Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00211023 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)(Repeated violation -- 6/21/22) Beginning 4/1/22 to present, individual #1's SNAP benefit logs are not kept current and up to date.(2) Disbursements made to or for the individual. This occurred due to staff not following the procedure for SNAP benefit balance recording. This will be retrained on by the program manager when she returns the week of 09/19/2022 during the house meeting. SNAP benefit balance sheets will be reviewed for other homes prior to 10/1/2022 to ensure that balance sheets are accurate and kept current. 10/01/2022 Implemented
6400.141(c)(14)(Repeated violation -- 6/21/22 and 1/4/22) The information pertinent to diagnosis or treatment in case of an emergency section on individual #1's physical examination completed on 3/30/22 is blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. This was determined to be missing when the self-assessments were completed. The staff reached out to the provider, however, it was advised that the original form not be altered because the physician was not going to sign again. There has been a new Annual Physical Form that created that has all of the necessary regulatory requirements present and the program specialist can prefill the information in and review it with the physician prior to the physician signing off on that section of the annual exam. Other physical exams were already checked in the month of August and physicians were reached out to. Amendments were made to physicals where documentation was received from the physician. 09/25/2022 Implemented
6400.141(c)(15)(Repeated Violation -- 1/4/22) The diet section on individual #1's physical examination completed on 3/30/22 is blank.The physical examination shall include:Special instructions for the individual's diet. This was determined to be missing when the self-assessments were completed. The staff reached out to the provider, however, it was advised that the original form not be altered because the physician was not going to sign again. There has been a new Annual Physical Form that created that has all of the necessary regulatory requirements present and the program specialist can prefill the information in and review it with the physician prior to the physician signing off on that section of the annual exam. Other physical exams were already checked in the month of August and physicians were reached out to. Amendments were made to physicals where documentation was received from the physician. 09/25/2022 Implemented
6400.144(Repeated Violation -- 6/21/22 and 1/4/22) · Individual #1's physical completed on 3/30/22 states that they should drink 80-90 ounces of fluid daily. In reviewing individual #1's fluid intake charts from April 2022 to current, individual #1 has not been offered or consuming the recommended amount of fluids. · On 5/9/22, individual #1's podiatrist states to continue using Ketoconazole cream and antifungal cream on their toe nails. In reviewing May 2022 to present Medication Administration records, these medications were not administered. · Individual #1 was seen by the neurologist on 7/13/21 and was to be seen for a follow-up appointment in six months. During this inspection, Typical Life Corporation was not able to produce verification that this appointment was scheduled or offered to Individual #1. · Individual #1 was prescribed Remedy No-rinse cleanser to use as needed for appropriate cleansing after bowel movements on 6/17/2021. During this inspection, this medication was not available in the home. · During this inspection, a prescription for Glycerin Pediatric suppository to be used as needed for constipation was available in the home. Typical Life Corporation is unsure as to when this prescription is to be used as individual #1 has a standing order for constipation that doesn't include this medication. · Individual #1's bowel protocol, implemented on 8/4/22, states to give 1 capful daily of Miralax at 8am, hold for 2 days if experiences diarrhea, if no BM for 2 days give an additional nightly dose at 8pm until BM is achieved. Individual #1's bowel movement chart for August 2022 indicates that they should've received Miralax at 8pm on the following dates but did not: 8/8/22, 8/9/22, 8/10/22, 8/13/22, 8/14/22, 8/17/22, 8/18/22, 8/21/22, 8/24/22, and 8/25/22.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. The program specialist has made all necessary appointments and has reached out to the physician to confirm medication orders. The protocols have all been updated to reflect these changes. Quality is continuing to review provider appointment forms to ensure that all necessary follow up appointments have been made. Quality will ensure that program specialists are made aware of appointments that need to be scheduled by 10/1/2022. See attachments: Martin Foot&Ankle - TC 2022 05 09; Martin Foot&Ankle - TC 2022 08 24; MyWellSpan - TC - Suppository; TC Protocols 10/01/2022 Implemented
