Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221552 Renewal 03/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)The water in the home did not reach a hot temperature. The shower measured at 75.6 degrees Fahrenheit at the time of testing. Water in sinks also measured at approximately 75 degrees on the hot setting.A home shall have hot and cold running water under pressure. Plan to fix the immediate problem: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f. 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 check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f, if noncompliance is discovered on a monthly basis. What will be corrected: The hot water temperature was 75.6 degrees. When and How: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f, if noncompliance is discovered on a monthly basis. - Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn¿t exceed 120 f. 05/01/2023 Implemented
6400.112(e)There was a time period of greater than 6 months between sleeping overnight fire drills. The asleep fire drills occurred on 4/29/22 at 3:00am and 11/21/22 at 12:30 am.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. 05/01/2023 Implemented
6400.32(r)None of the bedroom doors were equipped with locks to ensure privacy. There was no indication in assessments or ISPs that the right to lock their bedroom doors was discussed with the individuals living in the home.An individual has the right to lock the individual's bedroom door.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. We will work with support coordinator to update ISP to discuss the inability of safety when dangerous occurs with locked door. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. What will be corrected: Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy. 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 work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. . - Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. - Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors, by 06/01/2023 05/01/2023 Implemented
SIN-00202293 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)There is insufficient evidence within Staff 1's record to establish that the staff had been a resident of the state of Pennsylvania for two or more years prior to their date of hire on 03/13/2022. An application for a Federal Bureau of Investigation (FBI) criminal history record check was not submitted for this staff within 5 working days of their date of hire.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. Plan to fix the immediate problem: Trainer will review all staff files and to ensure all staff have proper documentation such as FBI Clearance if living or have lived out of the state in the last 2 years upon 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 such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed 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 such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed. 06/01/2022 Implemented
6400.68(b)Hot water from the bathtub faucet was measured at 141.0° Fahrenheit, exceeding the 120° Fahrenheit allowable temperature. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water temperature in the 2nd floor bathtub was 132° Fahrenheit. Plan to fix the immediate problem: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f. 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 check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f, if noncompliance is discovered on a monthly basis. What will be corrected: The hot water temperature was 132° Fahrenheit. When and How: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f, if noncompliance is discovered on a monthly basis. - Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn¿t exceed 120 f. 06/01/2022 Implemented
6400.112(e)A sleeping fire drill was not held every 6 months.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 06/01/2022 06/01/2022 Implemented
6400.151(a)Four issues relating to this citation number were noted during the inspection: 1. Staff 5, whose date of hire was 02/02/2022, did not have a physical examination completed until 02/23/2022. While there was a Driver's License physical for this staff on file, dated 07/13/2021, the contents of that form do not support that the physical conducted satisfied the requirements for a physical examination under Chapter 6400 regulations. 2. Staff 6, whose date of hire was 06/17/2021, did not have a physical examination completed until 08/05/2021. 3. There is no documentation within Staff 7's record to indicate that a physical examination occurred prior to this staff's hire date of 03/13/2022; further, there is no documentation to indicate that a physical examination has been completed for this staff since this staff's hire date. 4. There is no documentation within Staff 8's record to indicate that a physical examination occurred prior to this staff's hire date of 03/13/2022; further, there is no documentation to indicate that a physical examination has been completed for this staff since this staff's hire date. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Plan to fix the immediate problem: Trainer will review all staff files and to ensure all staff have proper documentation such as a current physical 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 such as a current physical 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 such as a current physical 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 such as a current physical prior to hire and as needed - staff physical wasn¿t prior to hire or within the grace period. - Trainer will review all staff files and to ensure all staff have such as a current physical prior to hire and as needed in accordance to the 6400 regulation, by 06/01/2022. 06/01/2022 Implemented
6400.151(c)(2)Staff 2's latest Physical Form, dated 08/28/2021, states that a Mantoux test was completed, and the results were negative; however, the form does not state the dates the Mantoux test was administered and read. The space left on the form for the testing dates is blank. Staff 2 was hired by the provider on 02/09/2022, and there is no record of a previous Mantoux test or testing results within the staff record. As the Mantoux date line is blank on the physical and there are no other records available regarding the test, it cannot be reasonably determined whether the test referenced by the physician was conducted at the time of the physical or whether the physician was referencing testing results from another, historical test occurring at an earlier date. As such, it cannot be reasonably determined whether a Mantoux Test has been conducted for Staff 2 once every 2 years as required. 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 06/01/2022. 06/01/2022 Implemented
6400.151(c)(3)Two issues relating to this citation number were noted during the inspection: 1. Staff 3's Physical Form, dated 11/17/2021, does not indicate whether or not the staff is free of communicable diseases. 2. Staff 4's Physical Form, dated 03/04/2022, does not indicate whether or not the staff is free of communicable diseases. 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 06/01/2022 Implemented
6400.165(b)Medication ONDANSETRON ODT 4mg. was observed in the Individual 1's medication box, but was not listed on the Medication Administration Record (MAR) maintained for Individual 1's medication administrations.A prescription order shall be kept current.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure prescribed orders are kept current, to assure safety and to avoid any medication errors. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager will call the individuals doctors, if needed to ensure prescribed orders are up to date with house records, while adhering to 6400 regulations. What will be corrected: bring prescribed orders in to compliance in order to adhere to 6400 regulations. The compliance manager will call the individuals doctors, if needed to ensure prescribed orders are up to date with house records. When and How: Compliance manger 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 recognizing when prescribed orders are not current and calling the compliance manager, to ensure prescribed orders are current. - Medication logs had a prescribed order that wasn¿t current. 06/01/2022 Implemented
