Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221550 Renewal 03/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light at the back door was not operable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to having proper lighting. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents, by 04/01/2023. 05/03/2023 Implemented
6400.82(f)There was no hand towel in the bathroom.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. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. What will be corrected: Make sure are sites are on clean and sanitary conditions especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal, As of 04/01/2023. 05/01/2023 Implemented
6400.112(e)The most recent overnight fire drill occurred on 6/22/22 at 4:00am. Greater than 6 months have elapsed since then with no sleeping fire drill having been conducted.A fire drill shall be held during sleeping hours at least every 6 months. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 05/01/2023 05/01/2023 Implemented
SIN-00156857 Renewal 06/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)The initial fire safety training for individual #4 was not completed upon admission on 7/12/2018. The most recent fire safety training documented was completed in March 2019 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. Plan to fix the immediate problem: Compliance manager will create an initial fire safety training for new participants and retrain current participant to ensure, they are aware of fire safety protocol, exit, and meeting location. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will place created form in the intake packet to ensure all new participants are 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. What will be corrected: The creation of a form that signify all new participants were 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 When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will place created form in the intake packet to ensure all new participants are 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. - House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Compliance manager will create an initial fire safety training for new participants and retrain current participant to ensure, they are aware of fire safety protocol, exit, and meeting location, by 06/06/2019 -C.E. O will oversee that compliance Manger via a monthly meeting to ensure walk throughs are being done and to ensure Compliance manager will create an initial fire safety training for new participants and retrain current participant to ensure, they are aware of fire safety protocol, exit, and meeting location. Meetings will continue and will meet monthly before or around the 5th of the month, starting July of 2019. A plan to prevent future occurrence: C.E.O will continue to meet with Compliance Manager monthly. 07/15/2019 Implemented
6400.181(a)The Assessment for individual #4 was not completed within 60 days of admission. The Date of admission was 7/12/18 and the assessment was not completed until 10/12/18 Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Plan to fix the immediate problem: Program specialist will review all individuals' assessment to make sure the initial assessment was written in 60 days after arrival. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals' assessment to make sure the initial assessment will be written in 60 days after arrival for any new participant and annual thereafter. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure the initial assessment will be written in 60 days after arrival for any new participant and annual thereafter. When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that the initial assessment will be written in 60 days after arrival for any new participant and annual thereafter. . -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 08/01/2019 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 08/05/2019 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 08/01/2019 Implemented
6400.181(e)(1)Individual #4's assessment completed on 10/12/18 did not contain the individual's Strengths or needs. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Plan to fix the immediate problem: Program specialist will review all individuals' assessment to make sure that progress and growth in the area of functional strengths, needs and preferences of the individual. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals' assessment to make sure that they were written progress and growth in the area of functional strengths, needs and preferences of the individual, in current assessments and make sure all progress and growth in the area of functional strengths, needs and preferences of the individual. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of functional strengths, needs and preferences of the individual. When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of functional strengths, needs and preferences of the individual. -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 08/01/2019 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 08/05/2019 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 08/01/2019 Implemented
SIN-00131530 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(c)There was no record of the CEO having twenty four hours of training. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Plan to fix the immediate problem: Program specialist will send out a written request to ensure service address is accurate in the person being served ISP. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review the ISP in detail upon receipt to verify the service address is correct. Program specialist will send out a written request to ensure service address is accurate in the person being served ISP. What will be corrected: Program specialist will send out a written request to ensure service address is accurate in the person being served ISP. When and How: Program Specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will review the ISP in detail upon receipt to verify the service address is correct. Program specialist will send out a written request to ensure service address is accurate in the person being served to SC or plan lead, as applicable, and plan team member when address in not current. -A written request will be made - Program specialist will review the ISP in detail upon receipt to verify the service address is correct. Program specialist will send out a written request to ensure service address is accurate in the person being served ISP, by 04/04/2018 -C.E.O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2018 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. Implemented
