Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232941 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, date of admission 11/28/22, was instructed in the individual's primary language or mode of communication 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 on 12/01/22.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.On the date of admission, the program specialist will be provided with a checklist from the residential director outlining all necessary documentation that must be completed on the day of admission to ensure compliance. 10/27/2023 Implemented
6400.141(a)Individual #1, date of admission 11/28/22, had a physical examination prior to admission on 04/13/22, but no documentation of any additional physical examination was provided to measure compliance with this regulation. This exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Residential house manager will maintain an electronic calendars with reminders set to help ensure compliance with all annual regulatory appointments. 10/27/2023 Implemented
6400.142(a)Individual #1, date of admission 11/28/22, did not have a dental examination. Individual #1 is 18 years of age or older.An 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 individual will be granted admission to the agency without proof of documentation that a dental examination has been completed within the last year. 10/27/2023 Implemented
6400.34(a)Individual #1, date of admission 11/28/22, was informed and explained individual rights on 11/29/22.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.On the date of admission, the program specialist will be provided with a checklist from the residential director outlining all necessary documentation that must be completed on the day of admission to ensure compliance. 10/27/2023 Implemented
6400.165(g)Individual #1, date of admission 11/28/22, is prescribed medications to treat symptoms of a psychiatric illness. Individual #1 did not have a review by a licensed physician of the medications. This exceeds the every 3-month requirement,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.Residential house managers will maintain electronic calendars with reminders set to help ensure compliance with all regulatory appointments to include 3-month psych med reviews. 10/27/2023 Implemented
6400.213(8)Individual #1's record does not include a copy of any psychological evaluation.Each individual's record must include the following information: Copies of psychological evaluations, if applicable.No individual will be granted admission to the agency without proof of documentation that a psych evaluation has been performed prior to admission. 10/27/2023 Implemented
SIN-00213555 Renewal 10/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1's most recent prostate examination was completed on 3/20/2021.The physical examination shall include: A prostate examination for men 40 years of age or older. Individual #1 has been rescheduled for a prostate examination on 11/14/2022, he will be assisted by the Assistant Program Director. Individual #1 will sign a Refusal of Treatment Document for the initial appointment he refused. 11/15/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 5/2/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter.(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.Old versions of the self-assessment tool were shredded and discarded. Staff were asked to complete the self-assessment on the correct version this will be completed by 11/22/2022 The correct version of the Self Assessment Tool was sought out by new Quality and Compliance Coordinator and supplied by inspector. All expired versions of the Self Assessment Tools were erased off the internal databases by Quality and Compliance Coordinator. Updated version was placed on internal site by direction of IT. 11/22/2022 Implemented
6400.163(d)At 10:43AM on 10/20/2022, Individual #2's prescription medication, Latanoprost .005% eye drops, was on his nightstand next to his bed. At 10:53AM on 10/20/2022, a bag of over the counter medication including Anti-Diarrheal, Adult Tussin, Regular Strength Pain Relief Acetaminophen and Tylenol Extra Strength was in the unlocked cabinet in the kitchen cabinet.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.All medications at the site were locked up during the inspection by the Assistant Program Director and Program Specialist along with the Direct Care employee at the time of the inspection. 12/19/2022 Implemented
6400.165(c)Individual #1's October 2022 Medication Administration Record lists Bacitracin as "PRN" (Pro Re Nata) and the medication label states, "apply to affected area topically daily." Individual #1's October 2022 Medication Administration Record lists Mupirocin 2% ointment as "PRN" (Pro Re Nata), but the medication label states, "apply topically three a day."A prescription medication shall be administered as prescribed.Site has corrected the MAR to match the label of the prescribed medication on 10/22/2022. All Direct Care Staff and Assistant Program Director will all be re-medication administration trained by 12/19/2022. The Program Specialist will be re-medication administration trained on 11/09/2022. 12/19/2022 Implemented
