Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209013 Renewal 07/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)All of the fire extinguishers throughout the home, kitchen, main hallway, and basement were last serviced in January 2021. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. All fire extinguishers throughout the home have been serviced and the date is on the current FiIre Extinguishers. 08/15/2022 Implemented
6400.112(d)The Fire Drill on 3/2/22 indicated an evacuation time of 2 mins 45 seconds. A subsequent fire drill or extended evacuation time was not completed or provided. 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. A staff meeting was held on 8/16/22 with all Staff at the site to review fire drills and the correct evacuation time of a fire drill, also if a Fire drill should take longer than 2 1/2 minutes, Staff were advised to notify supervisor immediately so another fire drill can be arranged 08/16/2022 Implemented
6400.181(e)(14)Individual 2's assessment did not adequately discuss the individuals ability to swim.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. Individual#2's assessment was updated with the Individual's ability to swim. Individual #2 is unable to swim. He does not like being in the pool and any attempt to persuade him to even enter the pool leads to anxiety and physical aggression. The assessment has been updated to reflect Individual #2 inability to swim. 08/04/2022 Implemented
SIN-00190539 Renewal 07/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dressers located in Individual #4 and Individual #5's bedrooms were not in good repair. Both were missing knobs which didn't allow the individual to open their drawers.Floors, walls, ceilings and other surfaces shall be in good repair. The knobs were replaced on the dresser in Individual #4 and Individual #5 bedroom on 8/12/2021. Please see attached copy of dresser with knobs attached labeled Item #10. 08/12/2021 Implemented
6400.76(a)Furniture chairs in the dining room were damaged. Furniture and equipment shall be nonhazardous, clean and sturdy. New Dining room furniture was purchased on 9/24/2021. Please find attached a copy of the receipt for the furniture labeled Item #11 09/24/2021 Implemented
6400.77(b)The first aid kit did not contain tweezers or assortment bandages at time of inspection. 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. Tweezers and assorted bandages were placed in the first aid kit on 7/23/2021. please see attached picture of first aid kit with tweezers and assorted bandages. 07/23/2021 Implemented
6400.112(e)A sleeping fire drill was not held every 6 months for Briarwood.A fire drill shall be held during sleeping hours at least every 6 months. A sleeping fire drill was done on 8/8/2021, please see attached copy of sleeping fire drill labeled Item 13 09/23/2021 Implemented
6400.141(c)(6)TB tests for Individual #4 exceeded two year time limit. Previous TB test was 7/2018, most recent one was on 6/15/21, which is almost three years.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. TB Test for Individual #4 was done on 6/15/21. The next test is due 6/15/2023. The Royer Greave Nurse will administer and track all TB test. 09/23/2021 Implemented
6400.181(d)Program specialist did not sign and date the assessment for Individual #4.The program specialist shall sign and date the assessment. The program specialist has signed and dated Individual #4 assessment. Please see attached copy of signed assessment labeled Item #16 09/23/2021 Implemented
6400.165(b)Medication Loratadine Tab 10mg for Individual #4, was in his med box expired on 3/03/21 at time of inspection. Agency refilled the prescription for this medication.A prescription order shall be kept current.The medication Loratadine Tab 10mg was refilled on 7/21/2021. 09/23/2021 Implemented
6400.169(d)Medication administration training did not contain a feedback date where it's indicated Staff #4 passed the training.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.Staff #4 feedback date was documented on her training form. Please see attached copy of staff #4 training paperwork labeled #17 09/23/2021 Implemented
SIN-00169738 Renewal 01/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The Dining room chairs were not sturdy, and wobbled to the touch Furniture and equipment shall be nonhazardous, clean and sturdy. Chairs were repaired by Maintenance on 2/25/2020. To ensure that this issue does not happen again the staff will do daily check on all furniture and if there is an issue the Program Supervisor will submit a maintenance report to the Maintenance department for repairs. A copy of the work order labeled Item # 9 is submitted with this report. 02/25/2020 Implemented
6400.106The last furnace inspection was completed on 12/7/18, inspections not completed annually.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. To make sure that the furnace is inspected annually the Maintenance Supervisor will track all furnace inspection and make sure that they are completed in a timely fashion. The furnace was inspected on 3/11/2020. a copy of the current report labeled Item # 8 is submitted with this report. 03/11/2020 Implemented