6400.67(b)At some point the dryer hose leading away from the unit had broken. At the time of inspection it was found to be disconnected and a large build up of dryer lint was found in back of the unit, up the back of the dryer and on the wall. The following day it was re-inspected and found to be fixed and fully operational. Floors, walls, ceilings and other surfaces shall be free of hazards.Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.112(d)There were two dates that the evacuation time exceeded the two and half minute window. Once on 1/2/18 it took 2.36 minutes and again on 6/28/17 it took 10 minutes.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 employee 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.Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
SIN-00113348 Renewal 04/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)There was a thick layer of lint in the lint trap of the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. The program specialist will ensure that replacement items are purchased and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. Meetings will continue monthly and we will meet before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.81(k)(6)Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as mirrors are on all individuals walls in their rooms, the broke items will be removed or replaced correctly. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as mirrors are on all individuals walls in their rooms. The broke items will be removed or replaced correctly. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: no mirrors were found in one individual room. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as mirrors are on all individuals walls in their rooms. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as mirrors are on all individuals walls in their rooms. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as mirrors are on all individuals walls in their rooms, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done, to ensure items such as mirrors are on all individuals walls in their rooms. Meetings will continue on a monthly basis and we will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.141(c)(10) Individual #1's physical examination dated 2/20/17 did not list communicable disease precautions. The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Individual #1's physical examination dated 2/20/17 did not list communicable disease precautions. Plan to fix the immediate problem: Staff will review all Individuals files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will review all individual¿s files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations. In order for individual to get the services they or may not require. What will be corrected: Staff will review all Individuals files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Staff will review all Individuals files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations. - No Documentation that they are free of communicable disease on yearly physical - Staff will review all Individuals files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations, by 07/03/2017. -C.E. O will oversee staff¿s practices via a monthly meeting to review paperwork of all Individuals files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations. Meetings will continue monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with staff monthly to review all Individuals files and to ensure all individuals have proper documentation that they are free of communicable disease when they have their yearly physical and as needed in accordance to the 6400 regulations. 07/03/2017 Implemented
6400.141(c)(14) Individual #1's physical examination dated 2/20/17 did not list information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's physical examination dated 2/20/17 did not list information pertinent to diagnosis in case of an emergency. Plan to fix the immediate problem: staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will review all individual¿s files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. In order for individual to get the services they or may not require. What will be corrected: Staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. - No Documentation that lists information pertinent to diagnosis in case of an emergency on yearly physical - Staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations, by 07/03/2017. -C.E. O will oversee staff¿s practices via a monthly meeting to review paperwork of all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. Meetings will continue monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with staff monthly to review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. 07/03/2017 Implemented
