Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215069 Renewal 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The rug in the living room is torn and is a possible tripping hazard Floors, walls, ceilings and other surfaces shall be free of hazards.Community Support Facilitator immediately glued down the corner of the rug that was sticking up to prevent it from being a possible tripping hazard prior to leaving that location on 11/21/22. (ATTACHMENT # 22) 11/21/2022 Implemented
SIN-00197340 Renewal 11/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)PRN Medications in individual 1's med box that had expired: · ALBUTEROL SULFATE INHALER (Expired: 2/01/2020) · ROBITUSSIN CF (Expired: 08/08/2020) · ENULOSE 10mg SOLUTION (EXPIRED: 07/01/2020)A prescription order shall be kept current.*Associate Director immediately removed the expired medications from the individuals' medication box, reordered any needed PRN medications and confirmed that all medications were current. *Service Director identified a CSW Point Person for each team who is tasked with the responsibility of ensuring that medications are current and available utilizing a newly created Medication Check Record 02/01/2022 Implemented
6400.165(c)PRN Medication: Not physically in individual #1's Medication Box: · CYCLOBENZAPRINE 5 mg Tab · LORATADINE 10mg Tab · ONDANSETRON ODT 4 mg TabA prescription medication shall be administered as prescribed.*Associate Director reviewed the individuals¿ MAR and verified that all prescribed PRN medications were available in the medication box and the MAR accurately reflected on individuals¿ prescribed medications. *Service Director identified a CSW Point Person for each team who is tasked with the responsibility of ensuring that medications are current and available utilizing a newly created Medication Check Record 02/01/2022 Implemented
SIN-00181014 Renewal 11/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(d)There was a box containing all of the individual's medications on the kitchen counter that was unlocked.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Service Director immediately ensured all of the individual¿s medications were relocated to a locked area in the home (11/18/2020). A new medication box with a lock was purchased and all staff working in the home have been trained on the proper usage/storage of medication using the new medication lock box as of 1/20/2021. Service Director also completed a review of other homes where staff administer medications to individuals to ensure there were no other areas of concern with this regulation on 12/22/2020. Service Director will ensure monthly visits to each home are completed by Community Support Facilitator to confirm medications for individuals are properly stored/locked moving forward. Attachment 1: Photo of new lock box with lock Attachment 2: Memo to staff regarding new lock box for new medications 01/20/2021 Implemented
SIN-00109996 Renewal 12/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)There were two snap mouse traps and one glue trap in the laundry room of the home.There may not be evidence of infestation of insects or rodents in the home. Values Into Action has removed the mouse traps that were in this home for preventative measures. Values Into Action will ensure that mouse traps are not present in homes moving forward. In order to continue preventative measures while remaining in regulatory compliance, Values Into Action has purchased sonic mouse repellers as an alternative. Team Coordinators have been retrained on this regulation so that clarity around the language of it is understood in terms of evidence of infestation versus preventative measures. 04/17/2017 Implemented
6400.67(b)There was a large opening in the wall located in the laundry. Floors, walls, ceilings and other surfaces shall be free of hazards.Values Into Action immediately notified the property owner to ensure timely remedy to this situation. The hole has been temporarily covered, and Values Into Action will ensure that the hole is fully repaired no later than 4/30/17. Team Coordinators have been retrained on this regulation to ensure that all areas of the home receive regular and thorough inspections and meet regulations accordingly. 03/23/2017 Implemented
6400.68(b)The water temperature was measured and found to be 129 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Values Into Action immediately adjusted the water temperature in this home to measure less than 120 degrees. The water heater/tank in this home has been marked so that the dial may not be turned above the correct water temperature. Moving forward, Values Into Action will ensure that water temperatures in homes do not exceed the 120 degrees by testing water temperature on a quarterly basis at minimum. Team Coordinators have been retrained on this regulation as of 4/17/17. 04/17/2017 Implemented
6400.213(1)(i)Individual #3's record did not list current weight. 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.Values Into Action has assisted Individual #3 with attending an appointment with her Primary Care Physician to request a referral so that the individual can access a healthcare provider with a hoyer lift scale or wheelchair scale in order to ensure a current weight is available. Moving forward, Values Into Action will ensure that each individual is weighed at least annually on/around the time of his/her annual physical examination to ensure that all information is current and correct in the individual record. Team Coordinators will be trained on this expectation by the Project Director by 4/17/17. Records will be audited on a quarterly basis by the Project Director to ensure ongoing compliance. 04/17/2017 Implemented
