Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234220 Unannounced Monitoring 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At the time of the 11/08/23 onsite inspection, the light at the front door did not illuminate.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The outside light fixture at the front entrance to the home has been replaced. Attachment 46 11/23/2023 Implemented
6400.103The emergency evacuation plan lists two separate groups of hotels for the individuals to relocate to in the event of an emergency; the Comfort Inn in Mechanicsburg or the Hilton Garden Inn in Gettysburg, alternatively, another form lists Homewood Suites in Mechanicsburg or TownPlace Suites in Mechanicsburg and Hampton Inn Camp Hill is listed on another form in the record.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Emergency Evacuation Plan has been edited to eliminate contradictory relocation information. Each home has one primary relocation site and one alternate site in the plan. Attachment 47 11/23/2023 Implemented
6400.112(c)The written fire drill records from June 2023 to current, did not record the date of the fire drill at the time of completion of the fire drill record. The fire drill records are completed electronically and do not include a date of completion. Sometime after the electronic records are printed, a handwritten date is added to the form. The name and date of the person making this addition is never documented.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 electronic Fire Drill form has been reformatted to include the name of the person conducting the drill, the date of the drill being completed, a separate entry for AM or PM and an entry field for the designated meeting place. All entry fields are required for successful submission of the form. Each home has an assigned designated meeting place which is identified in the Fire Safety Manual at the home. Attachment 2 11/23/2023 Implemented
6400.112(h)According to the home's monthly fire drill records, individuals evacuated to the meeting place during the drill. However, the home does not have a defined meeting place in any evacuation plans or procedures or included with the fire safety training. Therefore, it is unknown where the individuals are evacuating to during every fire drill as the meeting place is never documented or defined. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The electronic Fire Drill form has been reformatted to include the name of the person conducting the drill, the date of the drill being completed, a separate entry for AM or PM and an entry field for the designated meeting place. All entry fields are required for successful submission of the form. Each home has an assigned designated meeting place which is identified in the Fire Safety Manual at the home. Attachment 48 11/23/2023 Implemented
6400.113(a)The agency's fire safety training provided to the individuals does not include training on the designated meeting place for individuals or the smoking safety procedures; the fire training course includes generic training and is not specific to the home. 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. The Training record has been amended with documentation of the content of topics specific to their home. Including: General Fire Safety Evacuation Procedures Responsibilities during fire drills The designated meeting place outside of the building or within the fire safe area in the event of an actual fire. Smoking Safety Procedures. Attachment 49 11/23/2023 Implemented
SIN-00177917 Unannounced Monitoring 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The rear entry door light switch cover had a brown stain which was able to be scrubbed and removed during the physical site walkthrough.Clean and sanitary conditions shall be maintained in the home. Critical Analysis of cause of violation.: Light switch covers which are located next to entries are particularly susceptible to becoming soiled due to the frequency of their use as well as the likelihood that outside elements may be transferred to the surface as people enter the home. The failure to keep such surfaces clean indicates a need to specify that task be completed on a frequent basis. Immediate Correction: As noted in the citation, the rear entry door light switch cover was cleaned during the inspection. Change in procedure: Monthly job duties are assigned to all staff to include dusting, mopping, and cleaning oven. The duties assignments have been modified to increase the frequency of occurrence and expanded to include wiping down cabinets twice monthly, cleaning trash cans weekly, wall plates and surrounding wall surfaces monthly. Specific steps to be taken: House Supervisors will instruct all Direct Support Staff on the revised Job Duty Assignment sheet and insure that they are aware that they are to complete each task as assigned and initial the list once the job is completed. House Coordinators will review the list and the home each week to insure job assignments are being completed. Attachment B The Executive Director will conduct random unannounced inspections of the home and provide written feedback to the House Coordinators and Direct Support Staff on the findings of the inspections. In the event that deficiencies are found, the House Coordinator will conduct hands on training with the Direct Support Staff to insure that they have the proper skills and supplies to complete the assigned tasks. Any such training will be documented to include the specific task being trained and a signed acknowledgement will kept on file. In the event of further deficiencies being found, the responsible person will be subject to formal disciplinary actions intended to insure that the home consistently maintains a clean and healthy environment. 10/27/2020 Implemented