6400.144Individual #1's medication log and medication label for prescription Lithium Carbonate ER 450mg did not match. The label read 1 tablet 3 times per day, and the MAR read 1 tablet in the am. 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. Individual #1's medication log and medication label for prescription Lithium Carbonate ER 450mg did not match. The label read 1 tablet 3 times per day, and the MAR read 1 tablet in the am. Plan to fix the immediate problem: Staff will make sure all individuals have medication logs that match the labels after doctor visit. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit, while adhering to 6400 regulations. What will be corrected: Staff will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on calling the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit. - Medication logs had a medication that didn¿t match the labels after doctor visit. - Program specialist will be retraining all staff on individual service plans, focusing on calling the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit, by 07/03/2017. -C.E. O will oversee Program specialist to make sure they are making sure the medication logs are matching the labels. C.E.O will continue to meetings will be continued and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program Specialist monthly and review all training to ensure all employees remain trained on individual service plans, focusing on an individual's medication logs a making sure the medication that matches the labels after doctor visit. 07/03/2017 Implemented
6400.213(1)(i)Individual #1's record did not list identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1's record did not list identifying marks. Plan to fix the immediate problem: Program specialist will go to all the sites and would review the individuals records to ensure that all intake paper is filled out correctly. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will go to all the sites and would review the individuals records to ensure that all intake paper is filled out correctly, after each new intake. Any current residence who have missing information will have the information put in and dated for the date the noncompliance was discovered. What will be corrected: Individual¿s record did not list identifying marks. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly. - Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure Program specialist will walk through the site after new intake is admitted to ensure all paper has been filled out correctly. Meetings will be continued and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
SIN-00110009 Unannounced Monitoring 10/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 10/06/2016, Individual # 1 exhibited aggressive behaviors towards Staff # 1 multiple times in a short amount time. Staff # 1 physically responded to these behaviors by scratching, hitting, choking and forcing Individual # 1 to the floor. Staff # 1 and a neighbor contacted the police and Individual # 1 was transported to the Montgomery County Emergency Services for outpatient treatment by Staff # 2. Staff # 2 yelled at Individual # 1 for aggressing towards staff prior to transporting Individual # 1.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Plan to fix the immediate problem: Amudipes program will relocate, retrain or dismiss staff and continue to support the individual health and safety. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will train all direct care workers in the content of health and safety needs. Program specialist will create a detail training on all aspects of client¿s rights with focus on neglected, abused, mistreated or subjected to corporal punishment. Program Specialist will train staff on our mission of following the sanctuary program model of being a strictly hands-off program and the used of ONLY behavioral plan, verbal de-escalation and to call the local authorities to protect the health, welfare and safety of everyone in the program. CEO will ensure that all trainings are completed by all staff members. What will be corrected: Amudipes program specialist will conduct training to all direct care workers on the client rights and the content of health and safety needs relevant to each individual and understand individual¿s may not be neglected, abused, mistreated or subjected to corporal punishment. When and How: Program Specialist train staff on all client rights and program model, with extra training on neglected, abused, mistreated or subjected to corporal punishment. Program Specialist coordinating the training of each direct care workers in the content of health and safety needs relevant to each individual. Staff will be trained individually to ensure that they have complete understanding of the health and safety needs of each individual. To be completed by 04/03/2017. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist quarterly to review incidents and training being completed by direct care staff to ensure all staff are trained starting 05/05/2017. 04/03/2017 Implemented
6400.44(b)(18)There was no documentation Staff # 1 or Staff # 3 were trained in Individual # 1's behavioral support plan.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. There was no documentation Staff # 1 or Staff # 3 were trained in Individual # 1's behavioral support plan. Plan to fix the immediate problem: All Staff files will be reviewed and all staff not trained on individual¿s behavioral support plan will be trained. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will ensure that all staff are trained on behavioral support plan of any individual that has a Behavioral support plan, if they were not trained What will be corrected: staff not trained on individual¿s behavioral support plan will be trained. When and How: Program specialist will contact behavioral specialist, and will have staff trained that were not trained on behavioral support plans of all individuals that have behavioral support plan. Program specialist will be ensuring that all staff are trained and understand all Individuals behavioral support plan which will included understanding the importance of the implementations of interventions. Staff was retrained on these components were these documents were found in non-compliance. - staff not trained on individual¿s behavioral support plan will be trained -Program specialist will set up the retaining for the staff on behavioral support plan for all individuals¿ by 05/01/2017 -C.E. O will oversee that program specialist via a monthly meeting to review progress and paperwork according to staff training. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly and review progress to ensure that all staff are trained on individual¿s behavioral support plan. 05/01/2017 Implemented