6400.165(c)Medication ESTARYLLA .25 is not being administered as prescribed for Individual 1. This medication is to be given once per day. The medication was not administered daily based on the state of the medication pack.A prescription medication shall be administered as prescribed.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure medication is administrated as prescribed, to assure safety and to avoid any medication errors. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager to ensure medication is administrated as prescribed, to assure safety and to avoid any medication errors, while adhering to 6400 regulations. What will be corrected: bring prescribed orders into compliance in order to adhere to 6400 regulations to ensure medication is administrated as prescribed, to assure safety and to avoid any medication errors. The compliance manager will call the individuals doctors, if needed to ensure prescribed orders are up to date with house records. When and How: Compliance manger 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 recognizing medication errors not and calling the compliance manager, to ensure medication is administrated as prescribed, to assure safety. - Medication logs had a prescribed medication that wasn¿t given correcting. 06/01/2022 Implemented
6400.166(a)(13)Medications for Individual 1 were not initialed in the medication record by the person administering the medication for the 03/22/2022, 7:00am administration time.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure medication is administrated as prescribed and initialed correctly, to assure safety and to avoid any medication errors. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager to ensure medication is administrated as prescribed and initialed correctly, to assure safety and to avoid any medication errors, while adhering to 6400 regulations. What will be corrected: bring prescribed orders into compliance in order to adhere to 6400 regulations to ensure medication is administrated as prescribed and initialed correctly, to assure safety and to avoid any medication errors. The compliance manager will call the individuals doctors, if needed to ensure prescribed orders are up to date with house records. When and How: Compliance manger 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 recognizing medication errors not and calling the compliance manager, to ensure medication is administrated as prescribed and initialed correctly, to assure safety. - Medication logs had a prescribed medication that wasn¿t given correcting but was signed out. - Program specialist will be retraining all staff on individual service plans, focusing on recognizing medication errors not and calling the compliance manager, to ensure medication is administrated as prescribed and initialed correctly, to assure safety, by 06/01/2022. 06/01/2022 Implemented
6400.167(a)(1)Individual 1's medication KETOCONAZOLE SHAMPOO had not been administered as prescribed. The shampoo was located within Individual 1's medication box, unopened but signed as having been administered.Medication errors include the following: Failure to administer a medication.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure medication is administrated as prescribed, to assure safety and to avoid any medication errors. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager to ensure medication is administrated as prescribed, to assure safety and to avoid any medication errors, while adhering to 6400 regulations. What will be corrected: bring prescribed orders into compliance in order to adhere to 6400 regulations to ensure medication is administrated as prescribed, to assure safety and to avoid any medication errors. The compliance manager will call the individuals doctors, if needed to ensure prescribed orders are up to date with house records. When and How: Compliance manger 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 recognizing medication errors not and calling the compliance manager, to ensure medication is administrated as prescribed, to assure safety. - Medication logs had a prescribed medication that wasn¿t given but was singed as given. - Program specialist will be retraining all staff on individual service plans, focusing on recognizing medication errors not and calling the compliance manager, to ensure medication is administrated as prescribed, to assure safety, by 06/01/2022. 06/01/2022 Implemented
SIN-00184594 Renewal 03/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The blinds located in the dining room were not in good repair. The blinds located in the living room were damaged. The blinds located in the kitchen were damaged. Individual #4's bedroom dresser drawer was missing knobsFloors, walls, ceilings and other surfaces shall be in good repair. 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 blinds to ensure good repair. 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 blinds. The owner will purchase blinds have them installed to ensure the home is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes blinds in the homes are presented in good repair. 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 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, especially when it comes to the blinds being in good repair. - 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 blinds being in good repair. - 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 blinds throughout the home, by 04/01/2021 04/01/2021 Implemented
6400.67(b)The dryer located in the basement contain a small golf ball size of lint in the filter, which could cause a hazard. 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 all dresser knobs to ensure good repair. 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 all dresser knobs to ensure good repair. The owner will purchase knob to ensure all dressers are in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to all dresser knobs be present to ensure good repair. 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 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, especially when it comes to all dresser knobs to ensure good repair. - 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 dresser all knobs to ensure good repair. - 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 all dresser knobs to ensure good repair, by 04/01/2021 04/01/2021 Implemented
6400.112(e)Between the dates of January 2020 and February 2021 there was only one sleep drill held on 12/19/2020.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 05/01/2021 05/01/2021 Implemented
6400.141(c)(15)Individual #4's annual physical dated 6/15/2020 did not indicate diet instructions. The line on the form was left blank.The physical examination shall include Special instructions for the individual's diet.Plan to fix the immediate problem: Compliance manager will make sure primary doctors have properly filled out physical form. Especially when it comes to including the following items; diet instructions, in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager will make sure primary doctors have properly filled out physical form. Especially when it comes to including the following items, diet instructions, in accordance to the 6400 regulations. 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 participants primary care physical properly fill out annual physical forms. When and How: Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individual¿s primary care physical properly fill out annual physical forms. - primary doctor did not complete all areas of the annual physical form. - Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individual¿s primary care physical properly fill out annual physical forms, by 06/01/2021. 06/01/2021 Implemented
