Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00198471 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
SIN-00194830 Unannounced Monitoring 10/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no record of a successful fire drill being conducted in August 2021. An unannounced fire drill shall be held at least once a month. Fire Drill Monitoring and the entry of appropriate post drill information has been reinforced with all Quality Staff to Monitor and with ADOS personnel concerning unoccupied locations. 11/05/2021 Implemented
SIN-00181495 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 8/11/20, 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-00141537 Renewal 11/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual # 1 signed Resident rights form 0n 12/06/16. No documentation of Rights information in 2017.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. It was found that the individuals rights were not completed for the year 2017. The clinical ados for this program did not complete this documentation requirement and an adequate monitoring tool for this was not established. Individual # 1's guardian has signed Resident Rights on 11/28/2018. See Attachment #10. All Clinical ADOS's are responsible to ensure Resident Rights are reviewed and signed annually each January. The signed Residents Rights and signature form will be scanned into AWARDS under the individual's filing cabinet by the ClinIcal ADOS. To monitor and ensure the individual rights are completed annually, training for the clinical ados will occur as part of their new hire orientation. This will also be a part of their management training, referencing the Practice and Guideline, to be completed by the DIrector of Service. The Practice and Guideline will be established to ensure resident's rights are completed per regulations and that resident rights are properly honored The Quality Department will review the individual records as part of pre-licensing to monitor for compliance. The Quality Department will ensure that Resident Rights are reviewed and signed within 3 days following any new admission and each January 20th to ensure completion. Additionally, the records will be randomly reviewed by the Director of Service to monitor for compliance. The Rights signature form will be scanned into AWARDS under the individual's filing cabinet by the ClinIcal ADOS. In addition members of the quality management team will randomly check residences to ensure the residences rights are being honored. This will be part of a quality management initiative modeled upon the MyODP quality training module. Meetings to begin this process will begin on 12/20/2018 and will continue each week. If the Individual's Rights are not completed as per the Practice and Guideline, human resource progressive disciplinary action will be taken, up to and including termination. 01/31/2019 Implemented
6400.31(c)Individual # 1 was not encouraged to exercise his/her rights, including right to privacy in bathroom and bedroom.Each individual shall be encouraged to exercise his rights.The Behavior Support Plan was revised to include privacy in the bathroom and bedroom. This plan was reviewed with the family. The BCBA discussed with the family, the Individual #1's right to privacy in the bathroom and bedroom and the importance of that right for Individual #1. See Attachment #11 Behavior Support Plan. The Director of Services will work the treatment team to compile and complete the biographical timeline for Individual #1. The Board Certified Behavior Analyst will continue to train the program team on ensuring individual #1's rights are complied with as per the regulation. Additionally, the BCBA will continue to work with the guardians to comply with these rights and the importance of promoting the individuals growth and independence. In addition members of the quality management team will randomly check residences to ensure the residences rights are being honored. This will be part of a quality management initiative modeled upon the MyODP quality training module. Meetings to begin this process will begin on 12/20/2018 and will continue each week. If the Individual's Rights are not completed as per the Practice and Guideline, human resource progressive disciplinary action will be taken, up to and including termination. 02/01/2019 Implemented