6400.62(c)There was an unlabeled bottle which contained all-purpose cleaner found in a cabinet located in the kitchen. Poisonous materials shall be stored in their original, labeled containers.Plan to fix the immediate problem: Program specialist will walk through the sites and would remove any unlabeled bottle which were being used to store house hold cleaner. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites to and remove any unlabeled bottle which were being used to store house hold cleaner. House hold cleaner will remain in original bottle only. What will be corrected: unlabeled bottle which were being used to store house hold cleaner will be removed from sites. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to ensure House hold cleaner will remain in original bottle only. - Program specialist will walk through the sites weekly to ensure House hold cleaner will remain in original bottle only. Program specialist will walk through the sites and will remove any unlabeled bottle which were being used to store house hold cleaner. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to ensure House hold cleaner will remain in original bottle only, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure House hold cleaner will remain in original bottle only at all sites, in order to sites to clean and sanitary conditions. Also, if in an emergence, staff could identify what the household cleaner is and what is in it. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.62(d)There were crackers found stored with all-purpose bleach, fabulouso cleaner and deodorant which indicated to contact poison control if ingested in a cabinet located in the kitchen.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Plan to fix the immediate problem: Program specialist will walk through the sites and will separate poisonous materials from snack items such as crackers. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will separate poisonous materials from where snack items such as crackers were being kept. Poisonous materials will be kept in a separate locked cabinet. What will be corrected: separation of poisonous materials from where snack items such as crackers were being kept. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will separate poisonous materials, from where snack items such as crackers were being kept. Poisonous materials will be kept in a separate locked cabinet. - Program specialist will walk through the sites weekly to ensure that poisonous materials are being kept separate from snack items such as crackers. Poisonous materials will be kept in a separate locked cabinet. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to ensure Poisonous materials are kept in a separate locked cabinet, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure Poisonous materials are being kept in a separate locked cabinet, in order to prevent an emergence, where individual could have ingested poisonous materials. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.64(a)There was a thick buildup of dust located on the ceiling fan blades in the kitchen. There was a black substance consistent with dirt found in the cabinet located under the kitchen sink. There was a wet, brown and gray stain approximately two feet by two feet on the bathroom wall. There were multiple black and brown stains varying in size on the bathroom wall. There was a rusted baseboard located in the bathroom. There was a wet towel wrapped around the pipe under the bathroom sink. Clean and sanitary conditions shall be maintained in the home. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: The broke items will be removed, replaced correctly and to make sure are sites are on clean and sanitary conditions. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.67(a)There was a piece of the floor approximately ten inch in length missing in Individual # 2's bedroom. The closet door was off the track and placed along the wall in Individual # 2's bedroom. There was a hole approximately three inches in length above the circuit breaker located in Individual # 2's bedroom. There was a broken drawer which was unable to be open located in the kitchen to the right of the dishwasher. There was tear approximately six inches in length on the floor exposing the wood in Individual # 1's bedroom. There was a missing piece of a baseboard located in Individual # 1's bedroom. There was a hole approximately the size of a quarter in the bathroom wall. There was missing trim and damage around the attic access. Floors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: The broke items will be removed, replaced correctly. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.72(b)There was a tear along the bottom and side of the screen in the front door which was repaired with electrical tape. Screens, windows and doors shall be in good repair. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: The broke items will be removed, replaced correctly. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.76(a)Individual # 2's dresser was missing three knobs and two handles. There was a broken bottom drawer on Individual # 2's dresser. There was a peeling finish and damage to the leg of the coffee table which exposed the wood located in the living room. Furniture and equipment shall be nonhazardous, clean and sturdy. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed, replaced or written into an individual¿s, individual service plan if items have sentimental value. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed, replaced or written into an individual¿s, individual service plan if items have sentimental value. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: The broke items will be removed, replaced or written into an individual¿s, individual service plan if items have sentimental value. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed, replaced or written into an individual¿s, individual service plan if items have sentimental value. