Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214769 Renewal 11/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Lint the size of a golf ball was present in the filter which could cause a hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.What was done immediately to correct the specific issue cited? At the time of inspection, on 11/15/2022, Supervisor discarded the lint found in the dryer. A sign has been posted in laundry are reminding staff to clean the lint filter after each use. What specific change will be made? All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff. Who (by title) will make the change? Program Director and Site Supervisor will be responsible for making the change. When will the change be made? Change was implemented immediately on 11/15/22. What system has been implemented to make sure the same violation does not occur again? Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution. What education and training has been provided to staff? Staff were educated on this regulation during a staff meeting held on 11/18/2022 All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process. Attachment #17 11/15/2022 Implemented
SIN-00196925 Renewal 11/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The April 2021 monthly fire drill were not provided at inspection. An unannounced fire drill shall be held at least once a month. 1. What was done immediately to correct the specific issue cited? On 11/17/2021, the Regional Director met with home leadership to review the 6400.112a regulations, which requires community home providers to conduct an unannounced fire drill to be held at least once a month. 2. What specific change will be made? The program director reviewed the new Fire Drill Process and Annual Monthly Fire Drill Tracker with the Site Supervisor. The Site Supervisor will train the staff at the site by 12/31/21. The program director will conduct a thorough review of completed fire drills forms on a monthly basis to ensure that all drills are completed. This review will be captured on the Annual Monthly Fire Drill Tracker that will be reviewed monthly by the Regional Director during monthly supervisions with Program Directors. 3. Who (by title) will make the change? The Site Supervisor, Program Director, Regional Director 4. When will the change be made? December 31, 2021 5. What system has been implemented to make sure the same violation does not occur again? To supplement the Emergency Response Policy and Procedure, a Fire Drill Process was developed that incorporates monthly reminders using an Annual Monthly Fire Drill Tracker. The Site Supervisor will train staff on the new Fire Drill Process and the use of the Annual Monthly Fire Drill Tracker by 12/31/21. To ensure that the site is compliant in conducting the required monthly drills, the ¿Annual Monthly Fire Drill Tracker¿ will be filed in the front of the Fire Drill Binder at the site. The tracker will be the first page of the binder and will be accessible to all staff working at the site, who will complete the tracker after the completion of each drill. The Program Director will review the Annual Monthly Fire Drill Tracker by the end of the 3rd week of each month to ensure the home is on track and follow up to ensure a drill is completed by the end of the month. The completed fire drill form will be uploaded by the Program Director into Horizon House¿s internal electronic storage drive for tracking by the 5th of the following month. 6. What education and training has been provided to staff? The Regional Director reviewed regulation 6400.112a with the Program Director and stressed the importance of their oversite responsibility on their reviews of the fire drill forms in an effort to prevent the reoccurrence of this citation. Staff at the site will also be trained on the new Fire Drill Process by 12/31/21. Attachment #6 12/31/2021 Implemented
6400.112(e)Only one sleep drill was provided, which was completed on 9/10/21.A fire drill shall be held during sleeping hours at least every 6 months. 1. What was done immediately to correct the specific issue cited? On 11/17/2021, the Regional Director met with home leadership to review the 6400.112e regulations that requires community home providers to conduct an unannounced fire drill to be held at least once a month and an overnight drill every 6 months. 2. What specific change will be made? The program director reviewed the new Fire Drill Process that incorporates completing an overnight drill at least every 6 months with the Site Supervisor. The Site Supervisor will train the staff at the site by 12/31/21. The process includes completing the unannounced overnight drill in a designated month for all programs, so that all locations will become accustomed to doing unannounced overnight drills in the same designated months. During the program director¿s monthly supervisions with their site supervisor, the Monthly Fire Drill Tracker will be reviewed to ensure that staff are completing the drills according to the Fire Drill Process. 3. Who (by title) will make the change? The Site Supervisor, Program Director, Regional Director 4. When will the change be made? December 31, 2021 5. What system has been implemented to make sure the same violation does not occur again? To supplement the Emergency Response Policy and Procedure, a Fire Drill Process was developed that incorporates monthly reminders using a Monthly Fire Drill Tracker. The program director will train all relevant staff on the new Fire Drill Process by 12/31/21. To ensure that the site is compliant in conducting the required number of ¿overnight¿ drills per year, the ¿Annual Monthly Fire Drill Tracker¿ will be filed in the front of the Fire Drill Binder at the site. The Monthly Fire Drill Tracker indicates the designated months that the unannounced overnight drills will be completed. The tracker will be the first page of the binder and will be accessible to all staff working at the site, who will complete the tracker after the completion of each drill. At least quarterly, during monthly staff meetings, Site Supervisors will review the timeframes for unannounced overnight drills to ensure that staff are on target to complete them. The Site Supervisor, Program Director, and Regional Director will review the tracker specifically for the overnight drills at least quarterly. 6. What education and training has been provided to staff? The Regional Director reviewed regulation 6400.112e with the Program Director and stressed the importance of their oversite responsibility in ensuring that unannounced overnight drills are completed at least every 6 months. Staff at the site will also be trained on the new Fire Drill Process by 12/31/21. Attachment #6.1 12/31/2021 Implemented