6400.194(c)Individual #1 plan includes a behavioral plan that has restrictive measures. However, the team has not met since 5/29/19 which is more than the allotted six months.The human rights team shall include a majority of persons who do not provide direct services to the individual.The Person Responsible for organizing and chairing the meetings will make sure that all the appropriate paperwork is completed for the review of restrictive procedure plans. The Human rights team met on 3/9/2020 to discuss the restrictive procedure plan for Individual #1. The next meeting Is scheduled for September 9, 2020 at 9:30am. This meeting was also put on the Teams electronic calendar. Copy of sign in sheet and supporting documents for the meeting labeled Item #7 will be faxed with this report. 03/09/2020 Implemented
6400.194(d)When the team met to discuss Individual #1 restrictive plan there was no record of the items that were discussed during the meeting.A record of the human rights team meetings shall be kept.The Person Responsible for organizing and chairing the meetings will make sure that all the appropriate paperwork is completed for the review of restrictive procedure plans. The Human rights team met on 3/9/2020 to discuss the restrictive procedure plan for Individual #1. . Copy of sign in sheet and supporting documents for the meeting labeled Item # 7 will be submitted wit this report. 03/09/2020 Implemented
SIN-00144253 Renewal 10/23/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination dated 6/18/18 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. A copy of Individual #1's Lifetime Medical which include information pertinent to diagnosis in case of emergency was attached to Individual #1's physical examination. To make sure that this error does not happen in the future, the RGS Nurse will review all physical examination paperwork to make sure that they are completed in its entirety. 01/04/2019 Implemented
6400.142(e)Individual #1's dental exam dated 2/20/18 recommended a full mouth rehab. Documentation that this dental work was completed was not available.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Individual #1 completed his dental appointment with Special Smiles on 1/15/2019, with instructions to follow up in 1 year. A copy of the Paperwork is submitted with this report. To make sure that this error does not occur again a chart was created to track all dental appointments. The Deputy executive director will review these charts monthly to make sure that all dental appointments are completed on time. 01/15/2019 Implemented
6400.181(e)(5)Individual # 1's assessment dated 6/22/18 did not evaluate their ability to self-administer medication.The assessment must include the following information:  The individual's ability to self-administer medications.Individual #1's assessment was updated to reflect his ability to self-administer. A copy of the updated information is submitted with this report. In the future the Deputy Executive Director will review all assessments and approve them before they are submitted. 01/04/2019 Implemented
SIN-00118440 Renewal 06/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)FIRE DRILL CONDUCTED ON 01/10/2017 DOES NOT DOCUMENT THE TIME OF DAY THE FIRE DRILL OCCURRED. 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. A training for Staff on proper documentation of Fire Drill records will be held on 8/18/2017 at 9am. Going forward the Asst. Executive Director will review all Fire Drills and approve them before they can be submitted. 08/18/2017 Implemented
6400.112(f)FIRE DRILLS FROM 10/2016 TO 03/2017 ALL USED THE FRONT DOOR TO EVACUATE AND DID NOT USE ALTERNATE ROUTES. Alternate exit routes shall be used during fire drills. Going forward fire drills dates and exits will be determined by the Program Director before the drill, and the information will be given to the staff at the time of the fire drill. The completed form will be reviewed by the Program Director before it is sent to the office. When it gets to the office the Assistant Executive Director will review the Fire drill forms to make sure that alternative exit routes are used. 12/12/2017 Implemented
6400.181(e)(14)THE ANNUAL ASSESSMENT DATED 07/24/2016 FOR INDIVIDUAL #1 DID NOT DOCUMENT THE INDIVIDUAL'S KNOWLEDGE OF WATER SAFETY OR ABILITY TO SWIM. 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. An updated Assessment was completed for Individual #1 on 07/05/2017. This Assessment includes the Individual's knowledge of water safety and ability to swim. In the future the Program Specialist and the Asst. Executive Director will review all Assessments to make sure that they include all the necessary information before approving them for distribution. 07/05/2017 Implemented
6400.181(f)THE ANNUAL ASSESSMENT DATED 07/24/2016 FOR INDIVIDUAL #1 WAS NOT SENT TO THE TEAM MEMBERS 30 DAYS PRIOR TO ISP MEETING THAT WAS HELD ON 08/01/2016.(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 updated Assessment was emailed to the Supports Coordinator on 07/18/2017. Going forward an electronic calendar has been established to track due dates all Reports with a list of all team members that needs to receive a copy of this report. The Program Specialist will be responsible for monitoring the calendar and making sure all reports are sent out to the team in a timely manner. 07/18/2017 Implemented
6400.213(1)(i)THE RECORD FOR INDIVIDUAL #1 DID NOT INCLUDE 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.ROYER GREAVES SCHOOL WAS ABLE TO CONTACT INDIVIDUAL # 1 MOTHER WHO INFORMED US THAT INDIVIDUAL #1 REGILIOUS AFFILATION WAS CATHOLIC. HIS PERSONAL DATA SUMMARY FORM HAS BEEN UPDATED TO REFLECT THIS INFORMATION. 08/01/2017 Implemented
SIN-00229696 Renewal 08/16/2023 Compliant - Finalized