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed, replaced or written into an individual¿s, individual service plan if items have sentimental value. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed, replaced or written into an individual¿s, individual service plan if items have sentimental value, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed, replaced or added to individual service plan. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.141(b)Individual # 1's physical examination dated 12/21/2015 was not signed or dated by the physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Plan to fix the immediate problem: staff will make sure primary doctors use original signature only and not electronically sign individual physical form in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individual¿s files and to ensure all primary doctors use original signature only and not electronically sign individual physical form in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided. What will be corrected: That all individual¿s primary doctors use original signature only and not electronically sign individual physical form When and How: Program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will review all individual¿s files and to ensure all individual¿s primary doctors use original signature only and not electronically sign individual physical form. - primary doctors used electronically signature to sign individual physical form on individual 1 record - Program specialist will review all individual¿s files and to ensure all individual¿s primary doctors use original signature only and not electronically sign individual physical form, in accordance to the 6400 regulation, by 04/03/2017. -C.E. O will oversee program specialist¿s practices via a monthly meeting to review individual¿s records. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with program specialist monthly and review all Individual record to ensure all individual¿s files and to ensure all individual¿s primary doctors use original signature only and not electronically sign individual physical form, accordance to the 6400 regulation. 04/03/2017 Implemented
6400.151(c)(2)Staff # 1's physical examination dated 08/19/2016 did not document TB testing. 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. Plan to fix the immediate problem: Trainer will review all staff files and to ensure all staff have proper documentation on TB testing prior to hire and as needed in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Trainer will review all staff files and to ensure all staff have proper documentation on TB testing prior to hire and as needed in accordance to the 6400 regulations, that entitles employees ability to serves the individuals. What will be corrected: Trainer will review all staff files and to ensure all staff have proper documentation on TB testing prior to hire and as needed. When and How: Trainer will review the components of the 6400 and how it should be applied to the areas of non-compliance. Trainer will review all staff files and to ensure all staff have proper documentation on TB testing prior to hire and as needed. - No Documentation for TB testing on staff 1 record - Trainer will review all staff files and to ensure all staff have proper documentation on TB testing prior to hire and as needed in accordance to the 6400 regulation, by 04/03/2017. -C.E. O will oversee trainer¿s practices via a monthly meeting to review paperwork of all employees and paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Trainer monthly and review all training to ensure all employees remain in compliance in regards to proper documentation on TB testing prior to hire and as needed in accordance to the 6400 regulation 04/03/2017 Implemented
6400.151(c)(3)Staff # 1's physical examination dated 08/19/2016 did not document if staff was free of communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Plan to fix the immediate problem: Trainer will review all staff files and to ensure all staff have proper documentation that they are free of communicable disease prior to hire and as needed in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Trainer will review all staff files and to ensure all staff have proper documentation that they are free of communicable disease prior to hire and as needed in accordance to the 6400 regulations, that entitles employees ability to serves the individuals. What will be corrected: Trainer will review all staff files and to ensure all staff have proper documentation that they are free of communicable disease prior to hire and as needed When and How: Trainer will review the components of the 6400 and how it should be applied to the areas of non-compliance. Trainer will review all staff files and to ensure all staff have proper documentation that they are free of communicable disease prior to hire and as needed - No Documentation that they are free of communicable disease on staff 1 record - Trainer will review all staff files and to ensure all staff have proper that they are free of communicable disease prior to hire and as needed in accordance to the 6400 regulation, by 04/03/2017. -C.E. O will oversee trainer¿s practices via a monthly meeting to review paperwork of all employees and paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Trainer monthly and review all training to ensure all employees remain in compliance in regards to proper documentation that they are free of communicable disease prior to hire and as needed in accordance to the 6400 regulation. 04/03/2017 Implemented
