Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00211024 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no tape in the first aid kit at the time of the 8/30/22 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. This occurred due to individual having an allergy to tape and adhesive. TLC applied for a waiver for this regulation to ensure that the health and safety of the individual is protected. All other first aid kits have been checked to ensure all contents were present. See attachment: TK Request for ODP Regulatory Waiver Form 09/20/2022 Implemented
SIN-00198467 Renewal 01/03/2022 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; not able to verify if it was completed during the correct time frame.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 by 2/22/22 02/22/2022 Implemented
6400.15(c)The Self-Assessment that was completed identified the following violations: 64a. No written summary of corrections 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 by 2/22/22 02/22/2022 Implemented
SIN-00181491 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 undated, so it is unclear when it was 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. 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
6400.103There are no written emergency evacuation procedures for this home.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Ensure a calm transition and the safety of people in care in an emergency situation Plans used in the past were found to be inadequate There has been an increased rate of staff and leadership turnover Directors will review the regulation and develop an evacation template plan that is sufficient for all residents. The Program Managers and Associate Director of Services will tailor to their specific locations. The Director of Compliance and the Residential Directors will meet semi-annually in June and November to review the evacaution plans for the residences. Any necessary corrections will be completed at that time 03/12/2021 Implemented
SIN-00121441 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The 8/18/16 fire notification letter indicated both individuals residing in the home are ambulatory however, Individual #1 required verbal and physical assistance to evacuate the home. Individual #2 required verbal prompts to evacuate.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. The fire drill letter has been updated to include the following for both individuals ¿This individual is ambulatory, but at any given time may require verbal or physical assistance to evacuate.¿ The fire drill letter was sent to the appropriate fire company. See attachment 104 Prospect. Moving forward all Fire drill letters will include the following ¿ at any given time an individual may require verbal and/or physical assistance to evacuate.¿ The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all Fire Drill Letters include ¿ at any given time an individual may require verbal and/or physical assistance to evacuate.¿ The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. 11/13/2017 Implemented
6400.144REPEATED VIOLATION - 10/26/16. Individual #1's 7/8/16 dental exam had a 6 month recall. Individual #1 did not return to the dentist until 1/30/17. 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 Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all medical and dental appointments are completed on time. The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. The PM assumed that the appointment met state regulation as it was within the 6th month. This PM is no longer employed with TLC. However, the PM overseeing the home currently is aware that appointments must be scheduled based on date, not month. 11/13/2017 Implemented
6400.163(c)REPEATED VIOLATION - 10/26/16. Individual #1's 3/22/17 psychiatric medication review was completed late. The previous review was completed on 12/5/16. The 3/22/17 medication review did not include the reason for prescribing the medications. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Moving forward, it is the responsibility of the Clinical ADOS/PS to ensure all medication review forms are completed accurately and entirely prior to a psychiatric medication review appointment. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all psychiatric medication review are completed on time. The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. 11/20/2017 Implemented
6400.167(b)REPEATED VIOLATION - 10/26/16. Individual #1 was prescribed L-Methylfolate,15mg to be administered by mouth at 8am. Wellspan indicated to discontinue the medication of the current psychiatrist feels it is no longer necessary. Typical Life Corporation did not follow up with the psychiatrist. The medication was discontinued on 3/17/17 without a physician's order to discontinue. The medication was restarted on 4/27/17 without a physician's order to restart the medication. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.An order was obtained from the PCP stating ¿Patient was discontinued from Methylfolate on 3/17/17 and restarted on 4/21/17.¿ See attachment 167(b). Moving forward, it is the responsibility of the Clinical ADOS/PS to follow-up with the psychiatrist in regards to medication management. 11/20/2017 Implemented
6400.181(e)(13)(ii)Individual #1's 1/31/17 assessment did not include progress over the past year in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). 11/09/2017 Implemented
6400.181(e)(13)(v)Individual #1's 1/31/17 assessment did not include progress over the past year in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). 11/09/2017 Implemented
6400.181(e)(13)(vii)Individual #1's 1/31/17 assessment did not include progress over the past year in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). 11/09/2017 Implemented
6400.186(c)(1)REPEATED VIOLATION - 10/26/16. Individual #1's 12/29/16, 3/17/17, 6/28/17, and 9/22/17 Individual Support Plan (ISP) reviews did not include progress on the ISP outcomes of activities and outings and independence.The ISP review must include the following: 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. The Clinical ADOSs were retrained on November 9th, 2017 to utilize specific language as to the individual¿s progress or regression in writing the annual assessment in all areas. See Attachment #213(11). 11/09/2017 Implemented
SIN-00084995 Unannounced Monitoring 09/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1's Lisinopril was discontinued on 6/18/2015 by his PCP. Staff from TLC did not notify the pharmacy of the change in medication. The medication was delivered in July, August, and September to Individual #1's home from the pharmacy. Staff #6 did not contact the pharmacy but destroyed July and August Lisinopril. During the transfer for Individual #1 on 9/18/2015 from TLC to another agency the September doses of Lisinopril were given to individual #1's family as a current medication. No medication documentation was given from TLC to the other agency until 9/22/2015 that listed the current medications and dosages for individual #1. Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.1. A policy was implemented that addresses the proper disposal of medications that have been discontinued. As part of this policy, there will be a record for each program that identifies the name of the medication, the prescription number, and the quantity of the medications being disposed of. This will be a two person system, with one person disposing of the medications, and the other witnessing the disposal. Both will sign the form. The Associate Director of Services that oversees the program will also sign, confirming that the medications are no longer at the program. The staff from the home are also responsible for calling the pharmacy to ensure no more of a discontinued medication is being sent to the program whenever there is a discontinuation. This policy is effective 10/17/2015. 2. Typical Life Corporation requires that monthly monitoring of all homes is completed, and a Medication Audit tool is used. This tool has the auditor check if discontinued medications are disposed of properly. This tool is being updated to ensure no discontinued meds remain in the home. The audit has been completed by staff that work in the home, but will now be completed by Program Managers and they will audit programs other than their own. The form was implemented on 10/14/2015 and managers trained on how to use the updated form. The rotation for medication audits will start 11/1/2015. 3. A policy was implemented regarding the transfer of an individual from Typical Life¿s residential program to another provider or family. This policy will ensure necessary medical information is given to the new provider of services or family at least seven days prior to the date of discharge. On the date of discharge, a discharge summary will be provided. This policy is effective 10/17/2015. 10/22/2015 Implemented
SIN-00241364 Renewal 04/01/2024 Compliant - Finalized
SIN-00068644 Renewal 08/04/2014 Compliant - Finalized
SIN-00068959 Renewal 08/04/2014 Compliant - Finalized
SIN-00066407 Renewal 08/04/2014 Compliant - Finalized