Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215906 Renewal 12/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(d)The staff number 4 (requested on 2/23/22); Staff 5 (requested on 9/6/2022); and Staff 6 (requested on 2/13/2022) criminal history checks at the time of the inspection were still Under Review. The providers record did not show their attempt to retrieve the findings as of 12/21/2022.A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept. The Director of Human Resource department printed out the final report for staff #4. Staff #5, and Staff #6 criminal record check (See exhibit F). On 1/5/2023, the CEO reviewed all charts to ensure the final report was contained in each staff chart, and retrained HR staff on timely printing of final reports of the State Police and FBI documents. 01/05/2023 Implemented
6400.64(a)The kitchen bottom freezer and ice maker have food residue that needs cleaning.Clean and sanitary conditions shall be maintained in the home. The CEO scheduled a house deep cleaning provided by a third-party cleaning agency on 1/16/2023. All current staff were retrained on house cleaning and sanitation (exhibit B). New weekly cleaning log developed and utilized for all shift responsibilities (Exhibit C). 01/16/2023 Implemented
6400.80(a)The outside gutter pipe is extending onto the patio creating a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. On 1/3/2023 the pipe was cut by All in One Construction agency to reduce risk of tripping hazard (see attached exhibit G). 01/03/2023 Implemented
6400.101The basement ceiling smoke detector is blocking the side back basement egress from opening fully.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 1/3/2023 the location of the smoke detector was changed in the basement to ensure that the basement egress can open fully. 01/03/2023 Implemented
6400.112(h)This is no meeting place designation indicated on the fire drill logs Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The CEO developed a new fire drill form to include the date, time, meeting location and all members involved in the fire drill (exhibit D). Staff were retrained on utilizing the new form and capturing all information (Exhibit B). 01/20/2023 Implemented
6400.151(c)(2)TB does not indicate a read date for Staff number 3. The TB test has a date given and a outcomes status only. Staff number 2 TB does not indicate a read date. The TB test has a date given and a outcomes status only. 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. The CEO updated the agency policy to include ensuring that the read date and outcome status is captured for 2-step PPD. The Human Resource department was retrained on the updated policy (see attached Policy) 01/03/2023 Implemented
6400.46(b)The Fire safety trainer was last certified in 2009. Fire safety trainer needs to be trained annually.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).On 1/3/2023, the fire safety trainer completed annual training with a fire safety expert (exhibit H). CEO completed retraining with the human resource department to ensure all fire safety experts are trained annually (exhibit E). 01/03/2023 Implemented
6400.52(b)(1)For Staff number 1 there were not 12 hours of training located in the recordThe following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.Staff #1 completed 12-hours of training on 7/1/2022. See attached training certificate with the agency policy (exhibit E). 01/03/2023 Implemented