Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227982 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.216(a)Individual #1's personal information binder including but not limited to Individual #1's Individual Service Plan, completed 9/26/2022, and personal demographics document were unlocked and unattended in a Metal Wall Mount File Holder mounted on the wall in the living room of the home. [Repeat Violation, 3/22/2023] An individual's records shall be kept locked when unattended. The binder that contained Individual #1's ISP plan and personal demographics was immediately removed from the home the day of inspection on 7/19/2023. 07/19/2023 Implemented
SIN-00227103 Unannounced Monitoring 06/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 11:20AM on 6/15/2023, the hot water temperature measured 135.6°F at the bathtub and 134.4°F at the sink in the bathroom on the second floor of the home. [Repeat Violation, 11/18/2022] Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water tank was immediately turned down. Water temperature was tested for the next three days to ensure hot water temperatures in bathtubs and showers did not exceed 120°F. 07/28/2023 Implemented
6400.163(h)At 11:27AM on 6/15/2023, two pills were in a plastic storage bag inside Individual #1's medication box with a sticker that read, "6/9/23 3:30 meds (2 pills)." [Repeat Violation, 11/18/2022]Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Medications were immediately removed from Individual#1's home and disposed of following KZL Agency's medication disposal policy. All medications in all KZL Agency homes were reviewed and any expired medication was removed and disposed of immediately 07/28/2023 Implemented
SIN-00224339 Unannounced Monitoring 05/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home.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. New stickers were immediately placed on the phone. Stickers were also placed on the walls in each of the rooms of the house. Residential Manager will review the Inspection tool with the Team Leads to ensure their understanding of the Regulations, and Inspection Tool. 05/31/2023 Implemented
6400.72(a)The screen in Individual #1's bedroom does not securely fit the window leaving a two-inch gap on the left side. In addition, the screen is taped at the top and bottom of the window. [Repeat Violation, 11/18/2022, 3/22/2023]Windows, including windows in doors, shall be securely screened when windows or doors are open. Screen Kit was ordered on May 24, 2023, and will be delivered 5/26/2023. Screen will be placed immediately upon delivery. Residential Manager will review the Inspection tool with the Team Leads to ensure their understanding of the Regulations, and Inspection Tool. 05/31/2023 Implemented
SIN-00221594 Unannounced Monitoring 03/22/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light in the second floor hallway cannot be turned on and off from the second floor light switch. [Repeat Violation, 11/18/2022]Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. LED, battery operated Puck Lights that are touch activated will be purchased and placed in the second floor hallway. 04/14/2023 Implemented
6400.72(a)There is not a screen in Individual #2's bedroom window. [Repeat Violation, 11/18/2022]Windows, including windows in doors, shall be securely screened when windows or doors are open. KZL Agency has contacted Lobos Management, see attached letter and have put in a Maintenance Ticket. Lobos stated that the screens have been ordered and they are waiting for them to be delivered. 05/31/2023 Not Implemented
6400.216(a)At 11:37AM on 3/22/2023, Individual #2 records including a 2021 Quarterly Individual Plan Review and Individual Plan, dated 6/3/2021, were unlocked and unattended in a binder on a shelf in the living room of the home. An individual's records shall be kept locked when unattended. The binder was removed from the home and Program Specialist reviewed and uploaded all documentation to THERAP, to which all staff have access. 04/07/2023 Implemented
6400.166(a)(5)Individual #1 is prescribed Lamotrogine. Individual #1's March 2023 Medication Administration Records reads, "75MG, take one tablet by mouth twice a day." The medication label reads, "150MG, take ½ tablet (75MG) by mouth twice a day with 100MG (Total 175MG) for Mood." [Repeat Violation, 11/18/2022]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Individual #1 MAR was immediately corrected 04/30/2023 Implemented
SIN-00215608 Renewal 11/17/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)There is not a lid on the trash receptacle containing trash inside the basement of the home. The trash receptacle is over 18 inches high.Trash receptacles over 18 inches high shall have lids. The trash receptacle over 18" higher with no lid was replaced with a new one with a lide. All trash receptacles over 18" higher were replaced as needed. 12/16/2022 Not Implemented
6400.66The light in the second floor hallway of the home is inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A maintenance request was put into Lobos Management to fix the light switch to the second floor hallway light. We will follow up weekly until the repairs are completed. 12/16/2022 Not Implemented
6400.67(a)There are two holes, each approximately 5 inches by four inches, in the wall at top of the steps leading to the second floor of the home.Floors, walls, ceilings and other surfaces shall be in good repair. Individual #1 has been transitioned to a new home, and KZL Agency has closed this location, and will not be renewing the lease at this home. 12/16/2022 Not Implemented
6400.68(b)At 12:02PM on 11/18/2022, the hot water temperature measured 122.9°F at the shower in the bathroom on the second floor of the home. At 12:03PM on 11/18/2022, the hot water temperature measured 129.2°F at the sink in the bathroom on the second floor of the home. [Repeat Violation, 12/2/2021] Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water tank was immediately turned down. Water temperature was tested for the next three days to ensure hot water temperatures in bathtubs and showers did not exceed 120°F. 12/16/2022 Not Implemented