6400.67(a)The bathtub drain stopper was not attached to the drain. Attempted to screw on the threads of the stopper but it did not catch. The Bathroom sink did not have a drain stopper.Floors, walls, ceilings and other surfaces shall be in good repair. Critical Analysis of cause of violation.: The bathtub drain stopper had been removed as it was not properly seated and was protruding beyond the tub surface. The bathtub is only used for showering so the absence of a stopper was not interfering with the use of the fixture. Similarly, the bathroom sink stopper is not routinely required for tooth brushing, hand washing or other activities involving the sink. While it is unknown as to how or why the stopper was removed, this may have contributed to the needed repair not being properly identified and placed on a work order for the maintenance person to attend to. Immediate Correction: The bathtub drain stopper has been replaced. The bathroom sink stopper has been replaced. Attachment B1 Change in procedure: Maintenance Person will monitor the status of all fixtures in all homes through regular inspections to ensure that they in good repair. This check has also been added to the Direct Support Staffs monthly job duty sheet. Attachment B Specific Steps to be taken: The House Supervisors will instruct the Direct Support Staff in the implementation of the revised Monthly Job Duty Assignment sheet including as it pertains to needed repairs in the homes. A written work order will be generated by the House Supervisor as a result of any identified needed repairs. The work order will be submitted to the Executive Director for review and forwarding to the Maintenance Person. Within thirty days, the Executive Director will reinstruct the Maintenance Person in the Physical Site section of the 6400 regulations. A signed acknowledgment of the content and completion of this training will maintained. The Executive Director has instructed the Maintenance Person to perform any needed repairs that are found regardless of the presence or absence of a written work order. The Executive Director will conduct random unannounced inspections of the home and provide written feedback to the Maintenance Person on the findings of the inspections. 10/27/2020 Implemented
6400.76(a)Individual #1 has a personal chair in his bedroom which has approximately 4 white stains on the seat cushion of the chair. Furniture and equipment shall be nonhazardous, clean and sturdy. Critical Analysis of cause of violation.: The source of the stains could not be determined however they were of similar color and consistency which may indicate that they were of the same substance. The Individual uses the chair in the privacy of his bedroom and was unable to provide information regarding the origin of the stain. It is unclear why the stains were not detected and reported by the Direct Support Staff. Immediate Correction: The chair was cleaned. Attachment B3. Change in Procedure: House Supervisors have been instructed to report all instances of furniture in need of cleaning and/or repair to the Executive Director who will ensure that the item is cleaned or replaced promptly. This check has also been added to the monthly job duty sheet. Attachment B Specific Steps to be Taken: The Executive Director within seven days will instruct all House Supervisors on the necessity of inspecting the furnishings of the home and reporting any issues relating to the cleanliness and/or disrepair of any items. House Supervisors will instruct all Direct Support Staff on the revised Job Duty Assignment sheet and insure that they are aware that they are to complete each task as assigned and initial the list once the job is completed. A signed acknowledgement of the content of the instructions will be maintained. House Coordinators will review the list and the home each week to insure job assignments are being completed. Attachment B The Executive Director will conduct random unannounced inspections of the home and provide written reports to the President on the findings and corrective actions resulting from the inspections. 10/27/2020 Implemented
SIN-00143934 Renewal 10/31/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Drywall strip hanging off of ceiling above the exit door that leads into the garage. in the bathroom on the Left, above the shower and around the toilet are spackled walls but the repair is not completed. Board walk way located at the back of the home has 3 deteriorated boards that are broken with nails exposed and they need replaced. The last wooden board at the end of the ramp off of the back deck is loose and needs replaced. The blinds in the back shed are broken and need replaced.Floors, walls, ceilings and other surfaces shall be in good repair. Drywall strip has been repaired and fixed by maintenance. Spackle in bathroom has been sanded and areas have been painted by maintenance. Ongoing physical site inspections will be completed by House Coordinators and Program Director. Any issues will be reported to Executive Director (upon discovery) to be corrected. Attachments 9 through 13. 11/09/2018 Implemented
6400.74There is a cement ramp that leads to the basketball court and one that is located off of the back porch, neither have non-skid surfaces.Interior stairs and outside steps shall have a nonskid surface. The cement ramp has been corrected by maintenance worker with a rubber non skid matting. Ongoing physical site inspections will be completed by House Coordinators and Program Director. Any issues will be reported to Executive Director to correct. Attachments 7 and 8 11/13/2018 Implemented
