Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00208864 Unannounced Monitoring 07/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.171At the time of the inspection, there was an opened box of rice being stored in a kitchen cabinet and it was not properly closed.Food shall be protected from contamination while being stored, prepared, transported and served. Executive Director recognizes this area of non-compliance and purchased food storage containers for all CLA homes to store all opened foods that have the tendency for contamination. All staff were trained on the importance of using these containers for the health and safety of our individuals and for compliance of this regulation, by Associate Director on 8/4/22 8/9/22. All containers were labeled with name of food in container, and expiration date added to bottom of container, and changed each time new food is added. Food containers will be washed before new food is added. Weekly house check list was updated to include, checking food in cupboards for proper storage. See attached Staff food storage/housekeeping training, weekly house checklist completed, shift housekeeping checklists, and picture of container with label and expiration date. 08/09/2022 Implemented
SIN-00203059 Unannounced Monitoring 04/05/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Individual #1 does not have a January 2022 financial log available. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Executive Director recognizes that this area of compliance is not able to be corrected for the individual #1 record. Staff will be trained on the importance of ensuring that all individuals have a financial ledger along with receipts that are kept locked storage area of individuals¿ home by April 30, 2022. Financial ledgers and receipts will be reviewed once weekly by Program Specialist and or Associate Director to ensure proper documentation is made by staff. Program Specialist or Associate Director will document on financial ledger that all information was documented and correct. See new financial ledger and voucher that will be implemented by April 30, 2022. 04/30/2022 Not Implemented
6400.22(e)(3)Individual #1 withdrew $100 on 1/7/21, which is titled as "clothes" on bank withdraw slip, however there is no receipt available showing purchase of any items. 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. Individual # 1s money was not completed for accuracy of compliance, due to lack of oversight of program. Program Specialist and Associate Director will review all individual¿s ability to manage money and ensure this is noted correctly in Assessments and ISP. Email will be sent to Supports Coordinator if information needs added or changed in ISP. If individual is unable to manage money, any money received will be added to their financial ledger and kept in locked area of home with staff oversight. All staff will be trained on financials and individual ability to manage financials by April 30, 2022. See financial ledger and voucher forms that will be implemented by April 30, 2022. 04/30/2022 Not Implemented
6400.141(c)(7)Individual #1's most recent annual gynecological exam was completed on 10/6/2020.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual # 1s gynecological examination was not completed for accuracy of compliance, due to lack of oversight of program. Individual #1 had a physical appointment on April 12, 2022, in which physician deferred gynecological examination indefinitely. All staff will be trained on new prepopulated physical form by April 30, 2022. See Individual # 1 physical dated April 12, 2022, attached with notes of deferment. 04/30/2022 Not Implemented
6400.141(c)(8)Individual #1's most recent mammogram was completed on 1/21/21. Annual mammogram has not been completed since.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Individual # 1s mammogram was not completed for accuracy of compliance, due to lack of oversight of program. Individual #1 had a physical appointment on April 12, 2022, in which appointment for mammogram is scheduled for April 21, 2022 and was added to shared outlook calendar and with alerts. All staff will be trained on the importance of individual mammogram dates and keeping in compliance with regulations by April 30, 2022. See Individual # 1 physical and order dated April 12, 2022. 04/30/2022 Not Implemented
6400.142(a)Repeat 1/4/2022: Individual #1's most recent annual dental exam was done on 3/4/2021. Annual dental exam would have been due 3/4/2022 and was not completed.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual # 1s dental examination was not completed for accuracy of compliance, due to lack of oversight of program. Individual #1 had has a dental appointment scheduled for April 21, 2022. New dental form was implemented that include dental examination and recommendations. Staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on new dental form and how to correctly complete all prepopulated information by April 30, 2022. See individual completed dental form dated April 11, 2022. 04/30/2022 Not Implemented
6400.143(a)Individual #1 was scheduled for annual gynecological exam in 2021, however it is documented that it was refused. Staff reported that Individual refuses mammogram and gynecological appointment often, however there is no refusal and continued attempts to train the individual about the need for healthcare documented in the record.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. Individual # 1s gynecological refusal plan was not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 gynecological examinations deferred as of April 12, 2022, see physical for deferment. All individuals that refuse medical appointments per regulations, will have a refusal plan implemented by April 30, 2022. Refusal plans will be added to Assessment and emailed to Supports Coordinator to update ISP. All staff will be trained on refusal plans by May 15, 2022. 05/15/2022 Not Implemented