6400.33(j)Individual # 1's assessment stated that he needs support in registering to vote. Staff (PS) informed that there is no documentation of registering or encouraging Individual # 1 to vote.An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections. It was found that the individual was not be supported in his right to vote. The clinical ados will work with the program team and guardian to ensure rights are adhered to, this will be done in program team meetings and annual recertification of safe crisis management. This will be documented through meeting minutes, training agendas and collateral notes when discussed with the guardian. Additionally, any rights that any individual needs supports for will be documented in the ISP and Assessment with a plan to support that right if needed. When a legal guardian is involved this will be reviewed with the legal guardian. To monitor and ensure the individual rights are completed annually, training for the clinical ados will occur as part of their new hire orientation. ADOS Orientation Checklist. Part of their management training will include training on the Practice and Guideline, to be completed by the Director of Service. The Practice and Guideline will be established to ensure resident's rights are completed per regulations and that resident rights are properly honored. Members of the quality management team will randomly check residences to ensure the residences rights are being honored. This will be part of a quality management initiative modeled upon the MyODP quality training module. Meetings to begin this process will begin on 12/20/2018 and will continue each week. If the Individual's Rights are not completed and rights are not being honored as per the Practice and Guideline, human resource progressive disciplinary action will be taken, up to and including termination. 01/31/2019 Implemented
6400.110(b)Smoke detector by bedroom was not functional during walk through.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. This noncompliance was resolved immediately upon notification of the smoke detector being non functional during the licensing walk through.The smoke detector is checked at a minimum of each month during the fire safety monitoring for the program. At the last monitor, it was working. At this home, the smoke detector is checked routinely as the individual will break the smoke detector on purpose. It is recessed in the ceiling to reduce the destruction but does still occur. This particular home has smoke detectors readily available to them for replacement. This noncompliance was resolved on 11/20/2018. It will also be the responsibility of staff at this particular home to check smoke detectors on a daily basis due to the destructive behavior of the individual that resides within the home. See Attachment 110b. On 12/2018 the Chapter 6400 General Safety and Fire Safety Checklist was revised to ensure proper oversight. The date of the revised safety checklist is indicated on the form. See Attachment #1 Completion of the Chapter 6400 General Safety and Fire Safety Checklist is the responsibility of the Operational ADOS/Program Manager to be completed monthly. This Checklist will be submitted to the Quality Department by the 5th of each month for review of compliance. Members of the quality management team will randomly check residences to ensure the residences are remaining compliant. All Program Managers will be trained in the use of the Chapter 6400 General Safety and Fire Safety Checklist as part of their new employee orientation and also management orientation. A Practice and Guideline will be implemented for reference on how to complete the Chapter 6400 General Safety and Fire Safety Checklist. If at any time a smoke detector is not readily available for replacement the maintenance department will be notified through the Maintenance Request Form. This form is reviewed daily by the maintenance department and prioritized for repair. Once repaired, the maintenance request is closed. The Quality Department will monitor the Maintenance Request Form to ensure any physical site non compliance's are resolved on a timely basis. 01/31/2019 Implemented
6400.141(a)Individual # 1 had physical on 08/23/17 and not again until 10/10/18An individual shall have a physical examination within 12 months prior to admission and annually thereafter. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Additionally, all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. The Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. 01/31/2019 Implemented
6400.141(c)(1)No documentation that Physician reviewed medical history on 10/10/18 physicalThe physical examination shall include: A review of previous medical history. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Additionally all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. The Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. 01/31/2019 Implemented
6400.141(c)(4)Individual # 1 did not receive Vision or Hearing Screening during 10/10/18 physical. "Unable to assess", "Normal by observation" on 08/23/17 physical.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Additionally all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. The Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. 01/31/2019 Implemented