6400.111(a)Fire extinguisher for the attic was located in the garage instead of in the attic.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Fire extinguisher was placed in attic by maintenance worker. Staff will insure that extinguishers are in place each month and reviewed by House Coordinator and HAP personnel. Any issues will be reported to Executive Director to correct. Attachment 6 11/02/2018 Implemented
6400.181(f)Assessment dated 2/2/18 does not have documentation of the assessment being provided to the SC and/or team members at least 30 days prior to ISP meeting.(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). Program Specialist reviewed and developed a form letter to include with every assessment written. these will be included each time an assessment is completed throughout the year and placed in each individuals record by House Coordinators. Ongoing review of records will be completed by Program Specialist and House Coordinators to insure documentation is accurate and up to date. Attachment 5 11/06/2018 Implemented
6400.213(11)Repeat from 11/07/2017- Assessment dated 2/2/18 indicates no allergies; ISP dated 6/11/18 indicates seasonal allergies. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Assessment was reviewed and corrected by Program Specialist Attachment 2. All assessments have been reviewed and any changes have been sent to SC to document on the ISP to coincide with our information Attachment 3. A new form has been created by Program Specialist to use a s a review tool each time an assessment is due for each individual. Attachment 4 11/01/2018 Implemented
6400.217Consent for info released- no release found in individual 1's client file. Quarterly assessments are sent to Lifetime Adult Day Program with no consent for info released in record.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. A consent for release form has been completed and placed in record. Records have been reviewed and signed consents were obtained where needed. These forms will be reviewed and updated annually by House Coordinators and given to respective parties. Routine monitoring of these forms will be completed by House Coordinators and reported to Program Specialist for any changes. Attachment 1 11/01/2018 Implemented
SIN-00121465 Renewal 11/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 8/23/17 however their certificate of compliance expired on 9/15/17.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. 6400.15(a) The agency completed the self assessment in February 2017 and August 2017. The agency shall complete a self assessment of all locations after April 1, 2018 and before April 30, 2018 which shall be within 3 to 6 months of the expiration of the current license ( 9/15/18). Executive Director was retrained on regulations noting specific due dates of self assessment. ED has placed the correct date of April 2018 for the next self assessment phase using a calendar/Microsoft outlook. Completed 11/10/2017. 11/10/2017 Implemented
6400.61(b)Individuals #1 and #2 utilize a shower chair with wheels. The front, left wheel was broken. It was snapped in half and rusted.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.6400.61(b) The front left wheel of the shower chair has been replaced. Program Director failed to notice the crack on the wheels when inspecting the home. Regulation has been reviewed with the Program Director and House Coordinator to insure understanding of the importance of having adaptive equipment in the home for people who may have disabilities and would be required to be in good repair in order to move about and function in the home.11/13/2017 11/13/2017 Implemented
6400.71REPEAT from 10/3/16 annual inspection: The telephone numbers to the nearest ambulance, fire and police department (911) were not located on or by the telephone 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. 6400.71 The 9 of 911 was rubbed off of the label on the back of the telephone handset. The label has been replaced. All other telephones for other homes have been inspected and found to be in compliance. Staff House Coordinator was retrained on the importance of the regulation noting that individuals as well as other staff need to be able to read all numbers for emergency purposes.11/10/2017. Transparent tape will be placed over all telephone emergency number labels to prevent future smudging. 12/14/17 12/14/2017 Implemented
6400.104REPEAT from 10/3/16 annual inspection: The notification letter sent to the fire department on 10/18/17 indicated that all individuals would evacuate the home independently. However, according to the fire drill log Individuals #1 and #2 required verbal and physical assistance on most of the drills completed over the last year. Individual #3 required occasional verbal and physical assistance.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. A letter was written and sent to the Fire Dept but was not properly secured in the fire drill manual. It has been sent again and is in place. All fire drill books have been reviewed and proper documentation is recorded. Executive Director will review fire drill manuals with Admin. Assistant every 3 months. 12/12/2017 Implemented