SIN-00156859 Renewal 06/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light bulb in the interior stairwell leading to the basement level was not functioning causing poor lighting.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. -C.E. O will oversee that Compliance 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 Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in August of 2019. 08/08/2019 Implemented
6400.67(a)The drain in the upper level main bathroom sink was clogged and very slow to drain. The upper right Dresser knob in individual #3's bedroom was missing.Floors, walls, ceilings and other surfaces shall be in good repair. 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, to make sure all sinks are draining, and furniture is in good repair. 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, to make sure all sinks are draining and furniture is in good repair. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to having proper draining of the sinks and dresser missing knobs. 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, to make sure all sinks are draining and furniture is in good repair. - 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 to the broke items will be removed or replaced correctly, to make sure all sinks are draining and furniture is in good repair. - 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, to make sure all sinks are draining and furniture is in good repair. -C.E. O will oversee that Compliance 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 broke items will be removed or replaced correctly, to make sure all sinks are draining and furniture is in good repair. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in August of 2019. 08/08/2019 Implemented
6400.72(b)All of the doors on the second floor, 4 total did not close. Screens, windows and doors shall be in good repair. 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 doors on second floor connecting to the hallway not closing completely . Who (job title) will be responsible for correcting the problem (each step in the process) in the future: 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 doors on the second level, connecting to the hallway not closing completely. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to doors on the second level connecting to the hallway not closing completely 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 doors on the second level connecting to the hallway not closing completely . - 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 to doors on the second level connecting to the hallway not closing completely. - 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 doors on the second level connecting to the hallway not closing completely. -C.E. O will oversee that Compliance 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 doors on the second level connecting to the hallway not closing completely. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in August of 2019. 08/08/2019 Implemented
SIN-00131532 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's family has provided the agency with monies to be used for spending and there is no clear record of how the funds were kept, how much was given and what amount should be left over.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Plan to fix the immediate problem: The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent. All financial records will be updated and correct. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. What will be corrected: The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, to ensure all financial records are remaining current and up to date. When and How: The C.E.O will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance : The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. - The C.E.O will create a written record of monies received and spent on individuals. The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. - The C.E.O will examine all financial records to ensure the accuracy of monies received and spent, to ensure all financial records are remaining current and up to date., by 04/20/2018 -C.E. O will be overseen by the owner via a monthly meeting to ensure create a record of monies received and spent on individuals completed and kept up to date and that The C.E.O examined all financial records to ensure the accuracy of monies received and spent, on a monthly basis to ensure all financial records are remaining current and up to date. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.67(a)The bathtub on the second floor was found to have rust on the rim of the tub.Floors, walls, ceilings and other surfaces shall be in good repair. 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. 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 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. - 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
6400.67(b)The living room floor was significantly worn and in need of refinishing. 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. 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 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. - 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. 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. 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 re Implemented
6400.67(b)The exhaust from the dryer was disconnected and lint was visible on the floor and wall. 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. 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 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. - 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. 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. 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 re Implemented
6400.73(a)The handrail on the exterior front had rust on its surface. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. 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. 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 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. - 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. 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. 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 re Implemented
6400.112(d)On 1/19/18 the fire drill record indicated that it took six minutes and thirty seconds to evacuate individual from the home.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 and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain why time was exceed and repeat of drill. 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 and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain why time was exceed and repeat of drill, monthly. What will be corrected: House Manager will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes explain why time was exceed and repeat of drill. 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. House Manager will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain why time was exceed and repeat of drill. - House Manager will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. House Manager will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain why time was exceed and repeat of drill. - 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 and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain why time was exceed and repeat of drill, by 05/01/2018 -C.E. O will oversee that House Manger via a monthly meeting to ensure walk throughs are being done and to ensure all fire drills are completed and evacuation is done within 2 ½ minutes or explain why time was exceed and repeat of drill. Meetings will continue and will meet monthly before or around the 5th of the month, starting May of 2018. A plan to prevent future occurrence: C.E.O will continue to meet with House Manager monthly. Implemented