6400.141(c)(14)Information pertinent to diagnosis in case of emergency blank on 10/10/18 physicalThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Additionally all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. The Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. 01/31/2019 Implemented
6400.183(4)ISP Last updated 09/05/18 does not include plans for reduction of intensive staffing supports for targeted behaviorsThe ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: 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. TLC understands that the ISP must include plans for reduction of intensive staffing supports for targeted behaviors. This is critical for the health and well being of people supported. This was an oversight by the Clinical ADOS which has now been resolved.On Thursday December 6th, 2018 individual number #1's ISP was updated to include " reduction of intensive staffing supports for targeted behaviors" Please see attachment #8.This will also be monitored annually during the time the ISP is updated and when there is any change to Behavior Support Plans, Restrictive Plans and critical revisions to the ISP. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally, the Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP's are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. 01/31/2019 Implemented
6400.186(a)ISP reviews not held every three months. Dates of reviews 11/25/17, 03/15/18, 06/05/18, 09/06/18The 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. TLC understands that ensuring the ISP is reviewed at least every three months or more is essential to promote the individuals well being, health and safety. It will be the responsibility of all Clinical ADOS's to ensure the ISP reviews contain required time frames. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the ISP reviews. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP reviews are properly monitored and contain required time frames. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination 01/31/2019 Implemented
6400.186(b)ISP reviews dated 06/05/18 and 03/15/18 are not signed by PS.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. TLC understands that ensuring the ISP Reviews are reviewed and signed upon completion. It will be the responsibility of all Clinical ADOS's to ensure the ISP reviews are reviewed and signed. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally, the Quality Management team will monitor the ISP reviews to ensure they are signed upon completion. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP reviews are properly monitored and contain signatures. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination 01/31/2019 Implemented
6400.195(e)(6)Individual # 1's Restrictive Plan does not include amount of time restrictive procedures may be applied. "If restraint occurs, it should only last as long as necessary and should be ended immediately as soon as Individual # 1 is calm."The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. Proper monitoring and oversight was not provided to ensure content discrepancies do not occur. Individual # 1's Restrictive Plan now includes amount of time restrictive procedures may be applied. The Treatment and Ethics Committee will ensure that this regulation is met during all reviews of Restrictive Plans. See Attachment #7 revised Restrictive Plan It will initially be the responsibility of all Clinical ADOS's to ensure Restrictive Plan's reflect the amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. This will also be monitored during the time The Treatment and Ethics Committee meets to review the Restrictive Plan's. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the Restrictive Plan in the record for content discrepancies. Typical Life has recently hired a behavioral support person who will be part of the Treatment and Ethics Committee to assist with ensuring all regulations are met when creating a Restrictive Plan. The behavioral support person will create a monitor by the end of January 2019 ensuring Restrictive Plans are properly written. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. 01/31/2019 Implemented