SIN-00101845 Renewal 10/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(18)Individual #1 had a seizure protocol which indicated that if his/her seizures last more than 4 minutes, staff were to call 911 and take him/her to the hospital. The program specialist indicated on 10/3/16 that all staff working in the home were not trained on this protocol. The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. Protocol was written and attached to seizure chart for his daily book and personal vita information.All staff working with individuals with a diagnosis of a seizure disorder will have completed seizure management and protocol training as given by HCQU and follow along with their instructions for individuals, unless otherwise specified by their physicians. House supervisors and Program Director will insure this is completed. 01/06/2017 10/08/2016 Implemented
6400.46(a)Staff #1's date of hire was 2/22/16. He/She was not trained in his/her job responsibilities yet at the time of licensing on 10/3/16.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Staff reviewed and signed job duties. copy attached.The Normalization and History of Developmental Disabilities Training material shall be presented to all new hires by the The job description shall be reviewed in detail at the preservice training and signed by the employee. Upon completion of the preservice training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file. The Executive Director has trained the accounting manager in the specific documents required for all employees. The accounting manager will review the personnel file to insure that all required documents are in place and notify the Executive Director of any additional information needed. The Executive Director shall contact any employee who does not have all of the required documentation on file in order to obtain such documentation. Executive Director during the first part of preservice training and all new hires will return the material to the Program Director or House Coordinatorwith their signature indicating that they have read the material at the time of the second part of preservice traininig. The Program Director previously responsible for this is no longer employed by the provider. The current Program Director has been trained in this requirement and will be monitored by the Executive Director. 10/09/2016 Implemented
6400.46(e)Staff #1's date of hire was 2/22/16. At the time of licensing on 10/3/16, he/she did not have training on the principles of normalization or rights. He/she did not have training on the areas of mental retardation until 3/31/16, more than 30 days after employment. Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Staff reviewed and completed. Copy attached. Moving forward, a new staff was hired on 12/08/2016 and completed training on 12/10/2016 The Normalization and History of Developmental Disabilities Training material shall be presented to all new hires by the The job description shall be reviewed in detail at the preservice training and signed by the employee. Upon completion of the preservice training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file. The Executive Director has trained the accounting manager in the specific documents required for all employees. The accounting manager will review the personnel file to insure that all required documents are in place and notify the Executive Director of any additional information needed. The Executive Director shall contact any employee who does not have all of the required documentation on file in order to obtain such documentation. Executive Director during the first part of preservice training and all new hires will return the material to the Program Director or House Coordinatorwith their signature indicating that they have read the material at the time of the second part of preservice traininig. The Program Director previously responsible for this is no longer employed by the provider. The current Program Director has been trained in this requirement and will be monitored by the Executive Director. 12/10/2016 Implemented
6400.62(a)Individual #1 was assessed by the agency to be unsafe around poisonous materials. A number of poisonous materials that contained a label indicating "contact poison control center if ingested" or "harmful of fatal if swallowed" were found unlocked and accessible in the garage; Lysol bathroom cleaner, 2 gallons of windshield washer fluid, and 10 gallons of calcium chloride pellets. Toothpaste containing a label, "contact poison control center if ingested" was unlocked and accessible in the bathroom. Poisonous materials shall be kept locked or made inaccessible to individuals.New supervisor has made all poisonous materials inaccessible. Materials are locked in staff room.A new home supervisor has been placed in charge of this home and has been instructed on all regulations, has read assessments on all individuals. She will routinely monitor paperwork along with PS and DSP. When LII are conducted quarterly, home supervisor will report back to Program Director for any violations with a plan of correction. 11/16/2016 11/16/2016 Implemented
6400.62(c)Calcium Chloride Pellets were stored in a 5 gallon bucket labeled Keralastic flexible acrylic latex additive. Poisonous materials shall be stored in their original, labeled containers.New home supervisor removed the pellets. she has been instructed on regulations and policies.A new home supervisor has been placed in charge of this home and has been instructed on all regulations, has read assessments on all individuals. She will routinely monitor paperwork along with PS and DSP. When LII are conducted quarterly, home supervisor will report back to Program Director for any violations with a plan of correction. 11/16/2016 11/16/2016 Implemented
6400.72(a)The front screen door contained approximately a 2 inch rip in the screen near the door handle. Windows, including windows in doors, shall be securely screened when windows or doors are open. Fixed by maintenance man. Invoice attached.Screen was repaired by HAP Maintenance on 10-13-2016. Invoice attached. 10/13/2016 Implemented