6400.144Repeat 1/4/2022: Individual #1's most recently updated ISP for 3/31/2022 states that they are to attend cardiology appointments annually or as needed. Individual has not had a cardiologist appointment since 2/11/2021.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual # 1s cardiologist examination was not completed for accuracy of compliance, due to lack of oversight of program. Individual #1 was scheduled for cardiologist appointment on April 14, 2022. New appointment form was implemented for staff to write a narrative of appointment, with date of appointment, date, and staff signature. Staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on new appointment form and how to correctly complete all information by April 30, 2022. See Individual # 1 Appointment record sheet for cardiologist appointment dated April 14, 2022. 04/30/2022 Not Implemented
6400.165(e)Individual #1's February and March MAR have listed 'One Touch Ultra Test STRP' used for blood sugar, testing twice daily. On February MAR, it is written "discontinued 1/17/22". AUCP reported that upon speaking to the pharmacy it was reported that a AUCP staff member called and asked for the prescribed test strip to be discontinued. There is no discontinue order available to show that a medical professional discontinued this prescription.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Individual # 1s One touch ultra-test strip was not completed for accuracy of compliance, due to lack of oversight of program. Individual #1 had a physical appointment on April 11, 2022, in which one-touch was discussed and physician noted on physical that individual is not diabetic and no need for accu checks. All staff will be trained by April 30, 2022, on regulation 6400.165(e) in which there needs a doctor¿s order to discontinue medication. See Individual #1 physical under recommendations if abnormal for description of discontinuation. 04/30/2022 Not Implemented
6400.165(g)Individual #1 has not had a quarterly psychiatric medication review completed since 12/10/2020.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual # 1s psychiatric reviews and appointments were not completed for accuracy of compliance, due to lack of oversight of program. Individual # 1 was scheduled an appointment with her psychiatrist for April 29, 2022. New prepopulated psychiatric/psychotropic quarterly review was implemented. Once review is completed by Psychiatrist, staff will scan and email form to Program Specialist and or Associate Director to review for compliance. All staff will be trained on quarterly psychiatric form and how to correctly complete all prepopulated information by April 30, 2022. See completed prepopulated quarterly psychiatric/psychotropic review dated April 13, 2022 04/30/2022 Not Implemented
SIN-00198950 Unannounced Monitoring 01/04/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(4)The regulatory violations demonstrate that there was a CEO failure to ensure compliance with Chapter 6400 regulations as per 44(b)(1); 44(b)(2); 141(a); 144; 176(a); 181(a); and 188(c).The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. Immediate corrections include termination of the CEO responsible for lapses in oversight in relation to citations of current inspection. A CEO has been immediately appointed, in order to execute responsibilities outlined in chapter 6400 regulations. AUCP is also in the process of hiring a permanent CEO who will be responsible for chapter 6400 compliance as well as oversight in implementation of corrective actions identified in this report. Ongoing corrective action includes the development of an audit tool to ensure compliance with 6400 regulations. 6400 regulations and the 6400 RCG will be used as a guide to develop the audit tool. The audit tool is being created by the Associate Director which will be approved by the CEO to be implemented. 03/09/2022 Not Implemented
6400.67(a)The carpet in the television room at contained multiple dark stains around both the couches.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance Personnel contacted Lowes who came to the Leidy CLA to measure and estimate the cost of replacing the carpet. The estimate was approved, and specific flooring was picked by the finance department. AUCP is awaiting a date from Lowes to install the carpet. The Maintenance personnel will follow up with Lowes by 2/25/2022 if a date of installment has not yet been set. The Associate Director will train the Field Manager and Maintenance personnel on using the Weekly Inspection Form to prevent future occurrence. 03/09/2022 Implemented
6400.76(a)Individual #3's night stand next to her bed, the top drawer is missing a knob. Furniture and equipment shall be nonhazardous, clean and sturdy. On 1/06/2022 maintenance personnel repaired the individuals dresser drawer by installing a new knob. 03/09/2022 Implemented
6400.103The current emergency evacuation procedures for individuals #1, #2, and #3 only focus on what to do in case of a fire.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. A new emergency evacuation document was created to include individual and staff responsibilities, means of transportation and an emergency shelter location. The Program Specialist will be trained on their responsibilities for updating any corrections to the Emergency Evacuation Document such as address change or relocation shelter change. 03/09/2022 Not Implemented