6400.217No signed releases contained in record. Ptogram Specialist reported that Parents will sign this afternoon 11/14/18.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Signed releases were completed on 11/21/2018. Release of Information forms will be reviewed and completed each January and July, upon admission and upon any new services being implemented. A Practice and Guideline will be completed outlining this requirement and the expectations and responsibilities of the Clinical ADOS. This will also be part of the ADOS Orientation checklist that all current and future ADOS's will sign off on stating they understand this regulation. This will be completed by the Clinical ADOS and monitored by the Director of Services. See Attachment #6 Signed Releases. Additionally, the Quality Management team will monitor the Release of Information forms. This monitor will be created by the end of January 2019 and will be completed monthly to ensure Release of Information forms are present.This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. 01/31/2019 Implemented
SIN-00137287 Unannounced Monitoring 06/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)An approximate 3-inch corner of missing drywall on the corner of the living room and basement door was observed. An approximate 10-inch hole in the wall in the living room to the right of the television and mantel was observed. Refrigerator door handle was missing.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance request forms were submitted for the following: An approximate 3-inch corner of missing drywall on the corner of the living room and basement door was observed. An approximate 10-inch hole in the wall in the living room to the right of the television and mantel was observed. Refrigerator door handle was missing. All Maintenance requests have been have addressed and all issues/concerns have been fixed. Director of Quality and Associate Director of Quality are performing monthly checklists to ensure all physical site regulations are in compliance. See Attachments #67(a) Pictures 1-4. 07/12/2018 Implemented
SIN-00120454 Unannounced Monitoring 08/24/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(d)Staff # 6 reported in a signed witness statement that staff # 5 would regularly stay outside of the home for 15-20 minutes at a time and would spend ¿more time outside the house than in the house¿. Staff # 5 reported that Staff # 4 hangs out in the 2nd staff bedroom for ¿more than 20-30 minutes and has been caught sleeping on a couple of occasions by myself¿ (08/21/17)An individual has the right to participate in program planning that affects the individual.Resident Rights are reviewed in Initial Training on Day One. See Attachment #33(d) 1. Resident Rights were reviewed with Behavioral Specialist and Chaplain of TLC to ensure they are aware of Individual # 1¿s right to be given the opportunity to decide if he/she wanted a visitor that day and the right to the opportunity to decline a visit from the agency chaplain. See Attachment 33(d) 2. Behavior Specialists and Chaplain have also been informed that all visits must be pre-planned and accepted by the individual. 11/03/2017 Implemented
6400.67(a)The kitchen stove was broken and duct taped (recent incident of property destruction), a hole in the kitchen drywall was patched but unpainted. The kitchen stove was missing (pulled down by individual), a two foot by 16 inch hole was in bedroom wall, Ultra ply premium underlayment was covering bathroom window (broken due to aggression) and the kitchen cabinet under the sink was missing door. Floors, walls, ceilings and other surfaces shall be in good repair. The kitchen stove has been fixed See Attachment Individual #1 67(a) Page 1. a Maintenance request has been submitted for the following: the hole in the kitchen drywall that was patched but unpainted. and for the two foot by 16 inch hole that is in the bedroom wall, Ultra ply premium underlayment was covering bathroom window (broken due to aggression) and the kitchen cabinet under the sink was missing door. See Attachment Individual #1 67(a) Page 2. The 7 inch plaster patch in the living room has been painted See Attachment individual # 2 67(a) Page3. The hole in the entrance stairway has been fixed See Attachment individual # 2 67(a) Page4. Individual #2's dresser has been replaced. See Attachment individual # 2 67(a) Page5. The light fixture has been replaced in the rear egress See Attachment individual # 2 67(a) Page6. The wooden deck has been fixed and repainted. Individual #2 does not have a wooden deck at his home. The picture is of Individual #3¿ wooden deck. See Attachment individual # 2 67(a) Page7. The center light bulb and ceiling lightbulb were replaced in the bathroom See Attachment individual # 2 67(a) Page8 and Page 9. The broken shelves have been removed See Attachment individual # 2 67(a) Page10. A Maintenance request has been submitted for Individual # 3's bedroom door jam that has part of the door chipped.See Attachment individual # 3 67(a) Page11. The bedroom dresser of Individual # 3 has been replaced. See Attachment individual # 3 67(a) Page12. The holes around the the heat/air conditioner controller upstairs in the living area have been filled and repainted. See Attachment individual # 3 67(a) Page13. Individual # 3's bedroom drywall was ripped to right of closet door. This has been repaired See Attachment individual # 3 67(a) Page14. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all physical site components are in compliance in the homes. The pre-licensing checklist will be used as the tool to monitor all 6400 Physical requirements . See attachment ¿Pre-licensing Checklist¿. 11/10/2017 Implemented