6400.82(f)There is not a trash receptacle in the bathroom on the first floor of the home.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. New trash receptacles were purchased and placed in each bathroom. 12/16/2022 Implemented
6400.101At 12:12PM on 11/18/2022, there was a table obstructing the door to exit the basement of the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The turn lock on the basement side door between the basement and garage posing an obstructed egress from the garage when engaged was replaced. All basement doors were checked and door knobs were replaced as needed. 12/16/2022 Not Implemented
6400.112(c)The written fire drill records for the fire drills conducted from 12/2021 to 5/2022 do not address problems encountered. This section was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. An electronic fire drill was created and implemented for December fire drills. The fire drill record includes the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. A comment section is included that will required documented before the fire drill documentation can be saved. 12/16/2022 Not Implemented
6400.113(a)Individual #1, date of admission 8/1/2022, was not instructed in fire safety upon admission. 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. Individual #1's immediately was instructed in fire safety, All individual's files were reviewed and fires safety was reviewed as needed. 12/16/2022 Implemented
6400.171At 11:55AM on 11/18/2022, there were two cartons of eggs with a "best by" date of 10/9/2022. and a container of sour cream with an expiration date of 9/12/2022 in the refrigerator in the kitchen in the home.Food shall be protected from contamination while being stored, prepared, transported and served. Agency purchased food covers, new containers and markers for properly storing and labeling food in houses. All refrigerators were checked to ensure food was protected from contamination while be being stored. 12/16/2022 Not Implemented
6400.181(a)Individual #1, date of admission 8/1/2022 had an initial assessment completed on 10/19/2022. 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. A checklist was made to ensure 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. (see attached). 12/16/2022 Not Implemented
6400.181(e)(4)Individual #1's assessment, completed 10/19/2022, does not address the individual's need for supervision. The assessment must include the following information: The individual's need for supervision. The assessment has been updated to show supervision requirements on the front page so that staff is able to easily locate the information. (see attached) All assessments will be updated accordingly. Please see attached document. 12/12/2022 Not Implemented
6400.181(e)(12)Individual #1's assessment, completed 10/19/2022, does not include recommendations for specific areas of training, programming and services. [Repeat Violation, 12/2/2021]The assessment must include the following information: Recommendations for specific areas of training, programming and services. The assessment has been updated to show supervision requirements last page so that staff is able to easily locate the information. (see attached) 12/12/2022 Not Implemented
6400.214(b)The most current copy of the Individual #1's assessment was not kept at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Copies of all assessments were placed in the homes to ensure that all staff can view the assessments and accurately know the abilities of the individuals. 12/12/2022 Not Implemented
6400.163(h)A Ventolin HFA inhaler with an expiration date of 4/2022 prescribed to an individual who does not resides in the home was on the dresser inside bedroom #1.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The blister packs containing expired prescription medications belonging to another individual, along with the medication dispenser were immediately removed from Individual#1's home and disposed of following KZL Agency's medication disposal policy. All medications in all KZL Agency homes were reviewed and any expired medication was removed and disposed of immediately. 12/16/2022 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 10/19/2022 to the plan team members for individual plan meeting on 11/16/202. [Repeat Violation, 12/2/2021]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A checklist was made to ensure each individual assessment will be provided to the individual plan team members at least 30 calendar days prior the individual plan meeting. 12/16/2022 Not Implemented
SIN-00198873 Renewal 12/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)During the 12/03/2021 on-site inspection the water temperature measured 122.3°F at 10:16am at the kitchen sink faucet. The water temperature measured 122.5°F at 10:22am at the bathtub faucet, in the bathroom on the second floor. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 12/06/2021, the hot water tank was re-adjusted and water temperature was later re-tested at 119.8 ºF. Thermometers have been purchased for each house and it will be the responsibility of the house team leads to test the water temperature in the kitchen and all bathrooms weekly to ensure the temperature does not exceed 120 ºF. Adjustments to the hot water will be made immediately if the hot water exceeds 120 ºF, and a recheck will be completed. 12/06/2021 Implemented
6400.106No documentation was provided of the home ever having a furnace inspection or cleaning by a professional furnace cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. A furnace inspection was done on December 1, 2021. KZL Agency has implemented a maintenance schedule to ensure that furnace are inspected and cleaned at least annually by a professional furnace company. 12/01/2021 Implemented
6400.142(a)Individual #1, date of admission 9/26/2020, has no record of having a dental examination (Repeated Violation-1/06/2021, et al).An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Residential Manager has been instructed to make a dentist appointment for individual #1. Director of Operations has reviewed regulation 6400.142(a), An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually, with the Residential Manager to ensure the understanding compliance of the regulation. 02/04/2021 Implemented