6400.162(a)Individual # 1's medication box contained aspirin which did not have a pharmaceutical label. The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Plan to fix the immediate problem: Staff will make sure all individuals have ongoing standing orders for over the counter medication such as lose dose aspirin following a psychiatric visit. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will call the individuals primary doctor to ensure that all individuals have ongoing standing orders for over the counter medication such as lose dose aspirin following a psychiatric visit, while adhering to 6400 regulations. What will be corrected: Staff will make sure all individuals have ongoing standing orders for over the counter medication such as lose dose aspirin following a psychiatric visit. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on having a standing order for over the counter, such as, low dose aspirin. - no standing order for over the counter, such as, low dose aspirin - program will be retraining all staff on individual service plans, focusing on having a standing order for over the counter, such as, low dose aspirin, by 04/03/2017. -C.E. O will oversee trainer¿s practices via a monthly meeting to review trainings o f all employees and paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Trainer monthly and review all training to ensure all employees remain trained on individual service plans, focusing on an individual¿s inability or ability to self-medicate. 04/03/2017 Implemented
6400.164(a)Individual # 1 administered nasal spray on 10/26/2016 however the individual support plan documents Individual # 1 does not self-medicate.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Plan to fix the immediate problem: Staff will remind individuals of their inability to self-medicate according to individual service plan, while adhering to their rights. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will remind individuals of their inability to self-medicate according to individual service plan, while adhering to their rights in accordance to the 6400 regulations, that entitles individuals to have the right to refuse the assist of the staff to administrator medications such as their Nasal spray. What will be corrected: Staff will continue to give reminders to individuals of their inability to self-medicate according to individual service plan. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on an individual¿s inability or ability to self-medicate. - individual does not self-medicate - program will be retraining all staff on individual service plans, focusing on an individual¿s inability or ability to self-medicate, by 04/03/2017. -C.E. O will oversee trainer¿s practices via a monthly meeting to review trainings of all employees and paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Trainer monthly and review all training to ensure all employees remain trained on individual service plans, focusing on an individual¿s inability or ability to self-medicate. 04/03/2017 Implemented
6400.168(a)Staff # 1's medication administration training dated 09/26/2016 was invalid as there were only two observations completed. Staff # 1 administrated medication to Individual # 1 on 10/03/2016, 10/04/2016, and 10/05/2016. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Plan to fix the immediate problem: Trainer will review all staff files and retrain all staff that don¿t show documentation for administrated medication, including dates held and staff attendance. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Trainer will make all employees new or recertification have the proper amount of observations allowed according to the 6400 regulations, that entitles employees to be able to give out medication, and retrain all staff that doesn¿t show proper observations to allow them to give out medication administrated. What will be corrected: observations completed to show that employees are trained and able to administrator medication. When and How: Trainer will review the components of the 6400 and how it should be applied to the areas of non-compliance. Trainer will be retraining all staff that the observations completed to show that employees are trained and able to administrator medication - invalid Observations - Trainer will be retraining all employees that doesn¿t have proper observations completed to show that employees are trained and able to administrator medication, by 04/03/2017. -C.E. O will oversee trainer¿s practices via a monthly meeting to review trainings of all employees and paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Trainer monthly and review all training to ensure all employees remain trained with proper observations completed and able are to administrator medication are retrained and observed. 04/03/2017 Implemented
6400.181(e)(13)(ii)Individual # 1's annual assessment dated 11/19/2015 did not document progress and growth in the area of 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. Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of motor and communication skills. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of motor and communication skills, in current assessments and make sure all progress and growth in the area of motor and communication skills. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of motor and communication skills. When and How: Program Specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of motor and communication skills. -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.181(e)(13)(iii)Individual # 1's annual assessment dated 11/19/2015 did not document progress and growth in the area of activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of activities of residential living. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of activities of residential living., in current assessments and make sure all progress and growth in the area of activities of residential living. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of activities of residential living. When and How: Program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of activities of residential living. -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.181(e)(13)(iv)Individual # 1's annual assessment dated 11/19/2015 did not document progress and growth in the area of personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of personal adjustment. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of personal adjustment, in current assessments and make sure all progress and growth in the area of personal adjustment. