Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00199786 Renewal 02/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There was no ventilation by a window or mechanical in bathroom #1 and bathroom #2. The ventilation fan was not operating.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Director of CLA program completed another work order for vent to be repaired on 2/9/2022. Deputy Director sent a work order again on 2/18/2022, requesting completion of vent repairs. Repair was completed on 2/24/2022. (Attachment 3 hall bath, attachment 17 primary bedroom confirmation of repaired vent) 02/24/2022 Implemented
6400.67(a)The dishwasher was not operating properly, there was standing water in the tub of the washer.Floors, walls, ceilings and other surfaces shall be in good repair. Director of CLA program completed another work order for dishwasher to be repaired on 2/9/2022. Deputy Director sent a work order again on 2/18/2022, requesting completion of dishwasher repairs. Repair was completed on 2/23/2022 (Attachment 4- Confirmation of repaired dishwasher photo) 02/24/2022 Implemented
SIN-00182602 Renewal 01/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)There was no indication that individual #6 had a prostate exam at the time of the last physical dated 9/24/2020.The physical examination shall include: A prostate examination for men 40 years of age or older. Director completed a training with all staff on Caring for Clients Medical Needs. All staff were trained on the process of accompanying a resident to a medical appointment. Included in the training was review of paperwork prior to leaving the medical office. Senior Resident Advisor will review paperwork upon return from office for accuracy of information, placing a check mark in top right corner to verify review. Medical documentation will be reviewed for a second time during monthly Program Book audits. Attachment: 6400.141(c) (9): Sign-off sheet Caring for Clients Medical Needs, Senior Resident Advisor Job description 02/27/2021 Implemented
6400.143(a)Individual #6 was scheduled for a dental exam on 4/9/2020. The exam was reported to be refused by the individual. However, there was no documentation for follow up regarding this appointment.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. A dental exam was completed for individual #6 on 1/27/2021. All staff completed a training on Caring for Clients Medical Needs. All staff were trained on the process of accompanying a resident to a medical appointment. All staff reviewed process of documentation when a resident refuses medical care, including ongoing education and prompting for following health care needs and documentation. Senior Resident Advisor will review documentation regarding medical appointments and refusals. Medical documentation will be reviewed for a second time during monthly Program Book audits. Attachment: 6400.143(a) individual #6 dental exam, Caring for Clients Medical Needs sign-off sheet, Senior Resident Advisor Job description 02/27/2021 Implemented
6400.18(i)The agency did not finalize the incident ID:8759770 timely for Individual #6 that occurred on 10/27/2020. The agency also did not request an extension in writing to the licensing body.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.Deputy Director and Director review incident in question on 1/13/2021. Upon review, the incident was not able to be finalized without addressing the late submission of incident. Late submission was addressed in HCISIS report. HCSIS report was approved and closed. Re-training for HCSIS submission was completed by Deputy Director, signed by Director on 1/28/2021. Attachment: 6400.18(i): Training sign-off sheet Completing Site Level Incidents in HCSIS 01/28/2021 Implemented
6400.169(d)Staff #1 administers medication to individuals. The home did not have documentation that staff #1 successfully completed a Department-approved medication administration training course. The provider representative stated that the staff person was trained by another agency and that the provider obtained verbal authorization that the staff person was trained but did not obtain documentation verifying same."A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.NECCBH contracted Staff #6, Certified Medication Trainer, to observe and train existing staff members. Observations for existing staff members was completed by 2/9/2021. Director of CLA, obtained her Train the Trainer Certification and will now oversee the training and observations of all existing and new staff members. Attachment: 6400.169(d): Staff #6 certification, paperwork and contract, Director of CLA's training certification. 02/19/2021 Implemented
SIN-00154235 Renewal 04/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)For Individual #1, the receipt for $17.00 Shady Brook Farm Markets dated 10/11/18 was not on the ledger for the month of October. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. On 4/19/19, the ledger was corrected to reflect receipt of $17.00 Shady Brook Farms dated 10/11/18 (Attachment I). On this same date, Program director implemented a peer review of the ledger to be conducted by Senior Residential Counselor on a weekly basis (Attachment H). Additionally, Program Director completed a review of the Policy and Procedure for all receipts for trips. Policy and Procedure for receipts and finances is attached (Attachment I). All ledgers were reviewed for accuracy. 04/19/2019 Implemented
6400.62(a)In the first aid kit, there were 2 packets of Tylenol 500mg tablets.Poisonous materials shall be kept locked or made inaccessible to individuals. On 4/18/19, Tylenol was removed from the First Aid kit by Senior Residential Counselor. The required contents and corresponding regulations pertaining to all First Aid kits were reviewed with all staff members by 4/26/19 (see Memo Attachment B). Ongoing monitoring of First Aid kits will be conducted on a weekly basis by assigned staff by completing Inventory Tracking Sheet (Attachment C). Attachment D has staff training record of new Policy and Procedure. Senior Residential Counselor will review tracking sheet on a weekly basis to assure compliance (Attachment E). All First Aid kits were inspected. 04/19/2019 Implemented