6400.67(b)3 electrical outlets in Individual # 1¿s bedroom were missing cover plates. Floors, walls, ceilings and other surfaces shall be free of hazards.Electrical Outlets have been replaced in IndividuaL #1¿s.home.See Attached pictures 67(b)1 and 67(b)2. These electrical outlet covers are made of metal so this should help with Individual #1 nt be able to break them. Additional metal covers have also been purchased to replace covers if they should be broken. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all electrical outlets are not broken in the homes. The pre-licensing checklist will be used as the tool to monitor all 6400 Physical requirements . See attachment ¿Pre-licensing Checklist¿. 11/03/2017 Implemented
6400.185(b)On August 14, 2017 at approximately 1:36 PM, staff # 3 or staff # 4 purchased a glass cylinder from ¿Puff N Snuff¿ store in Lancaster while on a ¿drive¿ with Individual #1. Individual #1's ISP requires 2 staff line of sight supervision while in the community. Individual #1 does not smoke.The ISP shall be implemented as written.An Investigation #8345961 was conducted on 8/22/2017 for Individual #1. The Investigation was Confirmed and staff # 3 and staff # 4 have been terminated as a result of the findings of the Investigation. See Attachment #8345961. Anytime an allegation of neglect, abuse, mistreatment or corporal punishment is suspected an Investigation will be conducted. Knives were removed from kitchen and placed in a secure area. An email was sent on 10/16/2017 with the changes which reflect that knIves no longer need to be locked. The ISP has been corrected and reflects the change that knives do not need to be locked for Individual #3. See attachment 185(b) Page 1 and Page 2 ISP for Individual #3 10/31/2017 Implemented
6400.195(e)(6)Individual # 1¿s Restrictive Procedure plan does not specify time that the Restrictive Procedure of manual restraint may be applied. Maximum time for manual restraint is not to exceed 30 minutes within any 2 hour time period. Individual # 1¿s RPP identifies length as ¿as long as necessary¿. The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. The Treatment and Ethics Committee now includes all Directors, Medical Director and Director of Outpatient during review of Restrictive Plans.This will help ensure all RPP¿s are in compliance. The Treatment and Ethics Committee is now using the ¿Treatment and Ethics Review Checklist¿ to ensure compliance with 6400 Regulations. See attachment 195(e)(6). Individual#1¿s RPP is scheduled to be reviewed at the next Ethics and Treatment Committee Meeting that is scheduled for November 7, 2017. During reviewal ¿ Maximum time for manual restraint is not to exceed 30 minutes within any 2 hour time period¿ will be reflected in the RPP. All Staff will be retrained in Individual #1¿s RPP. 11/07/2017 Implemented
6400.195(f)On 08/18/17, Individual # 1 received a single person restraint by staff # 7. RPP requires use of two person restraint only. The restrictive procedure plan shall be implemented as written. Individual#1¿s RPP is scheduled to be reviewed at the next Ethics and Treatment Committee Meeting that is scheduled for November 7, 2017. All Staff will be retrained in Individual #1¿s RPP. RPP will revised during the Treatment and Ethics Committee Meeting to include one person and two person restraints. 11/07/2017 Implemented
6400.213(2)¿ Individual # 1 was restrained on 09=8/09/17 and 08/11/17. These restraints were not recorded in HCSIS. Each individual's record must include the following information: Unusual incident reports relating to the individual. Staff at Individual #1¿s home will be in Incident Management and reporting requirements by 11/30/2017. All staff are trained in Incident Management upon hire and annually thereafter. Additionally all TLC Staff will complete an ODP Incident Management Course by December 31, 2017. Restraints from 8/9/2017 and 8/11/2017 have been entered into HCSIS. 12/31/2017 Implemented