SIN-00082210 Renewal 07/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bedroom had dust laying on the walls and floor boards. The inside of the bathroom closet door had a brown substance dripping down the door.Clean and sanitary conditions shall be maintained in the home. Values Into Action understands the importance of ensuring clean and sanitary conditions are maintained in the home. These areas were immediately cleaned by staff in the home. The Team Coordinator has also implemented a Deep Cleaning Schedule within this home to ensure that staff are consistently getting to these areas that are not always easy to access due to the individual's frequent use of them. Staff in the home are responsible for following the deep cleaning schedule. Team Coordinator will perform ongoing checks of the home throughout the month and Service Director will oversee compliance with this schedule/process by performing routine unannounced visits/checks. 07/31/2015 Implemented
6400.67(a)Individual #1's bedroom door had 5 small holes and 1 large hole. The hallway closet door is missing a knob and the closet door panel is falling off. There are several holes in the walls throughout the home.Floors, walls, ceilings and other surfaces shall be in good repair. Values Into Action understands the importance of ensuring floors, walls, ceilings, and other surfaces are in good repair within the homes of people accepting support in order to protect health and safety. Values Into Action has requested the necessary repairs in writing to this individual's landlord as of 8/26/15. The landlord has agreed to make necessary repairs to the home. The Team Coordinator will oversee completion of these repairs. If the repairs are not completed by 9/18/15, Values into Action will contract with a private handyman to ensure work is completed no later than 9/30/15. Service Director will oversee progress to ensure this correction is made within a reasonable timeframe. In addition, Service Director will oversee the completion of Quarterly Physical Site Inspections to ensure that all floors, walls, ceilings, & other surfaces remain in good repair. Inspections will be completed by the Team Lead then results shared with Team Coordinator to ensure issues/repairs are resolved. Service Director will track progress & oversee completion of needs noted. 09/30/2015 Implemented
6400.80(b)The shutters on the outside of the home were not secured to the exterior of the home and were sticking out from the building. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Values Into Action understands the importance of ensuring outside areas are well maintained, in good repair, and free from unsafe conditions in order to protect health and safety. Values Into Action has requested the necessary repairs in writing to this individual's landlord as of 8/26/15. The landlord has agreed to make necessary repairs to the home. The Team Coordinator will oversee completion of these repairs. If the repairs are not completed by 9/18/15, Values into Action will contract with a private handyman to ensure work is completed no later than 9/30/15. Service Director will oversee progress to ensure this correction is made within a reasonable timeframe. In addition, Service Director will oversee the completion of Quarterly Physical Site Inspections to ensure that all floors, walls, ceilings, & other surfaces remain in good repair. Inspections will be completed by the Team Lead then results shared with Team Coordinator to ensure issues/repairs are resolved. Service Director will track progress & oversee completion of needs noted. 09/30/2015 Implemented
6400.112(d)The fire drill held on 6/13/15 had an evacuation time of 3 minutes and 46 seconds. The extended evacuation letter allows for an evacuation time of 4 minutes however, the reasoning for the extended evuacation was based on the needs of the individual residing in the home, not the structure of the home or fire safe areas. The letter indicated there were standard doors to the bedrooms but no other fire safe barriers in the home. 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. Values Into Action understands the importance of ensuring those supported, as well as their supporters, are able to evacuate safely in the event of a fire. As soon as Values Into Action discovered that the Waiver Evacuation for this individual was not accepted by BHSL, it was communicated to the individual and staff that the home was not safe to allow a 4 minute evacuation. The Team Coordinator and Service Director began to assess with the individual and team different methods and techniques to allow a safe, yet quicker evacuation in order to ensure the individual and staff could indeed exit the home within the 2.5 minutes allotted. Due to the individual's extensive physical support needs, the evacuation from her bed, to her hoyer lift, into her power chair was assessed to be route that took the most effort and time, so this was assessed for improvement. When the individual's staff had all adaptive equipment in her bedroom and pre-set for an evacuation, the individual was able to exit the home using the nearest exit within the 2.5 minutes allotted. Thus, a protocol has been implemented Values Into Action Page 6 that before this individual is placed into bed, all adaptive equipment should be set up and prepared to be ready in the case of an emergency. This includes the individual having a hoyer sling set up on her bed in order to save time from staff needing to perform a roll movement technique to get her into the sling. All staff will continue to practice these techniques through unannounced drills held by the Team Lead, Team Coordinator, and Service Director as well as routine practice sessions to assure that all staff prior to working with this individual and regularly thereafter for practice-sake are able to perform this process successfully. Team Coordinator is responsible for ensuring all staff are trained prior to working independently with the individual and regularly thereafter. Service Director is responsible for overseeing the practice/training to ensure it is completed and also to oversee the fire drills that occur monthly/unannounced to remain aware of any foreseeable issues and to address proactively. 08/28/2015 Implemented