6400.112(g)The 6/9/2021 fire drill does not state the time of the drill. Fire drills shall be held on different days of the week and at different times of the day and night. A fire drill schedule was created to ensure that Chapter 6400 Regulations 6400.112(a), 6400.112(c), 6400.112(e), 6400.112(g), 6400.112(h), are compliant. The Field Manager and Lead RPW will be trained on the fire drill schedule and filing out a fire drill record entirely. A fire drill will be completed on ------ to ensure in person live training is done. 03/09/2022 Not Implemented
6400.113(a)Individual #2 and individual #3 documented fire safety training was held on 4/22/2021. No documentation that either individual had fire safety training at their residence during the year 2020. Also, the fire safety training documentation does not include all training content, including 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. 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. An annual fire safety training document was created to include 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, smoking safety procedures if individuals smoke at the home, use of fire extinguisher, contacting fire department. The annual dates of when the fire safety document needs to be completed will be entered into the automated reminder system for each individual by the Program Specialist. The Program Specialist will utilize the Annual Fire Safety Document to go over fire safety with each individual at AUCP. 03/09/2022 Not Implemented
6400.141(a)Individual #1's physical was completed 2/2/2021; Individual #2 had two physical exams completed 6/17/2021 and 12/17/2021 and both physical are incomplete; Individual #3 had a physical completed 12/17/2021; however, all individuals #1, #2, and #3 have no documented physical for the year 2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Program Specialist is reviewing each individual for annual medical dates. All individuals medical appointments not attended in the last 12 months will be scheduled and entered in the automated reminder system by the Program Specialist for tracking. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system quarterly for completion and accuracy. In conjunction with the automated reminder system an auditing tool is being created by the Associate Director to ensure compliance with 6400 regulations. The associate director will train the Program Specialist on the automated reminder system and auditing tool to assure medical appointments are completed on the due date. The Program specialist will also be trained on completion of annual medical forms by the Associate Director. 03/09/2022 Not Implemented
6400.144Individual #1 medical records contain a routine medical appointment on 2/2/2021 which includes a referral to colorectal surgeon for hemorrhoids. There is no documentation of a follow-up completed. The appointment also states her return visit was scheduled for 8/2/2021 with fasting bloodwork requested. There is no documentation the return visit occurred, nor the fasting bloodwork completed. Individual #1's 2/2/2021 physical states tuberculin test (TB) was completed on 1/10/2019; however, the next TB test was completed 2/8/2021, which is past the regulatory grace period. Per individual #1's physical 2/2/2021 it states the mammogram was completed on 8/25/2020; however, there is no formal documentation of this appointment. Under health maintenance of this same physical it states "yes"; however, does not explain what "yes" means. On the physical 2/2/2021 bloodwork is also stated to be completed every 6 months; there is no documentation if bloodwork is occurring every 6 months. This same physical and individual #1's current plan 1/13/2021 states individual #1 has an allergy to the medication Penicillin. Individual #1's December 2021 MAR states, "no known drug allergies". No special instructions for diet were given on the 2/2/2021 physical; however, individual #1's current individual plan dated 1/11/2022 states she has been diagnosed with ulcerative colitis and is recommended a high fiber diet. This individual plan states she does not digest regular milk or eggs well and she uses a substitute of lactose free milk and egg beaters in their place. Also, on January 5th, 2022, licensing staff witnessed individual #1 have an egg sandwiches and chips for lunch. When questioned staff #1 about individual #1's diet, she replied, "I never knew that. No one ever told me to read her individual support plan". Individual #1's current assessment (no date provided) states she has ulcerative colitis and has adjusted in her diet and is aware of the foods that exacerbate her colitis. Individual #1 had a dental appointment on 2/10/2021 stating, "needs help brushing teeth, has moderate plaque". Individual #1's current individual plan states she requires assistance with brushing her teeth. It continues to state, staff brush her teeth by applying the toothpaste to the toothbrush brushing her teeth for her and handing her the cup to rinse out the toothpaste. The dental care plan in individual #1's current plan states she requires hand over hand assistance from staff to brush her teeth and is encouraged to brush at least twice a day. Individual #1 is scheduled for appointments to attend the dentist regularly, she is encouraged to follow the dentist's recommendations. There