6400.104REPEAT from 9/29/15 renewal: When the home notified the fire deparment on 4/11/16, they did not include Individual #1's assistance needed for evacuation. Individual #1 required verbal and physical assistance to evacuate during fire drills since his admission on 4/9/16. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. New letter and diagram were written and sent to acting fire company. Copy attached.A new letter was written to include updated information on individuals living in the home as well as their placement in the home. 10/04/2016. Fire drill books will be reviewed on a quarterly basis to insure all appropriate information is logged and in compliance with the LII. (on-going) A new home supervisor has been placed in this house and has been instructed on all policies and regulations by the Executive Director. 11/16/2016 10/04/2016 Implemented
6400.113(a)Individual #1 moved to the residence on 4/9/16 and was not instructed in general fire safety until 4/11/16. 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. New supervisor has taken over foe the home. She has been advised on policies, regulations, and protocols.A new home supervisor has been placed in charge of this home and has been properly instructed by the Executive Director on Admission policies for Individuals entering into a group home per HAP Policies. 11/16/2016 11/16/2016 Implemented
6400.141(c)(14)Individual #1's 5/18/16 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. This field was left blank. A clarficiation was published by the department in April 2015 indicating that it was not permissible to leave blanks on an Individual's physical examination form. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Corrected and completed 10/05/2016. copy attached Annual physicals will be completed and reviewed by the PCP. Upon completion of paperwork, Home supervisor will review the documentation, noting any errors and/or blanks and make sure they are corrected by the responsible person. The paperwork will be scanned and submitted to PS who will also review for any errors and/or blanks. Paperwork will again be reviewed according to the LII by all employees to insure accurate documentation is completed. Target date : 02/28/2017 10/05/2016 Implemented
6400.164(a)REPEAT from 9/29/15 renewal: Individual #1 was prescribed Loratadine 10mg once per day as needed. Staff #2 initialed Individual #1's medication administration record (MAR) on 10/3/16 and Staff #3 initialed the MAR on 10/4/16 as administering Loratadine but neither indicated a time of administration. The medication label for Individual #1's Visine drops indicated "1-2 drops, 4 times per day." Individual #1's October 2016 MAR did not match the medication label and indicated "1-2 drops as needed" for the Visine drops. Individual #1's Amlactin medication label indicated it was to be applied 1-2 times per day. The October 2016 mar indicated Amlactin was to be applied to feet as needed, not matching the medication label. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. November med log reflects dates, times, and staff initials. Doctor changed Loratidine to 1 time daily on 12/1/16. The medication trainer responsible for maintaining records has been trained in proper record management. She has also trained 2 practicum observers for proper record keeping. Medication logs will be reviewed monthly to insure required documentation is appropriate and accurate. 12/01/2016 Implemented
6400.168(d)REPEAT from 9/29/15 renewal: Staff #4 completed medication administration training on 8/25/15 and not again until 10/3/16. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. New trainer is n charge of staff practicums and has developed a flow chart to reflect due dates. this person has completed a practicum on a staff member to show it is being completed on time.The Medication Trainer responsible for maintaining these records is no longer employed by the provider. The current Medication Trainer has been trained in the required record keeping of Medication Training, Practicums, and Observations. Upon completion of any and all components of the Medication Training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file. 12/02/2016 Implemented
6400.168(e)The medication observation forms that include dates completed and certification from a medication trainer were not kept for Staff #1 or #5. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.Certificate is on file and attached from 11/19/14 expires 2017.The Medication Trainer responsible for maintaining these records is no longer employed by the provider. The current Medication Trainer has been trained in the required record keeping of Medication Training, Practicums, and Observations. Upon completion of any and all components of the Medication Training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file. 12/21/2016 Implemented
6400.181(e)(14)Individual #1's ability to swim was not indicated in his/her 5/21/16 assessment. The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Ability to swim updated in ISP on 10/07/2016. Copy from HCSIS attached.ISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. 10/07/2016 Implemented
6400.183(3)Individual #1's Individual Support Plan (ISP) did not include the method of evaluation used to determine progress towards his/her outcomes to "wash hands," "make bed," and "wipe table." The ISP indicated that once the goal was made, then progress will be determined. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. ISP written indicates a 90% success rate for 3 consecutive months. Plan copied out of HCSIS. Updated 10/07/2016ISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. 10/07/2016 Implemented