SIN-00050627 Renewal 06/10/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The home held a fire drill on 09/13/2012 and Individual #1 did not evacuate the home within the fire safety expert's designated extended time period of 4 minutes. The Individual evacuated in 4 minutes and 59 seconds.(d) 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 employee 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. Values Into Action understands the importance of this regulation in relation to keeping individuals supported safe from the very serious potential threat of a fire or other emergency situation requiring timely evacuation from the home. Values Into Action conducted a fire drill on 9/13/12 in which the individual did not evacuate within the time specified in writing by a fire safety expert (This individual has an extended evacuation waiver for 4 minutes) and exceeded the allotted 4 minutes by an additional 59 seconds. This was due to an issue with the individual receiving assistance evacuating while in her hoyer lift rather than her electric wheelchair (and the hoyer lift being more difficult to get out the door due to the unsteadiness of the individual in the hoyer which requires more time and effort). To protect health & safety, Values Into Action immediately assessed the individual's home and adaptive equipment. The evacuation procedure for that individual was amended so this individual now receives assistance with evacuating in her electric wheelchair. Another drill was completed on 9/24/12 to ensure the new procedure was successful. The individual evacuated in 2 minutes and 19 seconds time. No concerns have presented since this time and all drills since have been successful. To monitor the effectiveness of this corrective action, any drill exceeding 4 minutes as per the extended evacuation waiver will immediately be communicated to the Service Director and/or Managing Director so that proper assessment can be completed to ensure safety (according to Values Into Action's Fire Drill Directions). Service Director will continue to review fire drill documentation at least twice monthly to ensure compliance with regulations. 09/24/2012 Implemented
6400.141(c)(6)Individual #1's did not have TB test completed within 2 years of the previous test on 1/24/2011.(6) 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. Values Into Action takes health and safety matters very seriously. We understand that Tuberculin skin testing needs to occur every 2 years for individuals supported's safety and also for staff's safety. Values Into Action did not ensure compliance worth this regulation as one individual did not obtain the Tuberculin testing within the 2 year timeframe. This individual's last Tuberculin test occurred on 1/24/11 and the most recent did not occur until 6/7/13. An analysis of the root cause reveals that only the most recent physical form was kept in the individual's records; therefore the last Tuberculin test was not recorded and easily viewable. Also, the individual's primary care physician instructed the individual that since she does not live in a group setting (as this person lives in her own home) the Tuberculin test would not be required every two years. Upon discovering this issue, Values Into Action immediately contacted the individual's primary care physician to schedule the Tuberculin test (mantoux) and reviewed the standard related to 6400.141(c)(6) the 6400 regulations. This was completed and presented during the inspection. To prevent a recurrence physical examination forms for at least 2 years prior are kept in the individual's record to ensure proper tracking of the Tuberculin test. To monitor the effectiveness of this corrective action the Service Coordinator will monitor health records on a weekly basis and Service Director will also complete monthly audits to ensure compliance with this standard. 06/07/2012 Implemented
6400.181(d)Individual #1's updated assessment was completed on 5/31/13 and was not signed by the Program Specialist.(d) The program specialist shall sign and date the assessment. Values Into Action understands the importance of signing and dating all assessment documentation to confirm that the documentation is accurate, thorough, and indeed completed by a qualified Program Specialist (Values Into Action refers to this role as a Service Coordinator). An individual had an assessment updated on 5/31/13. The Service Coordinator added a copy of this assessment to the record. In an attempt to review assessment findings with the individual and obtain her/his signature & validation, the Service Coordinator took the original assessment to the individual's home. The root cause of non-compliance resulted when the Service Coordinator did not file the signed assessment in the individual's record. Upon discovery, the original signed assessment was immediately placed into the individual's record on 6/10/13. To prevent a recurrence, Service Coordinators were issued a memo reinstating the expectation to sign and date the assessment (as well as add it to the record) immediately after completing/updating. To monitor the effectiveness of this corrective action the Service Director will complete unannounced monthly audits of individual records. 06/10/2013 Implemented
SIN-00153165 Renewal 03/27/2019 Compliant - Finalized
SIN-00126270 Renewal 12/14/2017 Compliant - Finalized
SIN-00108932 Renewal 12/19/2016 Compliant - Finalized