6400.166(a)(11)Individual #1's October 2022 Medication Administration Record does not include the diagnosis or purpose for Lisinopril, Ketoconazole and Nystop.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The purpose and the diagnosis was written in the MAR at the time of the inspection. 12/19/2022 Implemented
SIN-00196554 Renewal 11/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self assessment of the home.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. The Senior Residential Homes Managers will complete the self-assessment of their assigned homes by December 20, 2021. The Residential Director will review each plan prior to submission. 12/20/2021 Implemented
6400.112(c)The written fire drill record of the fire drill conducted on 08/04/21 does not include the time of day that the drill was conducted.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 Compliance Coordinator will do a review of all fire drill reports received from the Residential Homes Coordinators and with the assistance of the Program Specialists will ensure all information is completed and correct, including day and time that the drill was conducted. 12/06/2021 Implemented
6400.142(a)Individual #1 has a dental appointment on 09/30/19, and no other documentation provided to measure compliance with this regulation.An 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. The residential homes manager scheduled the earliest dental appointment for February, 2022. The compliance coordinator has also developed a spreadsheet indicating due dates with color code notices for 90 days and 30 days prior to appointments. 12/08/2021 Implemented
6400.51(b)(5)The orientation for Direct Service Worker #1, date of hire 07/19/21, did not encompass: job-related skills and knowledge.The orientation must encompass the following areas: Job-related knowledge and skills.Direct Service Worker #1 will complete this training by 12/17/21. 12/17/2021 Implemented
SIN-00180324 Renewal 12/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned by a professional cleaning company on 8/23/18 and then again on 11/26/19.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Facilities Director is responsible for coordinating all annual inspections. He indicated that due to COVID restrictions it was difficult to get the company to complete them. A checklist system is in place so that the Quality and Compliance Coordinator will send a notice at least three months in advance to the Facilities Director to have the inspections scheduled. The Quality and Compliance Coordinator will also send a two month and one month warning. All updated inspections were completed on January 11, 2021 and January 12, 2021. Copies will be emailed as proof. The Facilities Director and the Senior Residential Homes Coordinators were trained by the Quality and Compliance Coordinator about the regulation and the new tracking system. 01/12/2021 Implemented
6400.141(c)(9)Individual #1's physical examination, completed 10/13/20 did not include a prostate examination. This section of the form stated "N/A".The physical examination shall include: A prostate examination for men 40 years of age or older. The Residential Homes Manager will be trained on the proper completion of the form so that when the physician completes the form they are able to indicate all areas that need to be completed. Staff will be trained by their immediate supervisor. Programs specialists will audit 25% of the forms quarterly to ensure all necessary information is captured. [Individual #1 had bloodwork prostate testing on February 15, 2021. The staff, house managers and program specialist shall audit documentation upon completion as stated in the aforementioned plan of correction to ensure all physical examinations and testing are completed, timely. (DPOC by AES,HSLS on 2/16/21)] 01/11/2021 Implemented
6400.142(a)Individual #1 had a dental examination completed on 9/16/19, and then again on 11/8/2020.An 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. The Residential Homes Manager, who is responsible for scheduling and accompanying the individual was trained by the Quality and Compliance Coordinator on the regulation by reviewing the regulation and going over the dental examination form. 01/04/2021 Implemented
6400.142(g)Individual #1 had a dental hygiene plan completed on 9/16/19 and then again on 12/8/20.A dental hygiene plan shall be rewritten at least annually. The Residential Homes Manager and Program Specialist were trained, on the regulation, by the Quality and Compliance Coordinator. The Quality and Compliance Coordinator also created an updated dental hygiene form to be used. These are the individuals responsible for scheduling, assisting, and reviewing the forms to make sure they are completed and done so in a timely manner. 01/04/2021 Implemented
