Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233483 Renewal 11/07/2023 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)During the walk-though of the home on 11/8/23 the water in the kitchen sink tested at 129.2F. Also the water temperature in the bathroom sink was 126.3. This exceeds the 120F.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. Maintenance was contacted and a work order was put in to lower the water temperature. 11/15/2023 Accepted
6400.64(a)At the time of the inspection, the refrigerator was not clean. There was something spilled inside, and the drawers appeared dirty and needed cleaned.Clean and sanitary conditions shall be maintained in the home. Refrigerator was thoroughly cleaned by staff and a picture was sent to CEO for confirmation. 11/15/2023 Accepted
6400.66At the time of the inspection, there was no light bulb in the light outside the front door.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb has been replaced and is working. 11/15/2023 Accepted
6400.67(b)At the time of the inspection, the closet nearest to the kitchen was full of items that appeared as if they were just thrown in. There was no organization, and nothing was labeled. There was no way to enter the closet to see what items are in there safely. Floors, walls, ceilings and other surfaces shall be free of hazards.Closet has been organized by staff. 11/15/2023 Accepted
6400.68(b)At the time of inspection on 11/8/23 the water temperature in the bathtub was 126.8 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenance has been contacted and a work order put in to have the water temperature lowered. 11/15/2023 Accepted
6400.71At the time of inspection there were no emergency #'s posted by or near the living room phone or the phone in individual #1's bedroom.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 have been added back onto both house phones. 11/15/2023 Accepted
SIN-00217083 Unannounced Monitoring 01/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)(Repeated violation -- 10/19/22) Individual #1 requires assistance managing their finances and all cash is to be tracked. They also have a restrictive plan in place regarding how much money they are able to safely carry. There are numerous times between 8/1/22 and 1/3/23 that Individual #1's cash on hand does not match the current ledger, as well as many receipts that are not included on Individual #1's ledger. · At the end of September 2022, Individual #1's ledger indicated they should have $87.59 in cash, however, when the math was double-checked, there should have been $87.50. · In October 2022, there was a check received from Individual #1's rep payee for $750, however, this amount was only included on the ledger as $350. It is unclear where the other $400 went. · October 2022's ledger balance was $87.59 but should have been $87.50. According to the transactions logged, the final balance for October 2022 should have been $359.25, however, the ledger states the balance is $384.34. · Between 11/9/22 and 11/10/22, $11.21 is missing with no indication where this money went. · On 11/16/22, Individual #1's balance was noted as $39.06, but by 11/19/22, the balance was $.81. There is no indication where missing $38.25 went. · On 11/21/22, Individual #1's balance increased to $3.81. There is no indication where this extra money came from. · On 11/23/22, Individual #1's balance was $32.31. On 11/26/22, this balance was $7.39. There is no indication where the missing $24.92 went. · On 12/2/22, Individual #1's balance was $2.58. There is no indication where the missing $4.81 went. · On a separate December ledger, from 12/1/22 -- 12/16/22, there was a total of $89.16 spent, but no balance entered to indicate what Individual #1's current cash on hand should be. On 12/21/22, $30 was added making the total $32.67. · On 12/22/22, a "balance check" was completed that indicated there was $.71 cash on hand. It is unclear where the missing $31.96 went. · On 12/23/22, a "balance check" was completed that indicated that there was $2.71 cash on hand. It was unclear where this money came from. · On 12/26/22, a "balance check" was completed that indicated that there was $3.81 cash on hand. It was unclear where this extra money came from. · On 12/29/22, a "balance check" was completed indicating that there was $12.95 cash on hand. It is unclear where the missing $7.22 went. · On 12/30/22, a "balance check" was completed indicating that there was $13.23 cash on hand. It is unclear where the additional money came from. · On 12/31/22, a "balance check" was completed indicating that there was $3.23 cash on hand. It is unclear where the missing $10 went. · On 1/1/23, a "balance check" was completed indicating that there was $2.78 cash on hand. It is unclear where the missing $.45 went. · At the time of the 1/5/23 inspection, there was a bundle of $215 that was sitting in the drawer that was not on a ledger or accounted for.(2) Disbursements made to or for the individual. Separate tracking sheets will be utilized for each account and cash-on-hand. The DSP's will keep the receipts from all daily transactions and hand them in daily to the house manager. The manager will be doing daily "balance checks" and recording what the balance is. If there is a different in the balance, the manager will then note why there is a difference (withdrawal, interest payment, etc) and document a receipt for the difference. Any time a receipt is handwritten for a missing receipt, the individual will sign off on the receipt, confirming it is correct. An incident will be entered into EIM, initiating an investigation into Individual #1's finances to determine if Individual #1 is owed any money. 01/06/2023 Implemented