6400.183(7)(iii)REPEAT from 9/29/15 renewal: Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. ISP update written and reflects individuals potential. Copy of plan from HCSIS attached.ISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. 10/07/2016 Implemented
6400.183(7)(iv)Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive community-integrated employment. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. ISP plan updated 10/07/2016 to include this. Copy attached from HCSISISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. 10/07/2016 Implemented
6400.186(b)Individual #1's Individual Support Plan (ISP) review completed on 9/14/16 was not dated by the program specialist. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Corrected and completed. December review is attached to show Individual #1 signed and dated.Outcomes and reviews have been reviewed, dated, and signed for Individual #2. Homes will undergo quarterly LII inspections to insure all paperwork is up to date and appropriate documentation is included. Home supervisors along with DSP¿s will conduct inspections and review paperwork with Individual #1. Summaries will be given to Executive Director for review. Target date: 02/28/2017 and on-going. 10/05/2016 Implemented
6400.186(c)(1)Individual #1's Individual Support Plan (ISP) review completed on 6/13/16 did not review any outcomes. His/Her outcomes to wash hands, make bed, and wipe table were implemented on 5/21/16 and the 6/13/16 ISP review indicated that the outcomes will be reviewed on the next review. The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. June 13 stated outcomes for the above mentioned indicated that they would be assessed on the next quarterly for 9/14/2016. Goals were implemented July 2016. these outcomes are reflected on 9 month and 12 month quarterly.Outcomes and reviews have been reviewed, dated, and signed for Individual #1. Homes will undergo quarterly LII inspections to insure all paperwork is up to date and appropriate documentation is included. Home supervisors along with DSP¿s will conduct inspections and review paperwork with Individual #2. Summaries will be given to Executive Director for review. Target date: 02/28/2017 and on-going. 12/15/2016 Implemented
6400.186(c)(2)Individual #1's 9/14/16 and 6/13/16 Individual Support Plan (ISP) reviews did not include a review of his/her dental plan or his/her seizures and seizure protocol. Individual #1's record contained documentation indicated that he/she had seizures on 9/1/16, 8/21/16, 8/16/16, 5/28/16-5/30/16, 4/12/16, and more. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Individual #1 completed, corrected, and reviewed on 12/15/2016 quarterly. copy attached.Outcomes and reviews have been reviewed, dated, and signed forIndividual #1. Homes will undergo quarterly LII inspections to insure all paperwork is up to date and appropriate documentation is included. Home supervisors along with DSP¿s will conduct inspections and review paperwork with PS. Summaries will be given to Executive Director for review. Target date: 02/28/2017 and on-going. 12/15/2016 Implemented
6400.213(1)(i)Individual #1's record did not include his/her religious affiliation. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Vita sheet retyped and corrected.Individual #1 vita sheet was rewritten to include religious affiliation. All homes will be checked quarterly via a LII inspection summary to insure all paperwork is accurate. Home supervisors will conduct inspections with DSP and turn paperwork in to Executive Director for review. Target date: 02/28/2017 and on-going 10/05/2016 Implemented
SIN-00086094 Renewal 09/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)One strip of siding near the roof on the back deck is pealing off of the house. The strip not attached to the house was about 6 feet long.Floors, walls, ceilings and other surfaces shall be in good repair. Request for repair put in. Job completed 10/01/2015 Attachment #2, 3. 10/01/2015 Implemented
6400.104The most recent fire notification letter was last sent in 2004. Since then, individual #1 moved out of the home and no longer living there.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. A letter of notification was written and updated to include individual bedrooms and layout of the home. Attachment #1 11/11/2015 Implemented
SIN-00065541 Renewal 07/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #2's First Aid and CPR training was not completed within the annual time frame. Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. HAP will follow their own guidelines and due dates for annual training according to their schedule. Staff will be placed on HAP training list as opposed to other agency training due dates from her other employment. 08/01/2014 Implemented
SIN-00069341 Renewal 07/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #2's First Aid and CPR training was not completed within the annual time frameProgram specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. HAP will follow their own guidelines and due dates for annual training according to their schedule. Staff will be placed on HAP training list as opposed to other agency training due dates from her other employment. 07/21/2014 Implemented
SIN-00235437 Renewal 11/07/2023 Compliant - Finalized
SIN-00211017 Renewal 09/12/2022 Compliant - Finalized
SIN-00160838 Renewal 10/08/2019 Compliant - Finalized
SIN-00040437 Renewal 08/01/2012 Compliant - Finalized