6400.165(b)Individual #1's December 2020 Medication Administration record states Diazepam 5mg, take 1 tablet by mouth every 6 hours as needed for seizures. The instructions on the medication label for Diazepam 5mg read take 1 tablet by mouth as needed for anxiety. A current prescription order for the Diazepam was not available.A prescription order shall be kept current.A new prescription label was created by the pharmacy after several phone calls to the doctors office and pharmacy. The label indicates that the medication is to be used for Seizures and now matches the MAR. The Quality and Compliance Coordinator met with the Residential Homes Manager and staff to show them the MAR and explain that what is written on the MAR must match the medication label. This was done on 1/04/2021 and the label was received on 01/13/2021. [At least monthly, a designated staff person certified to administer medication shall audit all individuals' medication administration records, medications with labels and physicians' orders to ensure all individuals are administered medications as prescribed and medication administration are documented as required and medications administration records are accurate with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/21)] 01/13/2021 Implemented
SIN-00160391 Renewal 08/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Direct Service Worker #3 had fire safety training on 6/18/18 and then again 6/25/19.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The training coordinator will use the new training database to track the specific dates when staff are trained on fire safety to ensure that each year they are retrained prior to the previous year¿s expiration. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 25% sample of staff persons' fire safety training to ensure timely completion of fire safety training for all staff person. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 08/16/2019 Implemented
6400.112(d)The fire drill held on 5/5/19 had an evacuation time of 2 minutes 40 seconds. The home does not have an extended evacuation time in writing by a fire safety expert. [Repeat Violation 8/21/18, et. al.]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 employee 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.Program specialists will work with quality compliance coordinator to ensure houses with evacuation times over 2 ½ minutes obtain yearly letters from the fire department allotting extra time for evacuation. Staff will be retrained to clearly understand that the drill time ends as soon as the last resident exits the home and not when they reach the designated meeting place. [Fire drill held on 8/18/19 had an evacuation time of 1 minute and 20 seconds. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for conducting fire drills of the requirements of fire drill and the agency's policies and procedures if problems are encountered and fire drills are not conducted as required. Documentation of trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of fire drill records to ensure fire drill are held and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/13/2019 Implemented
6400.151(a)Direct Service Worker #1 had a physical examination completed 10/7/16 and then again 3/4/19. Direct Service Worker #2 had a physical examination completed 10/5/16 and then again 2/27/19. 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. The program specialists and quality compliance coordinator will maintain a database helping to track when staff physicals/TBs are due. A policy will be created stating that staff who have an expired physical or TB will not be allowed back to work until those tests are completed and the paperwork is turned in. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 25% sample of staff persons' physical examinations to ensure timely completion of staff persons' physical examinations. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 08/19/2019 Implemented
6400.151(c)(2)Direct Service Worker #1 had Tuberculin skin testing on 10/7/16 and then again 6/12/19. Direct Service Worker #2 had Tuberculin skin testing on 10/7/16 and then again 2/28/19. 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. The program specialists and quality compliance coordinator will maintain a database helping to track when staff physicals/TBs are due. A policy will be created stating that staff who have an expired physical or TB will not be allowed back to work until those tests are completed and the paperwork is turned in. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 25% sample of staff persons' physical examinations including tuberculin testing to ensure timely completion of staff persons' physical examinations including tuberculin testing. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 08/19/2019 Implemented
6400.163(h)Nyastatin Powder prescribed to Individual #1's on 6/4/19 for 14 days remained in the home on 8/8/19.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Staff will be retrained by the medication trainer on reviewing dates on prescription and following up with pharmacy over any printed errors on the labels. Residential Homes Managers will also be responsible for checking medications on a weekly basis to ensure none have expired. [On 9/13/19, there were not any medications that were discontinued or expired that remained in the home. All staff persons were reeducated on administering medications on 8/16/19. Documentation of aforementioned medications checks shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/01/2019 Implemented