6400.67(b)There was a golf ball size lint ball in the dryer at the time of the 1/4/23 inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.Lint was removed from the dryer 01/09/2023 Implemented
6400.144(Repeated Violation -- 3/8/22) Individual #1's dentist prescribed Prevident toothpaste on 11/22/22 as well as recommending that Individual #1 brush and floss twice daily with string floss. Individual #1's dental hygiene plan dated 4/11/22 was not updated with these recommendations, and while the prescription for Prevident was present in the home, it is not being tracked as administered, so it is unclear if this prescription is being used in the 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. Instructions from the dentist have been obtained and MAR has been created. Dental Hygiene plan has been updated to reflect dentist recommendations. 01/10/2023 Implemented
6400.211(b)(1)Individual #1's emergency contact information does not include their emergency contact's address.Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. Emergency Contact Information has been updated to include address 01/10/2023 Implemented
6400.211(b)(3)Individual #1's emergency medication consent information does not include their emergency medical consent contact's address.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Consent form has been updated to include the address. 01/10/2023 Implemented
6400.165(b)(Repeated Violation -- 3/8/22) Individual #1's PCP increased their twice daily dose of Topiramate from 125mg to 150mg on 8/26/22. This increase was not started in the home until 9/1/22.A prescription order shall be kept current.Managers have been retrained in Health Services and following doctors prescriptions as written. 01/10/2023 Implemented
6400.165(g)(Repeated Violation -- 3/8/22) Individual #1's 10/12/22 quarterly medication review does not include the need to continue the medications.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.Manager confirmed with doctor to continue all current medications. 01/08/2023 Implemented
6400.166(a)(4)Individual #1's prescription toothpaste, Prevident, is not present on Individual #1's medication administration records.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.MAR for Prevident has been created after receiving clear instructions from the dentist. 01/10/2023 Implemented
6400.166(a)(11)(Repeated Violation -- 3/8/22) Individual #1's Medication Administration Record does not include the diagnosis or purpose for the PRN medication Mobic/Meloxicam.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.All PRN medication MAR's have been updated. PRN medication list sent to doctor for confirmation. 01/10/2023 Implemented
6400.167(a)(1)Individual #1 did not receive their 8am dose of topiramate, esomeprazole, Latuda, metformin, propranolol, and fenofibrate on 10/21/22. Individual #1 did not receive their 5pm dose of guanfacine, Latuda, and metformin on 12/3/22. Individual #1 did not receive their 5pm dose of guanfacine, Latuda, and metformin and 8pm dose of guanfacine, hydroxyzine, topiramate, and trazodone on 12/25/22.Medication errors include the following: Failure to administer a medication.External incident reports have been completed for the missed medications. New medication trainer to do refresh training with staff. 01/10/2023 Implemented
6400.167(a)(3)(Repeated Violation -- 3/8/22) Individual #1 was prescribed an increased dose of Propranolol from 60mg to 80mg on 11/17/22. The increased dose was available at the home on 11/17/22; however, staff continued to administer 60mg through 11/24/22.Medication errors include the following: Administration of the wrong dose of medication.Emails will be sent by managers/staff after every appointment to include updates to medications/changes in health maintenance of client. 01/11/2023 Implemented
6400.167(c)The medication errors described in 6400.167a1 and 6400.167a3 were not reported as a medication error in the department's incident management system.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Medication errors have been reported in the incident management system. 01/10/2023 Implemented
6400.169(a)(Repeated Violation -- 3/8/22) Staff person #3's most recent completed medication administration annual practicum was completed on 1/16/21. As of 1/16/22, this staff person is no longer considered certified to administer medications. Staff person #3 administered medications to Individual #1 after this date.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Staff person #3 has completed medication administration training again and is currently medication trained as of 1/10/23 01/10/2023 Implemented
SIN-00202759 Renewal 03/08/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The emergency numbers to the nearest hospital, police department, fire department, ambulance and poison control center were not located on or near the telephone in Individual #1's bedroom.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. All emergency phone numbers are on the back of all landline phones. 03/16/2022 Not Implemented
6400.111(f)At the time of the 3/8/2022 inspection, there were no records maintained that the fire extinguishers were inspected in 2021. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. All fire extinguishers have been inspected by a fire professional and are up to date. 03/22/2022 Not Implemented
