Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00123398 Renewal 10/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light located outside the back door did not have a working light bulb.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. 1. What was done immediately to correct the specific issue cited? Staff member changed the old light bulb with a new light bulb to ensure proper lighting of the exterior on 10/19/2017. (Work Order -- Attachment 1) 2 What specific change will be made? Program Director has instructed the site level managers to check all areas of the physical site upon monthly completion of the Residential Site Checklist. 3 Who (by title) will make the change? Site Supervisors and Program Directors. 4. When will the change be made? October 20, 2017 and ongoing 5. What system has been implemented to make sure the same violation does not occur again? Supervisors are responsible for completing the monthly residential site checklist. When completing the checklist the supervisor checks all areas of the home for compliance including a check of the physical site. During the check the supervisor is responsible for answering the following questions: Are all exterior lights in good working order? 6. What education and training has been provided to staff? Supervisors receive training on the completion of the monthly Residential site checklist at the time of their orientation. Supervisors receive follow up education and training at the time of their monthly supervisions when the Monthly Residential Site Checklist is reviewed by the Program Director. Direct service employees receive training regarding physical site compliance during their initial on-site orientation. 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 monthly basis to inspect service locations for regulatory compliance. The information recorded on the Monthly Residential Site Checklist is also verified quarterly when the Program Director (Manager) completes quantitative record reviews and Residential Spot Checks. During monthly supervision when the Monthly Residential Site Checklist is submitted, supervisors are reminded to ensure the accuracy of their report and advised as to how to implement any needed corrective actions. 10/19/2017 Implemented
SIN-00066970 Complaints- Legal Location 07/31/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On July 1st 2014 Staff person A was observed grabbing individual #1 by the arm and pulling him out of the front door causing him to falll.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. All of the Direct Support Professionals (DSP) assigned to work at this service location will be trained (or re-trained) in the following three (3) courses: Ethics and Boundaries, Incident Management and Non-Violent Crisis Intervention within the next 30 days. The Nurse Manager will deliver training to DSP on the provisions of AJ's 2/12/14 Health Promotion Activities Plan (HPAP) to prevent falls within the next 30 days. The target of the investigation AC was debriefed on 9/2/14 and received written feedback as a result of the findings. AC was reassigned to a different service location on 9/04/14. The Team Coordinator and Human Resource Manager have scheduled a counseling session with AC on 9/09/14. Participant AJ was debriefed on the investigation findings on 8/26/14. He was reminded of his participant rights and the right to be free from abuse and neglect. The Team Coordinator also reminded AJ of his responsibility to report any injuries immediately to staff. All of the staff at this service location received a debriefing on the investigation on 8/26/14 regarding their shared negligence in reporting the participant's injuries and will receive written feedback for failure to adhere to agency policy and procedures and ensuring the health and safety of the participant. 10/07/2014 Implemented
6400.45(c)Individual #1 was left in his bedroom unsupervised and when he emerged from his room, was observed to have an injury to his left eye. An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual's ISP, as an outcome which requires the achievement of a higher level of independence. The updated Supervision and Independence Protocol was implemented on 7/24/2014. Since all DSP had been previously trained on the 30-minute protocol, the 15-minute protocol was implemented immediately in response to the licensing review for health and safety reasons. This change will be discussed with AJ when his team meets on 9/04/14. Immediately following this meeting, documentation of the checks will be reviewed with DSP. DSP will indicate on the evening shift of the Daily Progress note when AJ was in his room and at what time checks were completed. The overnight DSP will document the checks on a data sheet that will be used beginning on 9/04/14. The Program Specialist trained all DSP on 9/04/14. The Home Coordinator will monitor implementation of the protocol each week and provide feedback to DSP as needed. ¿ The Program Specialist will conduct monthly monitoring and will provide feedback to the Home Coordinator as needed. 09/04/2014 Implemented
SIN-00234686 Renewal 11/13/2023 Compliant - Finalized