6400.166(b)Bacolfen 20 mg, take 1/2 tab by mouth every morning, 1 tablet at 4:00PM, and 1 tablet at bedtime for muscle spasms prescribed to Individual #1 was not initialed as administered on 8/1/19 at 8:00AM. Loperamide, take one capsule every 4 hours as needed, prescribed to Individual #1 was not listed on Individual #1's August 2019 medication record and was administered on 8/1/19, 8/5/19, 8/6/19, 8/7/19 and 8/8/19 at 7:00AM and was not initialed as administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff will be retrained on signing MARS by the medication trainer. [Baclofen 10 mg prescribed to Individual #1 was not initialed as administered on 9/2/19 at 8:00PM. Immediately, the staff person responsible for this error shall be reeducated in medication administration training and observed at least 4 times while administering medication prior to administering medications without supervision by a staff person certified to administer medications. All staff persons were reeducated on administering medications on 8/16/19. At least weekly for 3 months and then continuing at least monthly, a staff person certified to administer medication shall audit all individuals' current medication administration records, current medications and physicians' orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of all medications audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/01/2019 Implemented
SIN-00121254 Renewal 09/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 5/12/17 at 5:20PM had an evacuation time of 2 minutes and 45 seconds. There is not an extended evacuation time for this home. (Repeated Violation-9/23/16, et al). 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. All previously documented fire drills were reviewed by the Quality Compliance and Privacy Officer, the drill held on May 12, 2017 was the only drill that was above the 2 and 1/2 minute time limitation. This drill was completed by a new staff person who may have not totally understood the timing method. This person is no longer with the agency. A supplemental training will be completed with staff to insure their complete understanding of the fire drill process. Future fire drills will be reviewed by the Program Specialist each month and if another drill indicates that the evacuation time is above the stated timeframe, a letter will be secured by a fire safety expert indicating the allowable evacuation time.[Documentation of audits and aforementioned trainings shall be kept. (AS 10/4/17)] 10/13/2017 Implemented
6400.181(d)Individual #1's assessment, dated 4/1/17 had the Program Specialist #1's name typed in place of the signature. The program specialist shall sign and date the assessment. All assigned Program Specialist(s) will sign and date all assessments effective immediately. In addition, Program Specialist will manually sign all previously typed signatures on assigned assessments[Immediately, the CEO or designee shall review with all program specialist(s) the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individuals' assessment to ensure the program specialist sign and date the individuals' assessments as required. (AS 10/4/17)] 10/06/2017 Implemented
6400.186(b)The Program Specialist's name was typed in place of the signature on Individual #1's ISP reviews, dated 11/16/16, 2/16/17, 5/16/17 and 8/16/17. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. All upcoming ISP review documents requiring a Program Specialist signature in the will be signed in ink as indicated in this regulation. This includes previously electronically signed notes. In these cases, the Program Specialist will sign in ink above or next to the electronica signature on these[Immediately, the CEO or designee shall review with all program specialist(s) the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individuals' ISP reviews to ensure the program specialist sign and date the individuals' ISP reviews as required. (AS 10/4/17)] 10/13/2017 Implemented
6400.186(d)The program specialist did not provide Individual #1's ISP review documentation completed 5/16/17 and 8/16/17 to the plan team members.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. The creation/implementation of an excel spread sheet that includes all programmatic dates/benchmarks for completion of programmatic activities including the ISP review documentation will be utilized by each Program Specialist to insure dates are met. This spreadsheet will be created by the Quality Compliance and Privacy Officer with the assistance of the IT department. [Immediately, the program specialist will provide Individual #1's ISP review documentation completed 5/16/17 and 8/16/17 to the plan team members. Within 45 days of receipt of the plan of correction, the program specialist shall be educated on the aforementioned tracking system to ensure all individuals' ISP review documentation is provided to plan team members as required, timely. At least quarterly for 1 year, the CEO or designee shall review the aforementioned tracking system and a 25% sample of correspondence documentation showing the program specialist provided ISP review documentation to plan team members as required, timely. Documentation of audits shall be kept. (AS 10/4/17)] 10/27/2017 Implemented