6400.112(d)The 01/18/22 fire drill record states that the evacuation took "14.78 minutes". No other fire drill was conducted during the month of January. 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. Protocol/Training was completed by all staff indicating instructions to follow when a fire drill takes more than 2.5 minutes. 04/04/2022 Implemented
6400.113(a)There are no records maintained to indicate that Individual #1 received training on fire safety annually. Their record indicates fire safety training was completed on 3/10/21 and again sometime in March 2022. The date of the training for 2022 is unknown. 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. HCA has retrained individual on fire safety plan and marked exact date. 03/21/2022 Implemented
SIN-00181114 Renewal 01/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain tweezers at the time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tweezers were taken out by the client prior to inspection. House Managers will do weekly checks to ensure all first aid materials are in the container and up to date. Tweezers were returned to the first aid kit during inspection. 01/25/2021 Implemented
6400.103The 04/09/20 Emergency Evacuation Plan does not include the Individual's responsibility in an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The following has been added into our Emergency Relocation/Emergency Evacuation Plan "In the event of an emergency, the individual will evacuate to the best of their ability, with staff verbal and physical assistance, and follow all directions to the best of their ability." 01/25/2021 Implemented
6400.141(c)(7)The last gynecological exam was conducted on 04/21/17, per the 01/01/19 and 01/08/20 physicals in the record. An attempted gynecological exam was attempted on 09/22/20 without success. Although there is a physicians recommendation for a Pap every three years, the gynecological and breast exam are still required on an annual basis.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. House Manager has added annual gynecological and breast exam to her annual physical appointment form - indicating this needs to be completed annually. Behavioral Specialist/Program Specialist will complete trainings prior to physical exam to stress the importance of participating in these exams annually. 01/25/2021 Implemented
6400.181(e)(7)The 4/15/20 Assessment does not address Individual #1's ability to "move away quickly from heat sources".The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. We have added this into the assessment and made it a two part assessment. Part 1: Individual has knowledge of the danger of heat sources. Part 2: Individual is able to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. 01/25/2021 Implemented
6400.32(r)The door leading to the shared bathroom from Individual #1 bedroom does not have a keyed lock, although the main door to the bedroom does. Individual #1 stated during the inspection that Individual #1 wanted both doors to the bedroom to have keyed locks.An individual has the right to lock the individual's bedroom door.We have added into the restrictive plan that the client does not have a key lock door that leads from the shared bathroom into her bedroom. This plan is under review. The client has stated that she will enter the bathroom when staff are in there. Given the client's behaviors, we do not feel it is safe for her to have access to the bathroom while staff are using it. The client continues to have a key lock door on the door that leads into her bedroom from the hallway. 01/25/2021 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 1/04/2021 annual inspection, Individual #1 was never informed of the additional individuals rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Document addressing individual rights has been updated to reflect the updated regulatory rights, effective 2/3/2020, to include all listed rights as well as process to report a rights violation. Clients will sign off upon intake and annually thereafter. 01/25/2021 Implemented
SIN-00160893 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The beige colored carpet in the living room area had large dark brown/black stains on it. The largest stain being in front of the couch, approx. 10"x10" in size, and smaller stains over the rest of the carpetClean and sanitary conditions shall be maintained in the home. A. What was the Issue/Violation- Carpet at 1501 Crestwyck Circle was stained and needed shampooed. B. Who is Responsible for Making these Corrections: CEO, President C. What action should have been taken/addressed- Clean and sanitary conditions shall be maintained in the home. D. When/How will the violation/issue be addressed- CEO/President will have the carpets at 1501 Crestwyck Circle professionally cleaned. E. Proof of Materials/Information to be Reviewed- Receipt from Professional Cleaning and picture of carpet at 1501 Crestwyck Circle. 09/23/2019 Implemented
SIN-00141596 Renewal 10/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation plan did not include individual responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. A. Who- CEO, Program Specialist, House Managers, DSPs B. What- The written emergency evacuation plan will include the individual responsibilities. C. When and How- As of 10/18/2018 all Emergency Evacuation Plans were updated by HCA CEO to include the responsibilities of the individual during an emergency evacuation. All updated Evacuation plans were reviewed with current staff and individuals to ensure all parties were aware of the responsibilities of the individual during an emergency evacuation. The plan will continue to include responsibilities of the individual and be reviewed annually or as needed for any changes throughout the year. 10/24/2018 Implemented