SIN-00123153 Unannounced Monitoring 08/24/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(g)Staff # 6 & 7 used Individual # 2¿s personal funds to purchase lunch on 07/25/17. There may be no borrowing of the individual's personal funds by staff persons or by the home.An Investigation #8336196 was conducted on 7/25/2017 for Individual #2. The Investigation was Confirmed and Targets SD0977 staff #6 and RE1024 staff #7 have been suspended upon notification of the misuse of funds allegation. All money has been returned to Individual #2¿s.Individual #2 has continued with his daily activities as usual. See Attachment #8326196. All receipts are reviewed by the fiscal department when turned in. Any time a misuse of funds is suspected CFO-Vicki Miller will notify Director of Quality to initiate an Investigation. 09/25/2017 Implemented
6400.33(a)Staff # 5 reported in a signed witness statement that staff # 4 would regularly stay outside of the home for 15-20 minutes at a time and would spend "more time outside the house than in the house". Staff # 4 reported in a signed witness statement that Staff # 3 hangs out in the 2nd staff bedroom for "more than 20-30 minutes and has been caught sleeping on a couple of occasions by myself" (08/21/17)An individual may not be neglected, abused, mistreated or subjected to corporal punishment. An Investigation #8345961 was conducted on 8/22/2017 for Individual #1. The Investigation was Confirmed and staff # 3 and staff # 4 have been terminated as a result of the findings of the Investigation. See Attachment #8345961. Anytime an allegation of neglect, abuse, mistreatment or corporal punishment is suspected an Investigation will be conducted. 08/22/2017 Implemented
6400.33(d)On 08/01/17 Behavior Specialist visited the home unplanned causing Individual # 1 to become anxious. Individual # 1 was not given the opportunity to decide if he/she wanted a visitor that day. Individual # 1 was restrained by staff who identified triggers as someone else in the home and wanting his/her T-Shirt right then. On 08/09/17, Individual # 1 was not provided the opportunity to decline a visit from the agency chaplain. An individual has the right to participate in program planning that affects the individual.Resident Rights are reviewed in Initial Training on Day One. See Attachment #33(d) 1. Resident Rights were reviewed with Behavioral Specialist and Chaplain of TLC to ensure they are aware of Individual # 1¿s right to be given the opportunity to decide if he/she wanted a visitor that day and the right to the opportunity to decline a visit from the agency chaplain. See Attachment 33(d) 2. Behavior Specialists and Chaplain have also been informed that all visits must be pre-planned and accepted by the individual. 11/03/2017 Implemented
6400.67(a)At Individual # 1's home, The kitchen stove was broken and duct taped (recent incident of property destruction), a hole in the kitchen drywall was patched but unpainted. The kitchen stove was missing (pulled down by individual), a two foot by 16 inch hole was in bedroom wall, Ultra ply premium underlayment was covering bathroom window (broken due to aggression) and the kitchen cabinet under the sink was missing door. At individual # 2's home, a 7 inch plaster patch in the living room was unpainted. A hole approximately 3 inches wide was located in the entrance stairway. Individual #2's bottom dresser drawer was broken, and a light bulb in the rear egress under the deck was not working. The wood deck was splintering. At individual # 2's home, the center light bulb and ceiling lightbulb were not working in bathroom, the bookshelf shelves were broken in room by individual # 2's bedroom. At individual # 3's home, the wood on the deck attached to the kitchen had paint chipping. Individual # 3's bedroom door jam had part of the door chipped. Individual # 3's bedroom drywall was ripped to right of closet door. The bedroom dresser of Individual # 3 had piece torn off of the bottom right drawer. The heat/air conditioner controller upstairs in the living area did not have a cover but was taken off. Floors, walls, ceilings and other surfaces shall be in good repair. The kitchen stove has been fixed See Attachment Individual #1 67(a) Page 1. a Maintenance request has been submitted for the following: the hole in the kitchen drywall that was patched but unpainted. and for the two foot by 16 inch hole that is in the bedroom wall, Ultra ply premium underlayment was covering bathroom window (broken due to aggression) and the kitchen cabinet under the sink was missing door. See Attachment Individual #1 67(a) Page 2. The 7 inch plaster patch in the living room has been painted See Attachment individual # 2 67(a) Page3. The hole in the entrance stairway has been fixed See Attachment individual # 2 67(a) Page4. Individual #2's dresser has been replaced. See Attachment individual # 2 67(a) Page5. The light fixture has been replaced in the rear egress See Attachment individual # 2 67(a) Page6. The