SIN-00101155 Renewal 09/23/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 12:14 PM, the hot water temperature in the shower in the main bathroom measured 131.5 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. A monthly residential checklist was created that includes the date that the hot water tank temperature was checked and verified to be 120 degrees. This will be the responsibility of the Residential Homes Manager who will complete this checklist monthly in all assigned homes. The completed chart is to be submitted to the Residential Associate Director by the 5th of the following month to be reviewed and filed. [The hot water temperature was adjusted the day of the inspection. The Residential Homes Manager shall measure the hot water temperature in the shower in the main bathroom at least daily for 1 week and then weekly and continuing monthly. Immediately, the CRO shall develop and implement policies and procedures to ensure the hot water temperatures in bathtubs and shower do not exceed 120°F. The procedures shall require at least monthly check, and detailed procedures to follow if the hot water temperature exceeds 120°F. Within 30 days of receipt of the plan of correction, all staff persons shall be trained in the aforementioned policies and procedures to include their responsibilities. Documentation of the policies, procedures, trainings, checklists and review of checklists shall be kept. (AS 11/7/16)] 10/13/2016 Implemented
6400.112(c)The fire drill record for the fire drill held on 3/8/16 did not include the time of the fire drill. [Repeated Violation 8/27/15 et al.]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. In an effort to ensure that fire drill documentation is complete and includes date, time, the amount of time it took for evacuation, the exit route used, any problems encountered and whether the fire alarm or smoke detector was operable, a monthly residential checklist was created that documents this information was reviewed and corrected by the Residential Homes Manager each month for each home they are assigned to. The completed chart is to be submitted to the Residential Associate Director by the 5th of the following month to be reviewed ad filed.[Immediately, the CRO will review the fire drill documentation along with 6400.112(A)-(I) and revise as needed to ensure accurate documentation of fire drills. Within 30 days of receipt of the plan of correction, the CRO will develop and implement policies and procedures to ensure fire drills are conducted and documented as require including evacuating in less than 2 and 1/2 minutes and procedures to follow if required evacuation time is not met. Within 30 days and continuing at least quarterly for 1 year all staff persons shall be trained in aforementioned policies and procedures. Within 60 days of receipt of the plan of correction, a program specialist(s) shall observe a fire drill at each community home to ensure an unannounced fire drill is completed and documented as required. At least quarterly, the CEO or designated management staff shall review all fire drill records to ensure fire drills are conducted and documented as required. Documentation of trainings and monthly and quarterly reviews of all fire drills shall be kept. (AS 11/7/16)] 10/13/2016 Implemented
6400.183(4)Individual #1's assessment, dated 5/1/16 states, Individual #1 can be alone up to 2 hours provided that Individual #1 is in his/her manual wheelchair with access to a telephone. Individual #1's ISP, last updated 3/8/16 states, Individual #1 can be alone up to 2 hours.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. Individual#1 ISP was updated on 9/24/16 to include conditions to be alone as stated on assessment. The Program Specialist functions as the Plan Lead for this individual because his funding source does not provide an entity to function in this capacity. A review of a Plan Leader's responsibilities was conducted with all CLASS's Residential Program Specialists by 10/10/16. [Within 30 days of receipt of the plan of correction and continuing at least quarterly, the program specialist shall review all individuals' ISPs to ensure all required information is present and accurate. Necessary updates and changes shall immediately be completed by the program specialist as required. At least quarterly for 1 year the Director or CRO shall review a 25% sample of ISP updates and revisions to ensure completion and accuracy. Documentation of all reviews shall be kept. (AS 11/7/16)] 10/10/2016 Implemented