6400.145(2)The written emergency medical plan did not list the following: The method of transportation to be used.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. A. Who- CEO, Program Specialist, House Managers, DSPs B. What- The written medical emergency plan will list the method of transportation being used. C. When and How- As of 10/18/2018 all Medical Emergency Plans were updated by HCA CEO to include the method of transportation used in the case of an emergency. All updated plans were reviewed with current staff and individuals to make all parties aware of the method of transportation used in a medical emergency. The plan will continue to include method of transportation used and be reviewed annually with staff and individuals or as changes are needed throughout the year. 10/24/2018 Implemented
6400.145(3)The written emergency medical plan did not list the following: An emergency staffing plan.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.A. Who- CEO, Program Specialist, House Managers, DSPs B. What- The written medical emergency plan must include a written emergency staffing plan. C. When and How- As of 10/18/2018 all Medical Emergency Plans were updated by HCA CEO to include an emergency staffing plan. All updated plans were reviewed with current staff and individuals to assure knowledge of the emergency staffing plan in place in the case of a medical emergency. The plan will continue to include an emergency staffing plan which will be reviewed annually or as changes are made throughout the year with all staff and individuals. 10/24/2018 Implemented
SIN-00121483 Renewal 10/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff #1 was hired on 4/11/16 however did not have his Tuberculin skin test read until 4/13/16. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. A. Who- The Executive Team B. What- TB tests will be completed prior to the staff member's official start date. C. When and How- Hoffman Care Associates will help ensure compliance by having two administrative staff members follow the new-hire process. The Chief Operating Officer and the Executive Administrator will both be responsible for tracking all new-hire requirements, including physical examinations and tuberculin skin tests. Physical examinations and tuberculin skin tests will be conducted prior to the new hire¿s official start date. To be sent by 11/2/2017 for corrective proof- - Updated New Hire Process 10/30/2017 Implemented
SIN-00101403 Renewal 09/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's license expiration date was 8/20/16. The self-assessment was not completed until 9/11/16, after their license expired. 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. Who- Program Specialist, CEO, House Managers B. What- The agency will complete a self-assessment of each home the agency operates serving eight or fewer individuals, 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. C. When and How- the CEO has created reminders on the agency¿s google calendar to ensure proper completion of the self-assessment packet. The CEO has scheduled a training for the completion of the assessment prior to the assessment packet due date in March of 2017. To be sent by 11/18/2016 for corrective proof: - Due dates listed on google calendar - Training proof provided to managers on completion of assessment packet. 11/18/2016 Implemented
6400.15(c)The self-assessment completed on 9/11/16, did not include a written summary of the corrections made to the recorded violations. 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. A. Who- Program Specialist, CEO, House Managers B. What- A copy of the agency¿s self-assessment results and written summary of corrections made shall be kept by the agency for at least one year. C. When and How- House managers and program specialist will be retrained on the completion of self-assessment packets to ensure proper completion. Training will be provided a month prior to the March 2017 completion of agency self-assessment packets. Managers will keep self-assessment packets in the home and comment on completion of corrections made. To be sent by 11/18/2016 for corrective proof: - Training materials on completion of agency self-assessment packet. 11/18/2016 Implemented
6400.80(b)The dryer vent on the outside of the front of the home was full of lint. Lint was observered to be coming out of the vent and in all of the louvers. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.A. Who- House managers, DSPs, Program Specialist, CEO B. What- The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. C. When and How- The dryer vent outside of the home has been cleaned by the complex as of 10/4/2016. The house managers and DSPs will report on the conditions of the outside of the home on daily crossovers and report any issues to the maintenance department within the complex to have the issue addressed. House managers will report any necessary information to the executive in regards to repairs or upkeep of the outside of the home through submission of daily crossovers when applicable. To be sent over by 11/18/2016 for corrective proof: - Crossovers including the status of the outside of the home. - Pictures of cleaned vent. 11/18/2016 Implemented
SIN-00177765 Renewal 04/05/2021 Compliant - Finalized
SIN-00069372 Renewal 05/14/2014 Compliant - Finalized