examination/TB test at least 14 days prior to the anniversary of the last examination. This due date may accommodate any unforeseen circumstances to ensure compliance. Note: The physical examination cannot be scheduled on a Thursday due to the TB test requirement to be read between 48-72 hours. 3. The staff must report back to the health care provider to have the TB test read between 48 ¿ 72 hours after the test was administered. The Administrative Officer will ensure all positive TB tests comply with the Regulations for further testing and documentation. If the staff fails to have the TB test read within the required time, it is their financial responsibility to have a second test completed and must ensure compliance with Regulations or will be subject to KVOU¿s Personnel Policies for non-compliance. 4. The staff will keep the Administrative Officer updated on the scheduled date of the physical examination/TB test by interoffice e-mail to maintain documentation of compliance. This scheduled examination must be kept. If in an emergent, unforeseen circumstance prevents the staff from attending the examination, they must reschedule with the health care provider at the earliest date prior to the due date. The staff must inform the Administrative Officer immediately by interoffice e-mail of the re-scheduled exam date. 5. The staff must obtain written permission from the Administrative Officer and/or Executive Director for all examinations that cannot be scheduled prior to 14 days from the anniversary date from the last 2 year physical exam/TB test. All staff that do not comply with the completion of the biennial physical examination/TB test according to Regulations will be immediately removed from the work schedule. Disciplinary action will be determined according to all applicable KVOU Personnel Policies including Behavior of Employee and Discipline Policy. 6. The Administrative Officer will be responsible for all correspondence with the staff and health care provider to ensure compliance. This will include tracking progress and maintaining all documentation for the entire biennial physical examination/TB test compliance process. FMLA or Leave of Absence When Biennial Physical is due When a staff is due for the biennial physical examination and is on an agency approved leave under FMLA (Family Medical Leave Act) or Leave of Absence, the Administrative Officer must provide documentation in the personnel file. Prior to the staff¿s return to work, the Administrative Officer must ensure the staff has the physical examination/TB test in compliance with the Regulations. What training will be provided to staff: The following is from the procedure: Training on Procedure All staff will receive training on the ¿Procedure for Staff Physical Examinations/Communicable Diseases¿ effective 12/22/2020. An acknowledgement form for every staff indicating the date of the training will be maintained in the agency¿s records. 12/23/2020 Implemented
6400.151(c)(2)Direct Service Worker #1 had a Tuberculin skin testing by Mantoux method read on 7/5/18 and then again on 8/5/20. 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 was made: A ¿Procedure for Staff Physical Examinations/Communicable Diseases¿ was written in compliance with 6400.151 and 6400.152 per RCG Guide to increase the notification to staff 60 days prior to the 2 year anniversary of the last physical/TB test. Staff are notified to schedule the physical examination/TB test by a due date at least 14 days prior to the last anniversary 2 year date. The Administrative Officer will utilize interoffice e-mail to closely monitor the progress of scheduling the examination and TB test including completion of both to comply with 6400.151c2. Who will make the change: The procedure was written by the Executive Director and Program Director will be responsible for training all staff. Administrative Officer will be responsible for the implementation of the procedure to ensure compliance with 6400.151c2. When will the change be made: Below is from the procedure written on 12/22/2020: Effective Date and Implementation The Administrative Officer will immediately notify all staff with physical examination/TB tests that are due in January and February 2021 following the applicable areas of this procedure. The Administrative Officer will closely monitor the staff¿s scheduled appointment and completion of the physical examination/TB test to include confirmation with the health care provider to ensure compliance with the Regulations. The 60 day staff notification shall be provided according to procedure for all physical examination/TB tests due March 2021 and thereafter. How will the change be made: The procedure effective 12/22/2020 will be electronically sent to all agency staff with an acknowledgement of training implemented by Program Director beginning 12/23/2020. What system have you implemented to make sure that the same violation will not occur again: The following is from the procedure: For Staff Biennial Physicals 1. The Administrative Officer will send the staff an interoffice e-mail with the following notifications: 1) Delivery Receipt 2) Read Receipt 3) High Importance at least 60 days prior to the biennial (2 year) anniversary of the last physical examination/TB Test. The email will include the date the physical examination is due, the health care provider contact information, the instructions for scheduling the examination, notifications required to update the Administrative Officer, disciplinary action for non-compliance and all required paperwork for completion. 2. The staff will be given a due date for completion of the physical examination/TB test at least 14 days prior to the anniversary of the last examination. This due date may accommodate any unforeseen circumstances to ensure compliance. Note: The physical examination cannot be scheduled on a Thursday due to the TB test requirement to be read between 48-72 hours. 3. The staff must report back to the health care provider to have the TB test read between 48 ¿ 72 hours after the test was administered. The Administrative Officer will ensure all positive TB tests comply with the Regulations for further testing and documentation. If the staff fails to have the TB test read within the required time, it is their financial responsibility to have a second test completed and must ensure compliance with Regulations or will be subject to KVOU¿s Personnel Policies for non-compliance. 