Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00130944 Renewal 03/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was a two foot long tear on the vinyl sheet floor in Individual #1's bedroomFloors, walls, ceilings and other surfaces shall be in good repair. The vinyl sheet tiles in Individual #1's bedroom, which had the two foot long tear has been replaced since 04/05/2018 by maintenance. Going forward, the Site supervisor will pay closer attention during their daily and weekly checks to ensure every surface is in good repair. Any concerns such as this will typically be reported to maintenance for a prompt resolution/fix. The Program Director will monitor the process for compliance. Please see attachment #2 for supporting documentation. 04/05/2018 Implemented
SIN-00088315 Renewal 01/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The upstairs bathtub had brown/black stains consistent with dirt. The kitchen had a thick black substance on the floor between the stove and kitchen counter. The steps leading to the upstairs black and white stains and the paint is scrapping off,Clean and sanitary conditions shall be maintained in the home. The upstairs bathtub, dirt between the stove and kitchen counter has been thoroughly cleaned out by staff, as well the steps leading to the upstairs repainted by maintenance as at 01/19/16. Please see attachment #4. All staff working at this Site was re-in serviced on cleanliness and performing all necessary chores each shift. A new chore list [also see attachment #4] was also created for the Site as well as all other Residential Sites, for which the Site Supervisor monitors the Site for cleanliness. In addition, once a repair is needed at a home, a maintenance request is submitted immediately and it should take maintenance 48 hours to complete repairs. A maintenance manager position has also been created to go behind the maintenance crew to ensure that all submitted maintenance requests are duly and timely completed. 01/19/2016 Implemented
6400.67(a)The closet door in individual # 2's bedroom had a broken surface on the door approximatly 6 inches wide and 8 inches long. Individual #3 bedroom was missing the inside door handle. The upstairs bathroom had the heater cover detached from the wood frame. Floors, walls, ceilings and other surfaces shall be in good repair. The broken surface on the door, the inside door handle and heater cover has been fixed or replaced as at 01/21/2016 by maintenance. Please see attachment #3. Once a repair is needed at a home, a maintenance request is submitted immediately and it should take maintenance 48 hours to complete repairs. A maintenance manager position has also been created to go behind the maintenance crew to ensure that all submitted maintenance requests are duly and timely completed. 01/21/2016 Implemented
6400.186(a)Individual #1's record did not have a quarterly review for the period of March, 2015 through May, 2015.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. An addendum quarterly report was completed for this Individual covering the months of March 2015 to May 2015; as well as the initial quarterly report updated for the months of January to February 2015 on 01/19/2016 and sent out on 01/21/2016 to his team by the Program Specialist. Please see attachment #2. This violation was as a result of miscalculation on the part of the Program Specialist based on the date the Individual joined the agency. However, the program specialist has gone back to ensure that all the Individuals served by Casmir Care Services have a review of the services and expected outcomes in their ISP reviewed every 3 months. The Residential Director will continue to monitor this to ensure compliance. 01/29/2016 Implemented
6400.213(1)(i)Individual # 1's record did not list his 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.Individual #1's record has been updated to include his religious affiliation. Please see attachment #1. The Program Specialist updated this information as well as all the required personal information for all the individuals served by Casmir Care Services. Going forward, the Program Specialist will ensure that any new individual admitted by Casmir Care Services will have all the required personal information captured in their records. An individual admitted into the agency on 01/21/2016 has all his required personal information as part of his records [also see attachment #1]. In addition, the Program Specialist will ensure that all required personal information for the current individuals served by Casmir is accurate and up to date by conducting quarterly review of their records. 01/21/2016 Implemented
SIN-00065659 Renewal 08/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature in the bathtub was 143 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water tank in the Site was adjusted down to a regulatory permissible temperature on 08/08/2014. In addition, all the hot water tanks in all Residential sites were rechecked for conformity to regulatory requirement for the health and safety of all the Individuals. A more efficient system has been developed for the monitoring of the hot water temperature in all the Residential Sites. By 09/30/14, all Staff would have been re-in-serviced to assure daily water checks are done each day in the kitchen and the bathroom. Site Supervisors now conduct weekly checks on the water temperature in all Sites. By 09/30/14, maintenance would have been re-in-serviced on the maximum allowable temperature in addition to other regulatory requirements. Maintenance will be required to check the temperature of the hot water tanks during routine site checks and maintenance work. If on staff check, the water temperature exceeds 120F, staff will notify supervisor immediately to enable maintenance effect an immediate adjustment or resolution to the problem. 08/08/2014 Implemented