is no documentation that this dental plan and dentist recommendations are being completed daily. Individual #2's current individual plan 11/8/2021 states over the past year there have been an increase in her ambulation issues. Individual #2 has had more falls over the past year. Occupational therapy and physical therapy are starting to be implemented to help figure out the best plan moving forward with ambulation concerns. There is no medical documentation stating occupational therapy and physical therapy were pursued. Individual #2's individual plan dated 11/8/21 states that a vision exam is completed annually; however, her current assessment 9/30/2020 states that individual #2 sees an eye doctor every 6 months due to glaucoma. Individual #3's individual plan dated 12/27/2021 states she is ambulatory can walk independently without assistance.; individual #3 is currently using a walk to assist in ambulation. The individual plan also states she is no longer on a fluid restriction; however, her medication still depletes the body of sodium, which then increases seizures, and too much fluid can also deplete the body of sodium, so she is encouraged to not drink 1800 cc of fluid a day. There is no documentation that a fluid restriction has been in place and tracked. Individual #3's current individual plan states she can independently evacuate the building during a fire drill; she cannot. Individual #3 requires physical assistance from a walker and verbal prompts from staff. Individual #3's individual plan states blood pressure and accu-checks are done twice daily. Staff are not doing blood pressure checks. Individual #3's individual plan also states the following: follow a low-fat, low cholesterol Mediterranean based diet; limit calories from added sugars and saturated fat; reduce sodium intake to maximum of 2.3 grams a day; no added salt; reduce added sugar like syrup; avoid excessive caffeine containing products. currently individual #3 is not following any of these stated dietary requirements. Individual #3's individual plan states she attends the Skills Monday thru Friday 8:30am to 2:30pm. Upon returning home, individual #1 can be left unsupervised for periods up to 1 ½ hours during awake hours and 3 hours during sleep hours. This is not being implemented or correct. Individual #3 has no unsupervised time at her home.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The Program Specialist will review all individuals ISPs and train all staff on current planned or prescribed treatment for each individual requested by the health service. The training will be documented and submitted to the HR Department to maintain, and a hard copy will be printed and placed in the permanent chart housed at the individuals home. 03/09/2022 Not Implemented
6400.181(a)Individual #1's current assessment does not have a date; there is correspondence, however, that the program specialist sent a copy to the supports coordinator on 1/27/2021. Individual #2's current assessment is dated 9/30/2020, no assessment completed for 2021. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals¿ assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individuals permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. 03/09/2022 Not Implemented
6400.181(d)All current assessments for individuals #1, #2, and #3 were not signed nor dated by a program specialist.The program specialist shall sign and date the assessment. Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals¿ assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individual¿s permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. 03/09/2022 Not Implemented
6400.62(b)Individual #1's current plan dated 1/13/2021 states that she understands poisons, but they are kept locked in her home; individual #1's current assessment (no date) states that she understands and avoids poisons, and they are not locked in her home. While licensing staff was out visiting individual #1's home on 1/5/2022 all poisons were not locked in the home.Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment.The Program Specialist and Associate Director will review all individuals ISP to see if the individual is safe to be around poisonous materials. The Program Specialist will fill out an ISP correction form and will send it to the Supports Coordinator and Associate Director. The Program Specialist will then print out a hard copy and place it in the individuals permanent chart. 03/09/2022 Not Implemented
6400.44(b)(1)As related to 181(a). Individual #1's current assessment does not have a date; there is correspondence, however, that the program specialist sent a copy to the supports coordinator on 1/27/2021. Individual #2's current assessment is dated 9/30/2020, no assessment completed for 2021.The program specialist shall be responsible for the following: Coordinating the completion of assessments.Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individuals permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. 03/09/2022 Not Implemented
6400.44(b)(2)As related to violation 186. The vast number of inconsistencies in individual #1, #2, and #3's current individual plan aligned with current assessments, medical documentation, and physicals are evident.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individuals permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. 03/09/2022 Not Implemented