6400.34(b)(Repeated Violation -- 1/4/22) The individual rights reviewed with individual #1 on 5/25/22 were not reviewed with individual #1's legal guardian.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.TLC is currently updating all POC and guardianship paperwork to ensure that all appointed guardians have the individual's rights reviewed with them and will have an Individual Rights form completed. The goal is to have all guardianship paperwork received by 10/10/2022 to ensure that the rights of the individuals are reviewed with the guardian by 10/15/2022. 10/15/2022 Implemented
6400.186(Repeated violation -- 6/21/22) Individual #1's ISP dated 8/10/22 states that individual #1 uses a long-handled loofah to assist with bowel movement hygiene. During this inspection, this device was not available in the home.The home shall implement the individual plan, including revisions.This occurred due to the staff throwing the loofa out during the physical site checklist and the Amazon delivery being later than expected. TLC has ordered TC several of the long-handled loofas to ensure that there is a spare at all times. The program specialist with be training the staff by 09/25/2022 on TC protocol and to ensure they are aware to always keep at least one extra at the house at all times. Program specialists are reviewing the ISP to ensure that the plan is being implemented as stated and if any changes are necessary, they will reach out to the SC by 10/1/2022 to make the changes in the ISP. 10/01/2022 Implemented
SIN-00198458 Renewal 01/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)(Repeat from inspection dated 1/11/21) The self-assessment that was completed was not dated. There is no way to verify the self-assessment was completed within the correct timeframe.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. This occurred due to Self-Assessments not being collected and reviewed for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly. Quality department will monitor for completion.Staff will be trained on how to complete the Self-Assessment form thoroughly on 2/22/22. 02/22/2022 Implemented
6400.15(c)The self-assessment that was completed identified the following violations: 19a3, 25a, 25b, 67a, 76a, and 141c6. No written plan of correction was completed.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. This occurred due to Self-Assessments not being collected and reviewed for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly. Quality department will monitor for completion.Staff will be trained on how to complete the Self-Assessment form thoroughly on 2/22/22. 02/22/2022 Implemented
6400.67(b)At the time of the inspection, there was a golf ball size amount of lint in the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.Lint was removed from the dryer immediately.· This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022. We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). 02/22/2022 Implemented
6400.82(f)At the time of the inspection, there was no soap at the bathroom sink.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Non-toxic, has been placed in the bathroom; ISP has been updated. This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022. We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). 02/22/2022 Implemented
6400.103(Repeat from inspection dated 1/11/21)-The written evacuation procedure does not include a specific location to be used as an emergency shelter in the even the home becomes inhabitable. The written plan speaks to locations as "nearest hotel," "with relative," "local hotel," "another TLC employee home," "another TLC home," but does not identify the specific location to be used.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. This occurred due to TLC using a standardized AWARDS form which was not individualized. Director of Services has developed a new written evacuation procedure based on the 6400.103 regulation. ATTACHMENT. Staff will be trained on the updated procedures from 02/16/2022-02/22/2022. 02/22/2022 Implemented
6400.104(Repeat from Inspection dated 1/11/21)-The home has not notified the local fire department of the individual's assistance needed to evacuate the home during fire drills and the location of their bedroom.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. This happened because moves were not being monitored or followed up with. This has also occurred due to a lack of training on regulations, and lack of accountability. All new fire letters are being sent out after all moves are finalized. Director of Residential will have Program Specialists send out Fire Letters for all homes to reflect current individuals in the homes, the layouts, and locations of the individuals by 2/15/22. 02/22/2022 Not Implemented
6400.112(a)(Repeat from inspections dated: 1/11/21, 5/10/21, and 10/12/21)-The home did not conduct a fire drill in August 2021. An unannounced fire drill shall be held at least once a month. This occurred due to TLC currently has a form on SharePoint that staff complete following a fire drill. Quality department will utilize the Fire Drill Log form which was updated on 1/20/2022 to determine which homes have not completed fire drills. Quality department will send email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained no later then 2/22/22. 02/28/2022 Implemented
