Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240343 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 3/6/24, at 11:11 AM, the hot water temperature measured at the bathroom sink on the first floor measured 123.2 degrees Fahrenheit.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Water temperatures will be monitored monthly through an Environmental Assessment forms completed by Direct Support Supervisors (DSS). Procedure will be changed to ensure multiple locations are checked, including kitchen sink and bathroom water sources. Also, during the monthly Fire Drills completed by DSSs, water temperatures will be checked and documented. The Fire Drill Form also requires 3 consecutive daily checks to be completed when a water temperature is over 120 degrees. All staff will be trained to report any temperatures greater than 120 degrees immediately to a supervisors so can be submitted to maintenance to be addressed. 03/15/2024 Implemented
SIN-00222364 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment was completed on 3/18/23. The agency certificate of compliance expires 10/18/23 and the last renewal inspection was completed 4/27/22.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. A self-assessment will be completed at least annually within the 3¿6-month time frame set forth in the 6400 regulations. The Self-Assessment Forms will be prepared by the Program Manager annually in April and are then scheduled to be completed in a timely manner to allow for corrections to be made and follow-up inspections to occur within the time frames. 04/23/2023 Implemented
6400.112(a)According to the written fire drill record submitted for the last 12 months, there were no fire drills held during the following months of 2022: April, June, August, September, and October. An unannounced fire drill shall be held at least once a month. The Residential Team Lead Supervisor (RTLS) will re-train the Direct Support Supervisors (DSS) and Direct Support Mentors (DSM) on the ODP Fire Drill 6400.112a-112h regulations and the Provider's policy on Fire Drills. The training will review the requirements and importance of completing the monthly fire drills at each service location. The RTSL will review the current monthly Fire Drill plan including how he will communicate assigned responsibilities for monthly fire drills, dates for completion and timely submission of paperwork to the team. 04/25/2023 Implemented
6400.46(b)Direct Support Professional #2's date-of-hire is 9/10/18. The only fire safety training in their record was completed on 3/3/22.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).All training tracking will be transitioned to an electronic learning management system (ELMS) which notifies the staff person and their supervisor of training coming due and trainings that are overdue. The previous annual training information will be entered into the ELMS by the designated Administrative Assistant for each required course. The system will notify staff and their supervisor when the training is due and/or overdue moving forward. 05/31/2023 Implemented
6400.52(c)(5)Direct Support Professional #1, date-of-hire 1/16/23, works with Individual #1 and Individual #2 who both have restrictive procedure plans. Their orientation training did not include trainings or reviews of Individual #1's and Individual #2's restrictive procedure plans.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.This Direct Support Professional will be trained and have training documented on the individual's restrictive procedure plans prior to working directly with these 2 individuals again. New Hire Orientation includes review of individual's restrictive procedure plans. 05/31/2023 Implemented
SIN-00204195 Renewal 04/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 refused a dental appointment on 7-22-21. There was no attempts to educate the individual about the need for this health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. A form has been created for after refusal counseling. This form was implemented 5/4/22. The individual was met with on 5/4/22 after a refused an appointment and the Medical Appointment Refusal/Counseling form was used. A training was held on 5/4/22 explaining the importance of the form, why it is relevant and how the sessions should take place. 05/04/2022 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 8-9-21 to the individual plan team members on 8-9-21 for the annual individual plan meeting on 8-13-21. [Repeated Violation 5/4/21 et al.]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A residential Due Date Calendar has been created in which due dates are added to the calendar that Managers accept onto their calendar, due dates are set prior to the deadline. ILA reminder has been set on the calendar for June 7, 2022, with due stipulation of July 9, 2022. Training occurred on 5/4/22 which included the program specialist and members of the management team. This training was related to due date requirements for 6400 regulations, time management and calendar training. Training occurred on 5-13-22 related to the new process for cross checking the calendar and printing reminders to send out weekly. 05/13/2022 Implemented
SIN-00187283 Renewal 05/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.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. A self-assessment will be completed for each home Between April 1st and July 30th, annually. Prior to the self-assessment being printed for use, the IDD Administrator will check the ODP website for the most current version and supply it to his House Coordinators and Program Specialist to complete the site parts of the assessment. The Program Specialist, Program Director and Program Manager will receive training on how to complete a self-assessment on 6/24/21 from 10am-3pm from the Regional Director. The Program Manager will review and advise House Coordinator and Assistant Program Directors on how to properly fill out the form on 06/29/21 during the weekly managers meeting. The Self Assessments will be completed on 6/30/21. 06/30/2021 Implemented
6400.141(a)Individual #1's most recent physical examination was completed on 2/27/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The individual completed her physical examination on May 6, 2021 with a follow-up on August 12, 2021. Due to the individuals allergy to the TB serum, she will be completed a chest xray on June 25, 2021. 06/25/2021 Implemented