6400.64(a)In individual #2 bathroom hallway area there was a very strong smell consistent with urine.Clean and sanitary conditions shall be maintained in the home. On 4/18/19, The bathroom was cleaned by Senior Residential Counselor. The required corresponding regulations pertaining to sanitation was reviewed with all staff members by 4/26/19. Ongoing monitoring will be conducted on a weekly basis by assigned staff. Implemented
6400.77(b)The first aid kit did not contain: Tape or a operational thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. On 4/18/19, medical tape and thermometer were placed in the First Aid kit by Senior Residential Counselor. The required contents and corresponding regulations pertaining to all First Aid kits were reviewed with all staff members by 4/19/19 (see Memo Attachment B). Ongoing monitoring of First Aid kits will be conducted on a weekly basis by assigned staff by completing Inventory Tracking Sheet (Attachment C). Attachment D has staff training record for new policy and procedure. Senior Residential Counselor will review tracking sheet on a weekly basis to assure compliance (Attachment E). All First Aid kits were inspected. 04/19/2019 Implemented
6400.213(1)(i)On Individual #1 file, the following was omitted: hair color, eye color, identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.On 4/19/19 Individual #1's (WF) face sheet was updated by Program Coordinator to include the omitted information: hair color, eye color and identifying marks (Attachment F). This was added to the individual's record which already included personal information, including the name, sex, admission date, birthdate and Social Security number. The Program Coordinator will assure that information is updated annually on the first of the calendar year with date of review indicated at the bottom of the face sheet. The Program Director will track compliance through ongoing chart reviews. All files were reviewed for compliance. Corrections were made to every record to maintain regulatory compliance for entire Community Homes Program 04/19/2019 Implemented
SIN-00128227 Renewal 01/22/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)THE ISP REVIEW DATED 08/04/2017 FOR INDIVIDUAL #1 WAS NOT SIGNED BY THE INDIVIDUAL.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Immediately, the Program Specialist (PS) and the individual shall sign and date all ISP review sheets upon review of the ISP. The PS will complete the ISP review and meet with the individual for review and to obtain signature. The PS will be responsible to assure compliance by continuing to utilize a tracking system which reflects such compliance. The tracking system has been enhanced to include an additional level of review by the PS's supervisor during regular weekly supervisory sessions to assure PS and individual have signed and dated all ISP reviews. (See attachment #1) The tracking system (see attachment #1) reflects the completion of an ISP (see attachment #2) which was reviewed and signed on 2/4/18 and reviewed for compliance by supervisor on 2/5/2018. On 1/31/18 the PS's supervisor reviewed all remaining individual resident files to assure compliance. (See attachment #1) On 1/31/18, the PS was retrained in the 6400 Regulations as well as on policy and procedure implemented to assure this violation does not occur in the future. (See attachment #3 A & B). 02/05/2018 Implemented
SIN-00108217 Renewal 01/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The physical for Individual # 1, dated 1/14/16, did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Effective 1/23/17 annual physicals will be attached to Agency medical appointment consultation form(see attachments #2 and #3) for PCP to review and complete at conclusion of visit. Included on form is a section that specifically lists client medical information pertinent to diagnosis and treatment in case of emergency. Senior Resident Adviser, Program Coordinator and Program Director will review annual physicals and medical consultation forms for any changes in individual medical information annually for changes and/or updates as needed. 01/23/2017 Implemented
6400.181(e)(12)The assessment for Individual # 1 dated 11/20/16 did not include specific recommendationsThe assessment must include the following information: Recommendations for specific areas of training, programming and services. Effective 1/23/17, assessment recommendations for specific areas of training, programming and services will be reviewed and updated annually by Program Director. Program Director will also implement tracking system to ensure completion of assessment recommendations.(see attachment #4) 01/23/2017 Implemented
SIN-00095722 Renewal 11/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Four gallons of Pine White Germicidal Ultra Bleach and two bottles of Fabuluso which indicated on label to "Contact Poison Control if Ingested" were found unlocked in the hallway closet.Poisonous materials shall be kept locked or made inaccessible to individuals.Poisonous materials shall be kept locked at all times. The Director immediately locked all hazardous materials in a secure, locked area on the day of licensing, 11/19/2015. Beginning 12/4/15, the Senior Resident Adviser oversees the completion of site inspections by staff, on a weekly basis, utilizing the weekly site inspection form (see attachment #6)to ensure ongoing compliance. 11/19/2015 Implemented
6400.71Emergency telephone numbers were not posted near the telephone and were found in a folder posted on a bulletin board in the kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency phone list will be posted next to the phone at all times. Emergency telephone numbers were posted immediately next to the telephone during the time of licensing inspection on 11/19/2015. Beginning 12/4/15, the Senior Resident Adviser will oversee the completion of site inspections by staff on a weekly basis, utilizing the weekly site inspection form (see attachment #6) to ensure ongoing compliance. 11/19/2015 Implemented
SIN-00219035 Renewal 02/08/2023 Compliant - Finalized
SIN-00078851 Renewal 07/21/2014 Compliant - Finalized