6400.201(b)Individual # 4 paid $560.00 for a broken bathroom window. An individual's personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages. This violation was corrected on 09/11/14, when Individual #4 was reimbursed the sum of $560 by means of a Casmir Care services check deposited into his account on 09/11/2014. Going forward, blanket consents would no longer be used to make restitution for any damage to property by any Individual. For each occasion of property damage, the legal guardian or representative payee (not including Casmir Care services) will give consent OR Casmir Care services will converge a team meeting whereby all team members, including the individual will give consent to using the Individual¿s personal funds to make payment for damages by the individual. The Program Specialist will ensure compliance to this and will be overseen by the Residential Director. 09/11/2014 Implemented
SIN-00051874 Renewal 07/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(e)Staff member A, hired on 4/28/10, did not have initial mental retardation training within 30 days of starting employment.(e) Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. For this violation, at the time of hire, staff were issued certificates and a checklist.There were no sign-in sheet. However, this individual did receive the training and has a checklist and a certificate indicating the trainings which she received and also intialled. Currently, all orientation trainings and annual trainings have sign in sheets. 01/01/2012 Implemented
6400.72(a)The home did not have screens in the left and right windows in the rear bedroom. Staff office did not have a screen in the window.(a) Windows, including windows in doors, shall be securely screened when windows or doors are open. This violation resulted from the inability of the Residential program to follow through on the regulation as it relates to screening of doors and windows in this home. A maintenance request has been submitted to enable the left and right windows in the rear bedroom to be screened. Going forward, Site supervisors shall include screen checks as part of their regular site inspections, and shall report to the Residential Director to enable maintenance purchase replacements if required. 08/31/2013 Implemented
SIN-00041467 Renewal 10/09/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(5)Individual #2's skill level for medication administration was not included in the assessment. (5)  The individual's ability to self-administer medications.This violation resulted from an oversight by the Program Specialist in following through with the regulation as it relates to all the relevant sections of an assessment. A new assessment dated 10/22/12 was completed to include this individual's skill level for medication administration. Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director. 10/22/2012 Implemented
6400.183(4)Individual # 1 does not have a protocol to address independence time in the community. (4) A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. This violation resulted from the inability of the Program Specialist to create a protocol around this individual's independence time in the community. A protocol dated 12/1/2012, has been created to address this individual's independence time in the community. The staff working with this individual in the home shall be trained on this protocol. Going forward, a protocol must be created to address any independence time as specified in the individual's assessment. The Program specialist shall review every ISP for independence time and ensure that a protocol exists for such. The Assistant Residential Director will ensure compliance to this. 12/01/2012 Implemented
6400.183(5)Individual # 2 did not have a Behavioral Support Plan (BSP)to address target behaviors - obsession with cigarettes - fictional story telling - physical aggression - drug and alcohol use - refusal of medication - regurgitation - sleep disturbance (up wanting to smoke) (5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. This violation resulted from the inability of the Program Specialist, to ensure that a BSP was developed to address the individual's target behaviors. A meeting was held on 10/26/2012 and in attendance was the program specialist, site supervisor, individual and SC supervisor. The SC supervisor adopted recommendations by the Program specialist for the ISP. The SC supervisor also authorized credits for a Behavioral support plan. The Behavior Specialist is currently formulating a BSP addressing the individual's target behaviors. The program specialist will review the new ISP and behavior plan to ensure both are updated and captures all that was discussed at the critical revision meeting. Going forward, the program specialist, as plan lead will ensure that there always exists a protocol to address the social, emotional, and environmental needs of an individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. 11/30/2012 Implemented
6400.186(c)(1)Indvidual # 2's ISP monthly reviews did not list progress on the following outcomes: - Attend Flatiroms- - Attend Medical Appointments - Seeking Employment (c) The ISP review must include the following: (1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. This violation resulted from the inability of the program specialist to ensure that progress exists for all the outcomes in the ISP. A meeting was held with the Individual's SC on 10/26/12 to effect a critical revision, in order to remove the outcomes that are not relevant to the individual's life. An amended quarterly report has been created for this individual which shows only the outcomes as specified in the revised ISP. Going forward, all ISP monthly reviews will show progress in all the outcomes as specified in the ISP.The Program specialist will ensure that this is the case for every individual. 10/26/2012 Implemented
SIN-00201806 Renewal 03/14/2022 Compliant - Finalized
SIN-00109537 Renewal 03/13/2017 Compliant - Finalized