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of personal adjustment. . When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of personal adjustment. -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.181(e)(13)(v)Individual # 1's annual assessment dated 11/19/2015 did not document progress and growth in the area of 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. Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of socialization. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of socialization, in current assessments and make sure all progress and growth in the area of socialization. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of socialization. . When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of socialization. -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.181(e)(13)(ix)Individual # 1's annual assessment dated 11/19/2015 did not document progress and growth in the area of community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of community integration. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of community integration, in current assessments and make sure all progress and growth in the area of community integration. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of community integration. When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of community integration. -Program specialist will create a spreadsheet `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.181(f)Individual # 1's ISP meeting was held on 11/19/2015 and Individual # 1's annual assessment was dated 11/19/2015.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Plan to fix the immediate problem: program specialist will create a form to be signed SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will create a form that will detail what is being given as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. What will be corrected: program specialist will create a form to be signed by SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. When and How: Program Specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a form that will be used to verify that the assessment is being given to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP. -will create a form - Program specialist will create a form to be signed by SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for as receipt that the assessment was received by team members for the, annual update and help with our input towards the revision of the ISP, by 04/03/2017 -C.E.O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 04/03/2017 Implemented
6400.183(4)Individual # 1 has 1:1 staffing and there was no plan to reduce this level of intensive staffing.The 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. Plan to fix the immediate problem: Program specialist will create a plan reduce this level of intensive staffing. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will ensure that monthly reports are written by the 5th of each month and are available for review within a week of completion in individual files. What will be corrected: Program specialist will create fade plan to ensure that Individuals with 1:1 staffing will have a plan to reduce this level of intensive staffing. When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retrained on intensive staffing and establishing a fade plan to reduce this intense staffing in time, which will be included understanding the importance of 1:1 staffing and its plan to be reduced. Program specialist was retrained on these components were these documents were found in non-compliance. -No plan to fade intense staffing -Program specialist will review create a plan to fade for any individual that currently receives intensive staffing by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review data sheets and paperwork according to due dates on data sheet. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly and review data sheet to ensure that all monthly are done on time and in accordance. 04/03/2017 Implemented
6400.185(b)Staff # 1 did not implemented the interventions identified in Individual # 1's behavioral support plan dated 06/28/2016 when Individual # 1 began to display challenging behaviors. The ISP shall be implemented as written.Plan to fix the immediate problem: All Staff files will be reviewed and all staff not trained on implementations and interventions of individual¿s behavioral support plan will be trained Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will ensure that all staff are trained on behavioral support plan of any individual that has a Behavioral support plan and make sure they know how to implement the interventions if they shall need to. What will be corrected: implement the interventions in accordance¿s to behavioral support plan dated 06/28/2016 when Individual # 1 began to display challenging behaviors. When and How: Program specialist will contact behavioral specialist, and will have them retrain staff on behavioral support plans of all individuals that have behavioral support plan. Program specialist will be ensuring that all staff are trained and understand all Individuals behavioral support plan which will included understanding the importance of the implementations of interventions. Staff was retrained on these components were these documents were found in non-compliance. -implementation of interventions -Program specialist will set up the retaining for the staff on behavioral support plan for all individuals¿ by 05/01/2017 -C.E. O will oversee that program specialist via a monthly meeting to review progress and paperwork according to staff training. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly and review progress to ensure that all staff are trained on individual¿s behavioral support plan. 05/01/2017 Implemented