6400.141(c)(3)Individual #1's most recent Tetanus immunization was administered on 3/7/2011.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The individual received a Tetanus immunization on 6/22/21 at 1pm. 06/22/2021 Implemented
6400.141(c)(4)Individual #1's most recent vision examination was completed on 2/27/2020.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual has a vision examination scheduled for June, 22, 2021. This appointment was cancelled due to a last minute emergency appointment. A new appointment has been scheduled 7/13/21. 07/13/2021 Implemented
6400.141(c)(7)Individual #1's most recent gynecological examination was completed on 7/16/2019.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. The individual attended her gynecological exam on June 11, 2021. 06/11/2021 Implemented
6400.141(c)(8)Individual #1's most recent mammogram was completed on 10/2/2018.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. The client completed a mammogram on May 10, 2021. 05/10/2021 Implemented
6400.142(a)Individual #1's most recent dental examination was completed on 1/23/2020.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. The individual has a dental appointment scheduled for 8/12/21. 08/12/2021 Implemented
SIN-00147375 Renewal 12/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.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. The agency will use the correct self-assessment form during the months we are to conduct the self-assessment. (The incorrect form was used). The Vice President reviewed the correct form with the Program Specialist, Program Director, and Operations Director on 12/17/18 during the audit after finding out that the incorrect self-assessment form was used. The Program Specialist copied 7 correct self-assessment forms to prepare to do the self-assessments for each license homes which is due between April and July of 2019 on 12/18/19 after the audit ended and showed it to the Vice President before she flew back to Glenside. The Program Specialist also added on the google calendar as well as a visual calendar in the office to remind her that the inspection is due. Assistant Office Manager also added to her outlook calendar as April 1, 2019 as a reminder send the team e-mail letting them know that the residential team needs to start to work on the self-assessments for each license homes. The Operations Director will be responsible to check the ODP website to ensure that the program is using the correct self-assessment forms 1 month prior to the start of the beginning quarter. To ensure that the correct forms are completed, the Operations Director will check the forms again in April when the program specialist begins to work with the Program Director on the self-assessment form. May of 2019, the Vice President added to her white board and calendar reminder on outlook to inquire the self-assessments to review to ensure the correct forms were utilized so there is ample time to redo the assessment if the incorrect form was used. 01/11/2019 Implemented
6400.112(c)The written fire drill record for the fire drill held on 7/12/18 at 3:53 PM did not include the amount of time it took for evacuation.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 Operations Director will review the fire drill form at the manager¿s meeting and provide training on the importance of completing all information on the form. When an Assistant Operations Director is hired, the Program Director will provide training on how to fill out the fire drill form as well as ensuring that all information is completed. Going forward, the manager conducting the fire drill will review the form after completion to ensure all information was filled out before handing it to the Program Director. The Program Director will also double check the form to ensure all information was filled out before filing the form. The Office Manager added to their outlook calendar on 1/8/19 to schedule random audit on the fire drill log once a month to check to see if all information was complete. The Office Managers will send a summary via e-mail on their findings. 01/14/2019 Implemented
SIN-00107597 Renewal 01/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1 had fire safety training on 2/5/15 then again 2/22/16. 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. The agency developed an alerting system where we are reminded of when the individuals need fire safety training 30 days prior to the expiration date so the individual can be reinstructed in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting area as well as an actual fire or smoking safety if the smoke is at their home. Program Specialist/Operations Director will oversee the reminder and alert the managers to do the fire safety training prior to the expiration date. [At least quarterly for 1 year, Residential Program Director shall review a 25% sample of Individuals' fire safety training documentation to ensure timely completion. Documentation of reviews shall be kept. (AS 3/14/17)] 02/16/2017 Implemented
6400.186(e)The program specialist #1 did not notify Individual #1's plan team members the option to decline the ISP review documentation. [Repeated violation 12/21/15] The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Operations Director/Program revised our ISP Review/Quarterly meeting signature sheet by adding a section Option to decline. Going forward, when there is a quarterly meetings participants have the option to decline receiving the ISP Review documentation. This has already been put into place on February 9, 2017 when a quarterly meeting took place. [On 3/13/17, the program specialist notified Individual #1's plan team members of the option to decline ISP review documentation via email. Documentation of the notification shall be kept. Immediately, the program specialist shall review all individuals' records to ensure all individuals' plan team members have been notified of the option to decline and documentation is kept in the individuals' record. The program specialist shall ensure all plan team members are included by reviewing all individuals' current ISP, invitation letters and other documentation to ensure all plan team members are notified of the option to decline. Within 30 days of receipt of the plan of correction, the Residential Program Director shall review all individuals' records to ensure the program specialist notified all plan team members for all individuals of the option to decline and the notification documentation is included in the individuals' records. (AS 3/14/17)] 02/16/2017 Implemented
SIN-00127932 Renewal 01/16/2018 Compliant - Finalized