wooden deck has been fixed and repainted. Individual #2 does not have a wooden deck at his home. The picture is of Individual #3¿ wooden deck. See Attachment individual # 2 67(a) Page7. The center light bulb and ceiling lightbulb were replaced in the bathroom See Attachment individual # 2 67(a) Page8 and Page 9. The broken shelves have been removed See Attachment individual # 2 67(a) Page10. A Maintenance request has been submitted for Individual # 3's bedroom door jam that has part of the door chipped.See Attachment individual # 3 67(a) Page11. The bedroom dresser of Individual # 3 has been replaced. See Attachment individual # 3 67(a) Page12. The holes around the the heat/air conditioner controller upstairs in the living area have been filled and repainted. See Attachment individual # 3 67(a) Page13. Individual # 3's bedroom drywall was ripped to right of closet door. This has been repaired See Attachment individual # 3 67(a) Page14. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all physical site components are in compliance in the homes. The pre-licensing checklist will be used as the tool to monitor all 6400 Physical requirements . See attachment ¿Pre-licensing Checklist¿ 11/10/2017 Implemented
6400.67(b)3 electrical outlets in Individual #1's bedroom were missing cover plates. Floors, walls, ceilings and other surfaces shall be free of hazards.Electrical Outlets have been replaced in IndividuaL #1¿s.home.See Attached pictures 67(b)1 and 67(b)2. These electrical outlet covers are made of metal so this should help with Individual #1 nt be able to break them. Additional metal covers have also been purchased to replace covers if they should be broken. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all electrical outlets are not broken in the homes. The pre-licensing checklist will be used as the tool to monitor all 6400 Physical requirements . See attachment ¿Pre-licensing Checklist¿. 11/03/2017 Implemented
6400.74At individual # 2's home, the fourth step up from the basement stairs had non-skid mat that was not secured and mat falls off the stairs. Interior stairs and outside steps shall have a nonskid surface. A Maintenance Request was submitted on 11/1/2017 to have non-skid mats replaced at Individual #2¿s home.Completion date was also 11/1/2017. See attachment #74. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure all Interior stairs and outside steps shall have a nonskid surface etc are in the homes. The pre-licensing checklist will be used as the tool to monitor all 6400 Physical requirements . See attachment ¿Pre-licensing Checklist¿. 11/01/2017 Implemented
6400.82(f)Individual # 2's bathroom did not have clean paper or cloth towels.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. Paper towels were placed in the bathroom as soon as it was noticed. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure paper towels, toilet paper etc are in the homes. The pre-licensing checklist will be used as the tool to monitor all 6400 Physical requirements . See attachment ¿Pre-licensing Checklist¿. 10/31/2017 Implemented
6400.101A deadbolt on the garage door of Individual # 3's home did not have a key permanently affixed to the door. At Individual # 2's home, a deadbolt in front door, rear garage door and rear door egress to garage did not have keys permanently affixed to door. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Deadbolts have been removed from Individual #3¿s home. See attachment 101 ISP for Individual #3 under the Know and Do Section paragraph number 4.An email was sent to the SC on 9/22/2017 to have dead bolts removed from Individual #3. See email dated 9/22/2017 with attached addendum. ISP has been updated to reflect all needed addendums. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure deadbolts in all individuals homes have the the key affixed to the door.. The pre-licensing checklist will be used as the tool to monitor the records. See attachment ¿Pre-licensing Checklist¿. 09/25/2017 Implemented
6400.185(b)On August 14, 2017 at approximately 1:36 PM, staff # 3 or staff # 4 purchased a glass cylinder from "Puff N Snuff" store in Lancaster while on a drive with Individual #1. Individual # 1's ISP requires 2 staff line of sight supervision while in the community. Individual # 1 does not smoke.Knives were found unlocked on the kitchen counter of Individual #3's home. Individual Support Plan dated 03/06/17 indicated that individual #3 is not safe around sharp objects. The ISP shall be implemented as written.An Investigation #8345961 was conducted on 8/22/2017 for Individual #1. The Investigation was Confirmed and staff # 3 and staff # 4 have been terminated as a result of the findings of the Investigation. See Attachment #8345961. Anytime an allegation of neglect, abuse, mistreatment or corporal punishment is suspected an Investigation will be conducted. Knives were removed from kitchen and placed in a secure area. An email was sent on 10/16/2017 with the changes which reflect that knives no longer need to be locked. The ISP has been corrected and reflects the change that knives do not need to be locked for Individual #3. See attachment 185(b) Page 1 and Page 2 ISP for Individual #3 10/31/2017 Implemented