6400.182(c)The current ISP for individual #1 is not current. It lists the individual as living at home with his family. The admission date to the agency on 10/1/17.The plan lead shall be responsible for developing and implementing the ISP, including annual updates and revisions. 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
SIN-00113350 Renewal 04/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The grout around the bathtub was moldy.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, especially when it comes a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. The 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 a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. 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 a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. 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 a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. - 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 a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. - 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 a black substance consistent with mildew was found on the caulking around the bathtub and tile wall, 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 a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. 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
6400.71The emergency numbers for the telephone was missing poison control.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The Program specialist will walk through the sites and make sure the poison control number is posted by everything phone. If the number is missing, posting is torn, discolored, or unreadable the posting will be replaced monthly. What will be corrected: Program specialist will walk through the sites and make sure the poison control number is posted by everything phone. If the number is missing, posting is torn, discolored, or unreadable the posting will be replaced. The 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 make sure the poison control number is posted by everything phone. If the number is missing, posting is torn, discolored, or unreadable the posting will be replaced. - 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 make sure the poison control number is posted by everything phone. If the number is missing, posting is torn, discolored, or unreadable the posting will be replaced. - 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 make sure the poison control number is posted by everything phone. If the number is missing, posting is torn, discolored, or unreadable the posting will be replaced, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all sites have the poison control number is posted by everything phone. If the number is missing, posting is torn, discolored, or unreadable the posting will be replaced. Meetings will continue and will meet monthly before or around the 5th of the month. 07/03/2017 Implemented
6400.101The doors at the basement, individual #1's bedroom, and the spare bedroom had key locks.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. This problem was taking care of the 04/11/2017 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 examine all furniture, surfaces, floors, walls and ceilings to ensure bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing. What will be corrected: Some bedrooms and basement doors had useable key locks 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 bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure items such as bedrooms or basement doors do have useable key locks, if so, they will be seal off immediately, by 04/11/2017 -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. 04/11/2017 Implemented
6400.112(d)The fire drill on 5/6/16 listed an evacuation time of 3 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 employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. 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 evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. 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 evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. - 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 evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. - 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 evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all fire drills are completed and evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. Meetings will continue 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
6400.112(e)The sleep fire drills were on 8/15/16 and 3/20/17, which was 7 months.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 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all sleep fire drills are done at least every six months or repeat of drill if exceeds that time period. Meetings will continue 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
6400.141(c)(7)Individual #1's gynecological examination was completed on 5/3/16 and did not have results. The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Plan to fix the immediate problem: staff will make sure to request result from gynecologist so we can remain in accordance to the 6400 regulations. The Program specialist will review all individual's files and to ensure results were provided, in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided. That all individual's gynecological examination was completed but did not have results The 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 gynecological examination was completed and have results. - 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 gynecological examination was completed and have results. - 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 gynecological examination was completed and have results., by 07/03/2017. -C.E. O will oversee program specialist¿s practices via a monthly meeting to review individual's records. Meetings continue 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 and review all Individual record to ensure all individual¿s files and to ensure all individual¿s examinations meet 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 gynecological examination was completed and have results. 07/03/2017 Implemented
6400.151(a)Staff person #1's date of hire 10/7/16 and their physical examination was completed on 11/1/16. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The Trainer will review all staff files and to ensure all staff have proper documentation physical examination prior to hire and as needed in accordance to the 6400 regulations. The Trainer will review all staff files and to ensure all staff have proper documentation physical examination 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 physical examination. 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 physical examination. - No Documentation for physical examination for 1 staff record - Trainer will review all staff files and to ensure all staff have proper documentation on physical examination and as needed in accordance to the 6400 regulations, by 07/03/2017. -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 continue 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 proper physical and as needed in accordance to the 6400 regulations. 07/03/2017 Implemented
6400.181(f) There was no documentation that individual #1's assessment dated 1/21/17 was sent to the supports coordinator. (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 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will continue 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
SIN-00076962 Renewal 04/08/2015 Compliant - Finalized
SIN-00042565 Initial review 10/26/2012 Compliant - Finalized