Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00156720 Renewal 06/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills held on 8/23/18, 11/30/18, 1/29/19, 05/15/19 do not address problems encountered; this section was left blank.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. Historically, we have instructed staff to document on the fire drill only if there was a problem encountered. If nothing occurred, there would be no documentation in this section. This has been our process for many years. It has not been discussed with us during any previous licensing inspection that we were not meeting the regulation or that we needed to consider making any changes. This would have been greatly appreciated, as we always value the guidance received during inspections and have made adjustments as needed. Going forward, all staff at all homes will be instructed to document ¿none¿ under ¿Problems Encountered¿ if there is no occurrence to be documented. Specialists will be trained by the Associate Director on 7/1/19. In turn, Specialists will train the Supervisors and they will train the DSPs. This training will be completed by 7/31/19. We will continue our current fire drill review process with an emphasis on no part of the documentation being left blank. The Supervisor of each home will review the Fire Drill to ensure that staff running the drill has completed the documentation in its entirety. The Supervisor will present the drill to the Specialist, who will also review the drill for accuracy and completion. The drill will then be submitted to the next reviewer, who will do the same. The Associate Director, Community Living will then complete a final review of the drill before filing. 07/31/2019 Implemented
SIN-00105254 Renewal 12/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 12/13/16 at 2:57 PM, the hot water temperature at the shower of the hallway bathroom measured 124.5°F.Hot water temperatures in bathtubs and showers may not exceed 120°F. On 12/13/16, the hot water tank was re-adjusted and water temperature was later re-tested at 118 degrees F. The Specialist will periodically test water temperature during site visits to ensure compliance. [Immediately and continuing at least monthly, the program specialist(s) shall measure the hot water temperatures in all bathtubs and showers in all community homes to ensure hot water temperatures in bathtubs and showers do not exceed 120°F. Adjustments will immediately made if the hot water temperature exceed 120°F and rechecks shall be completed daily for 1 week and weekly for 1 month and continue at least monthly as long as the hot water temperature does not exceed 120°F for all of the check. Documentation of checks shall be kept and reviewed at least quarterly for 1 year by the vice president, residential supports to ensure completion of check and hot water temperatures in bathtubs and showers do not exceed 120°F. (AS 1/12/17)] 01/10/2017 Implemented
6400.141(c)(14)The physical examination completed on 9/30/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Physical Examination form has been re-formatted, so that it is more user friendly for the physician to complete. It is now more clearly defined that "medical information pertinent to diagnosis and treatment in case of an emergency" is a separate question. On 1/9/17, an email was sent to all Supervisors reminding them to ensure that nothing is left unanswered on the physical examination form prior to leaving the appointment. [Individual #1's physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, the vice president residential supports shall train all supervisors of the required information to be included in individuals' physical examination as per 6400.141(c)(1)-(15). Documentation of training shall be kept. Within 30 days of receipt of the plan of correction, and upon completion, the supervisors shall review all individuals' current physical examinations to ensure all required information is present and there are not any areas of required information left blank and will immediately obtain missing information from the complete physician. Documentation of all reviews shall be kept. At least quarterly for 1 year, the program specialist shall review a 25% sample of physical examinations completed that quarter to ensure all required information is present and there are not any areas of required information left blank. (AS 1/12/17)] 01/10/2017 Implemented
6400.141(c)(15)The physical examination completed on 9/30/16 for Individual #1 did not include special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. On 1/9/17, an email was sent to all Supervisors reminding them to ensure that nothing is left unanswered on the physical examination form prior to leaving the appointment. Physical form was returned to the physician to complete the dietary instructions.[Individual #1's physical examination was updated to include special instructions for the individual's diet. Immediately, the vice president residential supports shall train all supervisors of the required information to be included in individuals' physical examination as per 6400.141(c)(1)-(15). Documentation of training shall be kept. Within 30 days of receipt of the plan of correction, and upon completion, the supervisors shall review all individuals' current physical examinations to ensure all required information is present and there are not any areas of required information left blank and will immediately obtain missing information from the complete physician. Documentation of all reviews shall be kept. At least quarterly for 1 year, the program specialist shall review a 25% sample of physical examinations completed that quarter to ensure all required information is present and there are not any areas of required information left blank. (AS 1/12/17)] 01/10/2017 Implemented
6400.213(1)(i)Individual #1's record did not include identifying marks. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (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.On 1/9/17, an email was sent to all Supervisors reminding them to ensure that "Identifying Marks" is not left blank and to document "None" if the Individual has no identifying Marks. [Immediately, Individual #1's record shall be updated by the program specialist to include identifying marks. Within 30 days of receipt of the plan of correction, the vice president, residential supports shall train the program specialist as to what is required in all individual records as per 6400.213(1)-(14). Documentation of training shall be kept. Immediately and continuing at least quarterly, the program specialist(s) shall review all individual records to ensure all required information is present. Documentation of record reviews shall be kept. (1/12/17)] 01/10/2017 Implemented
SIN-00051287 Renewal 09/05/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone in Individual #1¿s bedroom did not have emergency numbers on or near the phone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency numbers were replaced on the phone in the Individual's bedroom on 9/5/2013.On a monthly basis, the Community Homes Supervisor will utilize the portion of the LII related to Physical Site & Fire Safety as a resource to ensure that the home is in compliance. If any areas need addressed, the Community Homes Supervisor will make corrections to meet the regulations. If a correction needs to be made, they will e-mail this information to their Specialist. On the next visit to the home, the Community Homes Specialist will review the correction to ensure that it was completed and meets the regulations. On a quarterly basis, the Community Homes Specialist will complete the Quarterly Physical Site & Fire Safety Inspection form to ensure that the home is in compliance and submit this to the Residential Director. Should the Quarterly Physical Site & Fire Safety Inspection form reflect any concerns that need addressed in the work order system, the Community Homes Specialist will promptly enter the repair request. When the repair is completed, this will be documented on the form and submitted to the Residential Director. 09/22/2013 Implemented
6400.141(c)(7)The admission physical examination dated 7/25/13 for Individual #2 did not include a gynecological examination. Individual #2's date of admission was 8/5/13.(7) 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 program specialists will audit all individuals current physical examinations documentation to ensure that they contain all of the required regulatory components by 12/1/13. The Individual was an emergency placement. Prior to admission to residential supports on 8/5/2013, the family coordinated the completion of the physical exam. The gynecological exam was not completed. Residential staff scheduled the exam for 9/30/2013, which was the first available appointment. Prior to an Individual's admission, the Community Homes Specialist will review the physical exam to ensure that all preadmission requirements are met. Should a requirement not be met, the admission date will be rescheduled to a date after requirements have been met. 09/22/2013 Implemented
SIN-00215195 Renewal 11/01/2022 Compliant - Finalized