6400.195(e)(6)Individual # 1's Restrictive Procedure Plan, RPP, does not specify time that the Restrictive Procedure of manual restraint may be applied. Maximum time for manual restraint is not to exceed 30 minutes within any 2 hour time period. Individual # 1's RPP identifies length as "as long as necessary".The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. The Treatment and Ethics Committee now includes all Directors, Medical Director and Director of Outpatient during review of Restrictive Plans.This will help ensure all RPP¿s are in compliance. The Treatment and Ethics Committee is now using the ¿Treatment and Ethics Review Checklist¿ to ensure compliance with 6400 Regulations. See attachment 195(e)(6). Individual#1¿s RPP is scheduled to be reviewed at the next Ethics and Treatment Committee Meeting that is scheduled for November 7, 2017. During reviewal ¿ Maximum time for manual restraint is not to exceed 30 minutes within any 2 hour time period¿ will be reflected in the RPP. All Staff will be retrained in Individual #1¿s RPP 11/07/2017 Implemented
6400.195(f)On 08/18/17, Individual # 1 received a single person restraint by staff # 7. RPP requires use of two person restraint only. The restrictive procedure plan shall be implemented as written. Individual#1¿s RPP is scheduled to be reviewed at the next Ethics and Treatment Committee Meeting that is scheduled for November 7, 2017. All Staff will be retrained in Individual #1¿s RPP. RPP will revised during the Treatment and Ethics Committee Meeting to include one person and two person restraints 11/07/2017 Implemented
6400.213(2)Individual # 1 was restrained on 08/09/17 and 08/11/17. These restraints were not recorded in HCSIS. Each individual's record must include the following information: Unusual incident reports relating to the individual. Staff at Individual #1¿s home will be in Incident Management and reporting requirements by 11/30/2017. All staff are trained in Incident Management upon hire and annually thereafter. Additionally all TLC Staff will complete an ODP Incident Management Course by December 31, 2017. Restraints from 8/9/2017 and 8/11/2017 have been entered into HCSIS. 12/31/2017 Implemented
6400.213(9)Individual # 3 did not have a copy of the current ISP in the home record. Each individual's record must include the following information: A copy of the current ISP. We have requested changes for Individual # 3¿s ISP to reflect updates. This email was sent to the SC on 10/16/2017.See attachment email Pages 1-8. Plan was approved on 10/31/2017. See email from Renee Lavetan dated 10/31/2017. TLC has been working with the County to ensure all ISP¿s reflect current updates. Clinical ADOS¿s will be responsible to ensure all individuals ISP are current and correct.. TLC met with the County on 9/28/2017 to discuss needed updates and plan for ongoing collaboration to ensure all ISP¿S are current and correct. The Director of Quality and Assistant Director of Quality will be doing monthly monitorings on each home to ensure current Isp¿s are in the records. The pre-licensing checklist will be used as the tool to monitor the records. See Attachment Pre-licensing Checklist. 10/31/2017 Implemented
6400.213(11)July progress notes for Individual # 2 do not clearly state supervision needs. In communication area, it states TLC will provide 2:1 supportive habilitation staffing from 8 am-9pm 7 days/week. In the health and safety section it states that TLC will provide 2:1 supportive habilitation staffing from 7 am to 3pm M-Fr. TLC will provide 1:1 staffing from 3pm-11pm M-Fri and 8 hours on Saturday and Sunday. Independence outcome states 2:1 supportive habilitation staff from 7 AM-11 PM M-Fri and 7 AM-3 PM Saturday and Sunday. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Progress notes for individual #2 now clearly state individual¿s supervision needs. These supervision needs match for all 4 outcomes. See attachment 213(11)a. On 11/1/17 an addendum to individual #2 ISP was sent to Support Coordinator indicating further changes to supervision. See email attachment 213(11)b. 11/01/2017 Implemented
SIN-00241368 Renewal 04/01/2024 Compliant - Finalized
SIN-00224417 Renewal 05/22/2023 Compliant - Finalized
SIN-00086422 Renewal 10/20/2015 Compliant - Finalized