SIN-00181482 Renewal 01/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)REPEAT VIOLATION FROM 12/10/19: The self-assessment for this home is dated 8/6/20, which is outside of the required time frame. The self-assessment is also incomplete.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 is necessary to understand any deficiencies within a residence, be able to correct them in a timely manner, identify safety hazards for the supported people and provide guidance to the staff in areas necessary for regulatory compliance. Violations occurred because the self assessments were not completed nor submitted within the allowed 3-6 month window before license expiration A lack of complete understanding by new staff, including ADOS, Directors and Quality about when the 3-6 month window opens and closes for submittal of the document Within the months of February and March each ADOS, Directors of Residential Services, Quality Staff, including the Director of Compliance, the Quality Coordinator and Quality Assistant will receive trainiing in the completion of the self assessments. In addition, the Program Managers will participate in the trainings. A training log of participants will be kept and maintained by the Quality Department. 1. TLC commits to one timely self assessment in each calendar year. The self assessment will be done in May beginning in 2021 and will continue in 2022 and each succeeding year 2. The May self assessment will be submitted for each location in accordance with the regulation. 3. The Quality Department, specifically the Quality Assistant will maintain a paper copy as well as a folder in Sharepoint where each assessment will be electronically filed in a folder titled Self Assessments-Residential. 4. Each Service Area's ADOS staff will review within 4 weeks with the Director of Compliance, Quality Coordinator, Quality Assistant and appropriate Director of Services. 5. The assessment identification of deficiencies will be used to develop an in-house correction plan. 6. The Quality Coordinator and Quality Assistant will monitor the correction plan, report to the monthly quality meeting the status of the POCs and the Compliance Director will report at a quarterly meeting in of the Directors in writing the data/finidings regarding compliance with this POC and the status of each location's assessment. 7. All assessments will be reviewed and completed with Plans of Correction by June 20th. 8. All new leadership staff will complete a training during their orientation on self assessments and their importance to each location within the company. 03/05/2021 Implemented
SIN-00167413 Renewal 12/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no self-assessment completed for the home. Even though there was no one living in the home until August 2019, this home was considered open and a self-assessment needed to be completed.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. Director of Quality was informed by License Representative, during the Residential Licensing process, that all homes even if unoccupied must have an annual self assessment completed. Director of Quality will ensure all homes even if unoccupied will have an annual self assessment performed. Director of Quality will ensure that the Quality team is trained on this citation by January 15, 2020. It will be the responsibility of the Director of Quality to ensure all homes, even if unoccupied are on the Prelicensing self assessment list. See Attachment 15(a) 01/15/2020 Implemented
6400.113(a)Individual #1 moved into the home on 8/22/19 but did not have fire safety training until 8/26/19. 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. Performed the fire drill late in the process, but before the state inspection. The Program Manager received staff disciplinary action for their failure to follow procedures. Program Manager was educated of the importance of this fire safety process. See Attachment #113(a) Page 1 .When a new admission to a home occurs, the fire safety training and fire drill will be completed within 2 hours upon moving into the home. The signed training form and fire drill will be sent to the Program Manager and Associate Director of Services within an hour after the fire drill and fire safety training is completed.The ADOS will then submit the fire drill and fire safety training to the Residential Director of Services within the next hour. A Practice and Guideline will be created/implemented to ensure all ADOS', Program Managers, and Direct Service Professionals are trained on this procedure. See Attachment 113(a) Practice and Guideline and Training Log. 04/01/2020 Implemented
SIN-00121432 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a strong urine odor in the basement.Clean and sanitary conditions shall be maintained in the home. A new laundry basket was purchased to keep soiled linens enclosed while the washing and drying machine are already in use. See picture of laundry baskey. A chore chart has also been implemented at the residence to ensure laundry is completed on a routine basis. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all homes are clean and sanitary. The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. 11/21/2017 Implemented
SIN-00241355 Renewal 04/01/2024 Compliant - Finalized
SIN-00068643 Renewal 08/04/2014 Compliant - Finalized
SIN-00068956 Renewal 08/04/2014 Compliant - Finalized
SIN-00066405 Renewal 08/04/2014 Compliant - Finalized