4. The staff will keep the Administrative Officer updated on the scheduled date of the physical examination/TB test by interoffice e-mail to maintain documentation of compliance. This scheduled examination must be kept. If in an emergent, unforeseen circumstance prevents the staff from attending the examination, they must reschedule with the health care provider at the earliest date prior to the due date. The staff must inform the Administrative Officer immediately by interoffice e-mail of the re-scheduled exam date. 5. The staff must obtain written permission from the Administrative Officer and/or Executive Director for all examinations that cannot be scheduled prior to 14 days from the anniversary date from the last 2 year physical exam/TB test. All staff that do not comply with the completion of the biennial physical examination/TB test according to Regulations will be immediately removed from the work schedule. Disciplinary action will be determined according to all applicable KVOU Personnel Policies including Behavior of Employee and Discipline Policy. 6. The Administrative Officer will be responsible for all correspondence with the staff and health care provider to ensure compliance. This will include tracking progress and maintaining all documentation for the entire biennial physical examination/TB test compliance process. FMLA or Leave of Absence When Biennial Physical is due When a staff is due for the biennial physical examination and is on an agency approved leave under FMLA (Family Medical Leave Act) or Leave of Absence, the Administrative Officer must provide documentation in the personnel file. Prior to the staff¿s return to work, the Administrative Officer must ensure the staff has the physical examination/TB test in compliance with the Regulations. What training will be provided to staff: The following is from the procedure: Training on Procedure All staff will receive training on the ¿Procedure for Staff Physical Examinations/Communicable Diseases¿ effective 12/22/2020. An acknowledgement form for every staff indicating the date of the training will be maintained in the agency¿s records. 12/23/2020 Implemented
SIN-00140655 Renewal 08/28/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Individual #1, date of birth 12/10/45, had a mammogram completed on 9/21/16 and then again on 4/5/18.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. The agency hired an LPN on 8/27/2018 to monitor the completion of timely annual examinations as required by the 6400 regulations including 6400.141(c)(8) as well as other medical issues of our individuals. The Program Specialist will monitor the LPN in completion of required licensing annual medical appointments on an Individual Medical Appointment Chart. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educated the LPN of the requirements of individual physical examinations as per 6400.141(a)-(c)(1)-(15) and the tracking system to ensure all individuals have physical examinations including mammograms completed, timely, with all required information and there are not any required areas left blank. Documentation of the trainings shall be kept. At least quarterly for 1 year, the program specialist shall audit the tracking system to ensure individuals medical appointments are completed, timely. (DPOC by AES, HSLS on 9/17/18)] 09/13/2018 Implemented
SIN-00077926 Renewal 09/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment did not include a completion date; therefore, compliance was unable to be measured.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. A procedure will be written and staff trained that the Executive Director will disburse the current Licensing Inspection Instrument Scoresheet Facility Chapter 6400 Community Homes annually on or before January 19th which is 6 months prior to the expiration date of the Certificate of Compliance. The inspection instruments will be due from the following positions on or before March 31st: Residential Program Supervisor and Program Specialist. The inspection instrument will be due from the Administrative Officer who completes the Staffing section including the training requirements in Regulation 46 and Staff Health including physicals on or before April 15th which is approximately 3 months prior to the expiration of the Certificate of Compliance. The Executive Director will ensure the deadlines are met and then compile the data into one scoresheet for each residential home on or before April 18th which is 3 months prior to the expiration date. 10/04/2015 Implemented
6400.167(a)Direct Service Worker #1's most recent annual medication administration training was completed on 3/18/2014. On 4/1/2015 at 8:00 PM, Direct Service Worker #1 administered the following medication prescribed to Individual #1: Keppra 100MG/ML, Liquitears Drops(1 drop to both eyes), Metoprolol Tartrate 25mg, Chlorhexidine 0.12% rinse, Albuterol Inhaler (1 unit), Topamax 200mg and Calmoseptine ointment. On 4/13/2015 at 9:00 AM, Direct Service Worker #1 administered the following medication prescribed to Individual #1: Keppra 100MG/ML, Liquitears Drops, Metoprolol Tartrate 25mg, Topamax 200mg, Calmoseptine ointment, Ciclopirox 0.77% cream, Ferrous Sulfate Elixir 22, Folic Acid 1mg, Prevacid 30mg solutab, Baclofen 10mg tablet, Calcium 600+ Vitamin D 400 and Deep Sea 0.65% nose spray. Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. A procedure will be written that KVOU will have a Program Specialist who is a Certified Trainer overseeing the Practicum Observers to ensure staff have the required annual medication administration observations and medication administration record reviews to complete their annual practicum. In absence of the Program Specialist, another Certified Trainer will be assigned. There will be a Medication Pass and MAR Review Dates chart for each site and one master chart that will include all KVOU staff certified to pass medications. The Program Specialist will update these charts and oversee the Practicum Observers for compliance with Chapter 6400 Regulation 167(a) and 168(a). 10/04/2015 Implemented
SIN-00213315 Renewal 10/19/2022 Compliant - Finalized
SIN-00196568 Renewal 11/22/2021 Compliant - Finalized
SIN-00161206 Renewal 08/20/2019 Compliant - Finalized
SIN-00120683 Renewal 08/30/2017 Compliant - Finalized
SIN-00062974 Renewal 09/05/2014 Compliant - Finalized
SIN-00051312 Renewal 06/27/2013 Compliant - Finalized