SIN-00150104 Renewal 12/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen range exhaust fan, and adjoining cabinet had grease on its surface.Clean and sanitary conditions shall be maintained in the home. 1. What was done immediately to correct the specific issue cited? Home Coordinator and direct care staff cleaned the surfaces in the kitchen and other areas where grease had collected. 2. What specific change will be made? The staff sign-off on a daily chore list identifying areas that were cleaned which includes bathroom, kitchen, bedrooms, living space and dining area. Home Coordinator is reviewing chore chart weekly to ensure cleanliness of site. 3. Who (by title) will make the change? Home Coordinator reviews chore sheets on a weekly basis. Program Director reviews chore sheets on a monthly basis during supervision along with the Monthly Residential Site Checklist. Random spot checks are completed by administrative staff on a quarterly basis. 4. When will the change be made? December 12, 2018 and ongoing 5. What system has been implemented to make sure the same violation does not occur again? Daily chore check list are being reviewed weekly by manager to ensure task are being completed. Cleanliness of the site is being reviewed on a monthly basis during individual supervisions of direct care staff and during monthly staff meetings. Residential site checklist are completed by Home coordinator and reviewed monthly by Program Director. 6. What education and training has been provided to staff? Site supervisor and staff counseled on the importance of maintaining cleanliness and compliance with 6400 regulations and Horizon House standards. 7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up. Program Directors are required to visit each service location on a quarterly basis to inspect service locations for cleanliness. The information recorded on the Monthly Residential Site Checklist is also verified quarterly when the Program Director completes quantitative record reviews and Residential Spot Checks. During monthly supervision when the Monthly Residential Site Checklist is submitted, home coordinators are reminded to ensure the accuracy of their report and advised as to how to implement any needed corrective actions. 12/12/2018 Implemented
6400.67(a)Individual #1's door lock was loose.Floors, walls, ceilings and other surfaces shall be in good repair. 1. What was done immediately to correct the specific issue cited? A request was submitted the Horizon House maintenance department and contact made with the property management. The Door lock was fixed. 2. What specific change will be made? The staff sign-off on a daily chore list identifying areas that were cleaned which includes bathroom, kitchen, bedrooms, living space and dining area. Home Coordinator is reviewing chore chart weekly to ensure cleanliness of site. 3. Who (by title) will make the change? Home Coordinator reviews chore sheets on a weekly basis. Program Director reviews chore sheets on a monthly basis during supervision along with the Monthly Residential Site Checklist. Random spot checks are completed by administrative staff on a quarterly basis. 4. When will the change be made? December 12, 2018 and ongoing 5. What system has been implemented to make sure the same violation does not occur again? Daily chore check list are being reviewed weekly by manager to ensure task are being completed. Cleanliness of the site is being reviewed on a monthly basis during individual supervisions of direct care staff and during monthly staff meetings. Residential site checklist are completed by Home coordinator and reviewed monthly by Program Director. 6. What education and training has been provided to staff? Site supervisor and staff counseled on the importance of maintaining cleanliness and compliance with 6400 regulations and Horizon House standards. 7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up. Program Directors are required to visit each service location on a quarterly basis to inspect service locations for cleanliness. The information recorded on the Monthly Residential Site Checklist is also verified quarterly when the Program Director completes quantitative record reviews and Residential Spot Checks. During monthly supervision when the Monthly Residential Site Checklist is submitted, home coordinators are reminded to ensure the accuracy of their report and advised as to how to implement any needed corrective actions. 12/18/2018 Implemented
6400.80(b)The railing on the rear porch had peeling paint. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.1. What was done immediately to correct the specific issue cited? A request was submitted the Horizon House maintenance department and contact made with the property management. The area was sand and repainted on Jan. 15, 2019. 2. What specific change will be made? Residential staff completes visual checks weekly of equipment inside and outside areas. Should any area need to be repaired or replaced, communication is made with the supervisor and/or the program director. A request is then submitted to the Real Estate Dept. 3. Who (by title) will make the change? Residential Staff and site supervisors 4. When will the change be made? The change was made on 12/12/18 5. What system has been implemented to make sure the same violation does not occur again? When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery 6. What education and training has been provided to staff? Residential Site Checklist and EMAINT was reviewed with Site Manager to ensure that the site is inspected thoroughly each month and necessary follow up is done to ensure the repairs are completed in a timely manner. Site Managers and Program Directors will attend Real-Estate training class annually. 7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up. When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery. The supervisor will keep the PD apprised of any issues not resolved within 30 days. The PD will follow up with maintenance as necessary until the issue is resolved. The supervisor has informed all staff of the importance of reporting observed maintenance issues immediately so that steps may be taken to resolve them. 12/12/2018 Implemented
SIN-00084317 Renewal 02/03/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff #1 administered medications and has not completed the Department's Medication Administration training. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. 1. What was done immediately to correct the specific issue cited? The individual staff was immediately removed from administering medication and scheduled to attend a 4 day med training course. Because of her inability to attend the 4 day training, the employee resigned her position at Hazel Ave. 2. What specific change will be made? Any employee working in residential homes attends the 4 day medication training Giving Medication the Right Way, and must achieve a passing score of 90 or above. Once the employee passes the medication administration test, the medication observation is completed and the employee can administer medications. 3. Who (by title) will make the change? The Home Coordinator and Program Director follows up with any employee when administering medications to achiever accuracy in medication administration. 4. When will the change be made? The changed occurred on February 6, 2015. 5. What system has been implemented to make sure the same violation does not occur again The employee record of each staff person who administers medication has been reviewed by the Project Manager to ensure a complete annual/recertification packet is in the employee record. 6. What education and training has been provided to staff? Within 90 days of the date of hire, residential staff must successfully complete 4 day medication training course provided by Horizon House certified medication trainers. Completion of this employment requirement is documented on the on-site orientation checklist. 7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up. Each employees training list is reviewed each month by Home Coordinator/Team Coordinator. An employee who does not have a completed annual or re-certification packet in their perspective personnel file will be retained and the new certification date will be used to complete re-certifications annually thereafter. 02/06/2015 Implemented