6400.183(5)Individual #1's ISP, last updated 3/8/16, did not include a protocol to address social, emotional and environmental needs of the individual. Individual #1 is prescribed Seroquel, 5mg at bedtime and Trazadone, 25mg at bedtime to treat symptoms of depression. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. An update to individual#1 ISP was completed on 9/24/16 to include a summary of the social, emotional environmental plan. The Program Specialist functions as the Plan Lead for this individual because his funding source does not provide an entity to function in this capacity. A review of a Plan Leader's responsibilities was conducted with all CLASS's Residential Program Specialists by 10/10/16.[Within 30 days of receipt of the plan of correction and continuing at least quarterly, the program specialist shall review all individuals' ISPs to ensure all required information is present including social, emotional and environmental plan and accurate. Necessary updates and changes shall be completed as required. At least quarterly for 1 year the CRO shall review a 25% sample of ISP updates and revisions to ensure completion and accuracy. Documentation of all reviews shall be kept. (AS 11/7/16)] 10/10/2016 Implemented
SIN-00083439 Renewal 08/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 2/11/15 had an evacuation time of 2 minutes and 32 seconds. The fire drill conducted on 4/10/15 had an evacuation time of 2 minutes and 40 seconds. The most recent evacuation time specified in writing by a fire safety expert was dated 3/15/13. 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 Residential Homes Manager will deliver a letter to the responsible fire company indicating the maximum evacuation time the individuals in the home have demonstrated and request, the it is deemed safe and appropriate, for the responsible fire official to sign this letter. The letter will be placed in the fire drill log and be updated annually as needed.[The evacuation time must be written by a fire safety expert designating a time period. If said letter is not obtained, the individuals must evacuate within 2 1/2 minutes. Fire drill logs from September, October and November, 2015 were submitted to the department demonstrating that individuals are evacuating in less than 2 1/2 minutes. Fire drill logs will be reviewed by the CEO or designee monthly for the next 6 months ensuring individuals are evacuating within 2 1/2 minutes, if evacuation times are not within required timeframes, CEO or designee will provide training, staffing etc. to ensure individuals' safety.(AS 12/28/15)] 10/03/2015 Implemented
6400.141(c)(9)The most recent physical examination, dated 9/8/14 for Individual #1, date of birth is 3/1/69, did not include a prostate examination. The physical examination shall include: A prostate examination for men 40 years of age or older. CLASS's physical form was revised to state that a blood test for prostate is not acceptable. If physician deems that due to physical limitations, it is not possible to complete a manual prostate they will be asked to indicate this on the form. [As per conversation with CEO 10/23/15, the community support coordinator will be responsible for coordinating and transporting individuals to medical appointments using a tracking system with due dates. The Associate director will review the physical examination documentation to ensure completion and return to community support coordinator if all required elements are not completed who will in turn follow up until all requirements are met. (AS 10/23/15)] 10/03/2015 Implemented
6400.181(f)The assessment for Individual #1, dated 3/1/15, was not provided to the team members prior to the ISP meeting held on 4/7/15. The assessment for Individual #2, dated 4/1/15, was not provided to the team members prior to the ISP meeting held on 5/19/15. (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). The Program Specialist was reinstructed on this requirement and will provide each team member an assessment summary at least 30 days prior to the annual meeting based on the date of previous years meeting.[As per conversation with CEO on 10/23/15, CEO conducted a 15 minute in-service for the program specialists on the process to maintain documentation of what was sent to team members. The PS will review invitation letter and ISP to ensure all team members receive the assessments and ISP reviews for all individuals. CEO will review a 25 % sample of individuals' records at least monthly for the next 6 months to ensure assessments and ISP reviews are being sent and documentation is being maintained in the individuals¿ records as required. (AS 10/23/15)] 10/03/2015 Implemented
6400.186(d)The ISP review documents for Individual #1 dated 11/16/14, 2/16/15, 5/19/15 and 8/19/15 were not sent to plan team members. 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. Program Specialist was reinstructed on this regulation's requirements and shall provide each team member with ISP review documantation within the prescribed time frame effective immediately.[As per conversation with CEO on 10/23/15, CEO conducted a 15 minute in-service for the program specialists on the process to maintain documentation of what was sent to team members. The PS will review invitation letter and ISP to ensure all team members receive the assessments and ISP reviews for all individuals. CEO will review a 25 % sample of individuals' records at least monthly for the next 6 months to ensure assessments and ISP reviews are being sent and documentation is being maintained in the individuals' records as required. (AS 10/23/15)] 10/03/2015 Implemented
SIN-00140416 Renewal 08/21/2018 Compliant - Finalized
SIN-00067035 Initial review 08/22/2014 Compliant - Finalized