6400.167(a)(1)Medication administration records (MARS) over the past annual year, 2021, year were requested by licensing staff for individuals #1, #2, and #3. The MARS received by the provider included months September, November, and December 2021, respectively. The following medication errors have been identified: Individual #1's medication errors include Baby Shampoo Lid Scrubs not given 9PM on 12/28/2021; Clotrimazole 1% Cream not given 7AM on 11/30/2021; Docusate 100mg not given 7AM on 11/30/2021; Ketoconazole 2% Cream not given 7AM on 11/30/2021 Mesalamine ER 0.375mg not given 7AM on 11/30/2021; Oxybutynin CL ER 10mg not given 7AM on 11/30/2021; Pantoprazole Sod 40 mg not given 7AM on 11/30/21; Sertraline 100mg not given 7AM on 11/26, 11/27, 11/28 and 11/30/2021; Protonix 40mg not given 7AM on 11/30/2021; and Sulfasalazine 500mg not given 7AM on 11/30/2021. Individual #2's medication errors include Divalproex Sod DR 250mg not given 7AM on 11/24/21, note on MAR reads "No Meds in Box"; and Dermacin Cream not given 7AM on 12/31/21. Individual #3's medication errors include Neutrogena T-SAL Shampoo Apply to Scalp on Monday, Wednesday, and Friday - MAR indicates medication incorrectly given on 12/02/2021(Tuesday), 12/04/2021 (Saturday), 12/05/2021 (Sunday), 12/07/2021 (Tuesday), 12/09/2021 (Thursday), and 12/11/2021 (Saturday). Escitalopram 5mg Tab 7AM is signed on 12/05/21; however, but there is a note stating 8:07am "Does not have med" signed by TB. Lamotrigine 200mg Tab not given 7PM on 9/05/2021 and 9/30/2021; Levetiracetam 750mg not given 9PM on 9/05/2021 and 9/30/2021; Monistat Soothcare Pwdr 9PM not given 9/05, 9/25, and 9/26/2021; Neutrogena T-SAL Shampoo apply to Scalp on Mon, Wed & Fri at 7PM not given on 9/08, 9/15, and 9/29/2021; One Touch Ultra Test Strip for Hyperglycemia not given 9pm 9/05 and 9/30/2021; Atorvastatin 20mg Tab 9pm not given 9/05, 9/24, 9/25, 9/26, and 9/30/2021; Calcium Citrate +D HM 9PM not given on 9/05, 9/24, 9/25, 9/26, and 9/30/21; Clonazepam .5mg 9PM not given 9/05, 9/24, and 9/30/2021; Lamotrigine 100mg tab 7PM not given 9/05 and 9/30/2021.Medication errors include the following: Failure to administer a medication.Current medication passers will be trained on the protocol and policy surrounding failure to administer a medication by the Associate Director. 03/09/2022 Not Implemented
6400.186As related to violation 144. Also, Individual #1's current plan dated 1/13/2021 states that she understands poisons, but they are kept locked in her home; individual #1's current assessment (no date) states that she understands and avoids poisons, and they are not locked in her home. While licensing staff was out visiting individual #1's home on 1/6/2022 all poisons were not locked in the home.The home shall implement the individual plan, including revisions.The Program Specialist and Associate Director will review all individuals ISP to see if the individual is safe to be around poisonous materials. The Program Specialist will fill out an ISP correction form and will send it to the Supports Coordinator and Associate Director. The Program Specialist will then print out a hard copy and place it in the individuals permanent chart. 03/09/2022 Not Implemented
6400.188(c)Individual #3's individual plan states blood pressure and accu-checks are done twice daily. Staff are not doing blood pressure checks.The home shall provide services to the individual as specified in the individual plan.The Individual attended an appointment with her pcpto discuss the state of their current health and it was determined that blood pressure checks were not required to be performed by AUCP moving forward. A synopsis of the appointment was then shared with the supports coordinator to be reflected on the individuals plan. The programs specialist will be trained on sending isp corrections to the supports coordinator to be reflected in the individuals current isp. 03/09/2022 Not Implemented
SIN-00193508 Renewal 09/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)No summary of corrections was provided at the time of the inspection.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. An internal Plan of Correction was created to use when doing a self assessment. The document list the Regulation, description, what action is required and who is responsible 10/12/2021 Implemented
6400.112(c)The fire drill from 6/09/2021 did not indicate the time of day that the 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. The team will go over the fire drill document and recreate in the event that it is too complex to fill out by the supervisory staff. The supervisory staff will be trained on the regulations and the Associate Director will demonstrate the proper way to document a fire drill. 10/12/2021 Implemented
SIN-00117490 Renewal 07/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A bottle of Coppertone sensitive skin was unlocked in the toiletry closet. (contact poison control). Individual #1 is unsafe around poisons. Poisonous materials shall be kept locked or made inaccessible to individuals.Door to toiletry closet was immediately locked. All staff informed of this regulation. Documentation will be forwarded 07/28/2017 Implemented
6400.181(e)(13)(i)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of Health. Information was verbatim to 07/20/16 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: Health. Program Specialist has made revisions to Individual #1's assessment in the area of Health. The Health part has been re-written to show progress/regress and growth that has happened over the last calendar year and also including current level. Documentation will be forwarded 08/02/2017 Implemented