6400.186(a)Individual #1's record did not contain three month ISP review documentation. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Plan to fix the immediate problem: Program specialist will correct or replace all missing or incorrect Quarterly reports for all individuals, starting with individual 1. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will create a data sheet that will detail, ARU date, quarterly review date, Assessment due date, and 3-month review date for upcoming ISP. What will be corrected: Program specialist will correct or replace the missing quarterly reviews, or missing components from the quarterly reviews. When and How: Program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retrained on all Individuals ISP which will included understanding the importance of the ARU dates and quarterly reviews. Program specialist was retrained on these components were these documents were found in non-compliance. -Missing Quarterly reports -Program specialist will review all individuals¿ quarterly reports by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review data sheets and paperwork according to due dates on data sheet. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly and review data sheet to ensure that all quarterly¿s are done on time and in accordance to ARU date. 04/03/2017 Implemented
6400.186(c)(1)Individual #1's record did not contain monthly review documentation. 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. Plan to fix the immediate problem: Program specialist will correct all missing or incorrect monthly reports for all individuals. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will ensure that monthly reports are written by the 5th of each month and are available for review within a week of completion in individual files. What will be corrected: Program specialist will correct the incorrect, or missing components from the monthly note. When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retrained on all Individuals ISP which will included understanding the importance of the ARU dates. Program specialist was retrained on these components were these documents were found in non-compliance. -Missing monthly note -Program specialist will review all individuals¿ monthly notes reports by 04/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review data sheets and paperwork according to due dates on data sheet. Meetings will be started 05/05/2017 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly and review data sheet to ensure that all monthly are done on time and in accordance. 04/03/2017 Implemented
SIN-00060143 Renewal 03/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d) Six fire drills exceeded 2 ½ minutes. The fire drill dated 3-25-14 was 3:00 minutes. The fire drill dated 1-31-14 was 3:00 minutes. The fire drill dated 1-12-14 was 4:00 minutes. The fire drill dated 12-19-13 was 3:00 minutes. The fire drill dated 11-30-13 was 5:00 minutes. The fire drill dated 4-14-13 was 3:00 minutes. (d) 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 employee 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. Amudipes staff will continue to encourage and train clients to evacuate the entire building, within the 2 ½ minutes. Fire drills will be monitored monthly to ensure clients are evacuating in the 2 ½ minutes or less during a fire drill. CEO will monitor logs to ensure complaints. 04/01/2014 Implemented
6400.112(e)There was only one documented sleep fire drill which was held on 4-14-13.(e) A fire drill shall be held during sleeping hours at least every 6 months. Amudipes staff will have a fire drill held during sleeping hours at least every 6 months. Fire drills will be monitored monthly to ensure a fire drill is done in the overnight hours at least every 6 months. CEO will monitor logs to ensure complaints. 04/01/2014 Implemented
SIN-00047401 Renewal 04/16/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a) The self- assessment was not dated, signed and only partially completed.(a) 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. Amudipe¿s Residential and Day Treatment Facilities Inc will 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 regulation 6400.15 Self- assessment of homes. CEO will ensure that Program Specialists has dated and completed, signed and dated assessment 6 to 3 months prior to inspection. 06/03/2013 Implemented
6400.181(e)(12)There were no recommendations for programing/outcomes included in the assessment for individual #1 completed 4/9/13.(12) Recommendations for specific areas of training, programming and services. Amudipe¿s Residential and Day Treatment Facilities Inc. Program Specialist will make recommendations for programming/outcomes that will be included in the assessments for our residential clients. . CEO will ensure that Program Specialist has recommendations for programming/outcomes in their residential assessments 06/03/2013 Implemented
6400.181(f)The assessment completed for individual #1 on 4/9/13 was not sent to the Support Coordinator 30 days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Amudipe¿s Residential and Day Treatment Facilities Inc. Program Specialist will provide the assessment to the Support Coordinator, at least 30 calendar days prior to an ISP meeting. . CEO will ensure that Program Specialist assessment is provided to Support Coordinator¿s within 30 days of ISP meeting with signed statement of receipt from Support Coordinator to be kept in clients file 06/03/2013 Implemented
6400.186(a)Quarterly ISP reviews were not completed for individual #1 progress on outcomes for 7/23/12, 10/23/12 and 1/23/13.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Amudipe¿s Residential and Day Treatment Facilities Inc. Program Specialist will complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed and regulated in chapter 6400.186 (a) with individual every 3 months or more frequently if the individual¿s needs change which impacts the services as specified in the current ISP. CEO will ensure that Program Specialist has quarterly ISP¿s reviews completed with progress on outcomes signed and dated for all clients in our residential programs. 06/03/2013 Implemented
SIN-00184592 Renewal 03/09/2021 Compliant - Finalized