6400.181(e)(13)(ii)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of motor and communication skills. Information was verbatim to 07/20/16 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: Motor and communication skills. Program Specialist has made a revision to Individual #1's assessment that includes the area of Motor Skills. The term "Motor Skills" has also been added to the narrative section so not to be missed during time of assessment. Program Specialist has revised Individual #1's assessment to show progress/regress over the last 365 calendar days and also acknowledge current level. Documentation will be forwarded 08/02/2017 Implemented
6400.181(e)(13)(iii)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of Activities of residential living. Information was verbatim to 07/20/16 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: Activities of residential living. Program Specialist has made revisions to Individual #1's assessment in the area of Activities of Daily Living. The Activities of Daily Living portion has been re-written to show progress/regress that has happened over the last calendar year and also including current level. Documentation will be forwarded. SC has been informed of changes 08/02/2017 Implemented
6400.181(e)(13)(v)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of Socialization. Information was verbatim to 07/20/16 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: Socialization. Program Specialist has made revisions to Individual #1's assessment in the area of Socialization. The Socialization portion has been re-written to show progress/regress that has happened over the last calendar year and also including current level. Documentation will be forwarded. SC has been notified of changes. 08/02/2017 Implemented
6400.181(e)(13)(vi)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of Recreation. Information was verbatim to 07/20/16 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: Recreation. Program Specialist has made revisions to Individual #1's assessment in the area of Recreation. The Recreation portion has been re-written to show progress/regress that has happened over the last calendar year and also including current level. Documentation will be forwarded. SC informed of changes made 08/02/2017 Implemented
6400.181(e)(13)(viii)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of Managing personal property. Information was verbatim to 07/20/16 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: Managing personal property. Program Specialist has made revisions to Individual #1's assessment in the area of Managing Personal Property. The Managing Personal Property portion has been re-written to show progress/regress that has happened over the last calendar year and also including current level. Documentation will be forwarded. SC informed of changes 08/02/2017 Implemented
6400.181(e)(13)(ix)Individual # 1 annual assessment dated 07/20/17 did not include progress and growth over the last 365 calendar days in the area of Community Integration. Information was verbatim to 07/20/16 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: Community-integration.Program Specialist has made revisions to Individual #1's assessment in the area of Community Integration. The Community Integration part has been re-written to show progress/regress that has happened over the last calendar year and also including current level. Documentation will be forwarded. SC informed of changes made. 08/02/2017 Implemented
6400.186(c)(2)Individual Support Plan reviews dated 10/25/16, 01/25/17, 04/25/17 and 07/26/17 did not review SEEN plan strategies and effectiveness. Verbage on quarterlies is same. Frequency of SEEN plan interventions utilized and outcomes of interventions not documented for effectiveness. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Program Specialist has added the verbiage "SEEN" to the Behavior Concerns portion of all Quarterly Reviews of individuals that have behavior concerns so this will not be overlooked in future quarterlies. 7/26/17 Quarterly Review has been revised to show "SEEN" addition. Documentation will be forwarded. SC has been informed of changes made 08/02/2017 Implemented
SIN-00044577 Renewal 12/04/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(b)None of the staff physical exam forms reviewed were dated by the physician. All physicals were dated by the agency.(b) The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. PARTIALLY IMPLEMENTED, INADEQUATE PROGRESS. JW The Staff Health Appraisal forms have been modified, physician has been added to the date line and the date moved to correspond directly with the signature line (attachment 5). All staff have been trained on the protocol for staff physicals and the need to review physical forms prior to leaving the physician¿s office (attachment 6). In the event a health appraisal form is returned without the required information a new fax memo cover sheet has been developed by ALUCP which specifically states information to be completed by the attending physician (attachment 7). While the agency cannot validate a specific form is dated by a physician, certified nurse practitioner, or licensed physician¿s assistant this protocol will help ensure increased accuracy in overall staff health records. 01/29/2013 Implemented
SIN-00225222 Renewal 06/06/2023 Compliant - Finalized
SIN-00177885 Renewal 10/20/2020 Compliant - Finalized
SIN-00157390 Renewal 08/20/2019 Compliant - Finalized
SIN-00137738 Renewal 08/14/2018 Compliant - Finalized
SIN-00097231 Renewal 07/06/2016 Compliant - Finalized
SIN-00080397 Renewal 12/16/2014 Compliant - Finalized