6400.181(e)(12)Individual#1's assessment completed 11/09/2021 did not include: Recommendations for specific areas of training programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. KZL Agency has revised and updated Residential Annual Assessment to ensure all information as noted in Chapter 6440.181(e) is reflected, including specific recommendations for specific areas of training, programming, and services. KZL Agency Residential Program Specialist will begin using this revised assessment immediately, replacing the old assessment. 01/26/2022 Implemented
6400.34(a)Individual #1's most recent signed copy of rights completed 11/16/2021, did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j to voice concerns and 6400.32k to participation in the development and implementation of the individual plan; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.KZL Agency has revised and updated our agency Individual Rights policy to include all rights as noted in Chapter 6400 and Chapter 6100 regulations. KZL Agency has already been following the guidelines in the residential homes but had not updated written policy to reflect these guidelines. KZL Agency will ensure that this updated policy is what is shared with individuals going forward. 12/03/2021 Implemented
6400.165(g)Individual #1 had a psychiatric medication review completed 4/28/2021 and then again 9/22/2021. Individual #1's psychiatric medication reviews completed on 4/28/2021, 9/22/2021, and 12/03/2021 do not include physician's name nor credentials to document they are licensed. Individual #1's psychiatric medication review completed 4/28/2021 did not include the reason for prescribing Melatonin 3mg tablet and Olanzapine 20mg tablet.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.KZL Agency has revised its psychiatric medication review documentation to include the physicians¿ credentials, the reason for prescribing the medication, the need to continue the medication and the necessary dosage 02/01/2022 Implemented
SIN-00181205 Renewal 01/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's physical examination, completed on 8-27-20 does not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Individual #1 was transitioned to KZL in June of 2020, in which his physical was in completed while in the hospital prior to transitioning to KZL. At the time of transition we were not able to obtain his immunization records. We have scheduled an appointment his PCP on February 03, 2021 at which time we will get a copy of his immunizations. Our Agency has started using Therap this year, which I believe will help in keeping track of all documentation for our current and new individuals. Going forward the House Manager, who attends to all medical appointments for our individuals, will be required to review, & upload all documentation of new individuals within 10 days of their transition and have all needed medical appointments made within 30 days of their tradition. The Residential Manager will be required to also review individuals file on a monthly basis to make sure they are kept in compliance with all 6400 regulations. [Documentation of the scheduled appointment provided to the Department on 1/18/21. Immediately and upon hire, the CEO or designee shall educate the House Manager and the Residential Manager of the requirements of individual's physical examinations and their aforementioned responsibilities to audit the physical examination documentation to ensure timely completion with all required information, there are no required areas left blank and that health services are provided and arranged as stated in current physical examinations. Documentation of training shall be kept. Documentation of aforementioned audits shall be kept. (DPOC by AES,HSLS on 1/21/21)] 02/03/2021 Implemented
SIN-00162645 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #2's physical examination, dated 3/29/19, does not include a hearing and vision screening. This section was left blank.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #2 completed by physician to include vision and hearing screening [Copy provided, updates not dated or signed. (AES,HSLS on 11/8/19)] 11/11/2019 Implemented
6400.141(c)(11)Individual #1's physical examination, dated 5/22/19, does not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Physical Exam completed by physician to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals [Individual #1 had a physical examination updated to address heath maintenance needs on 10/20/19. Copy submitted to department on 11/11/9.(DPOC by AES,HSLS on 11/18/19)] 11/11/2019 Implemented
6400.141(c)(13)Individual #1's physical examination, dated 5/22/19, does not include allergies or contraindicated medications. Individual #2's physical examination, dated 3/29/19, does not include allergies. This section was left blank. [Repeat violation 9/12/18, et al.]The physical examination shall include: Allergies or contraindicated medications.Both Individual #1 and Individual #2 Physical addresses allergies. [Individual #1 had a physical examination updated on 10/21/19 to address allergies. Copy submitted to department on 11/11/9. [Individual #2 had a physical examination updated to address allergies. Copy submitted to department on 11/11/9.(DPOC by AES,HSLS on 11/18/19)] 11/11/2019 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 5/22/19, does not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Physical Form completed by physician that includes medical information pertinent to diagnosis and treatment in case of emergency was completed [Individual #1 had a physical examination updated on 10/21/19 to address medical information pertinent to diagnosis and treatment in case of an emergency. Copy submitted to department on 11/11/9. (DPOC by AES,HSLS on 11/18/19)] 11/11/2019 Implemented
6400.151(c)(3)Direct Service Worker #1's physical examination, dated 4/10/19, indicates that the employee has a communicable disease; however, the physical examination does not include specific precautions that will prevent the spread of the disease to the individuals. 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. Physical statement was that staff is free of communicable disease was completed by physical. [DSW #1 had a physical examination updated to included "No" to communicable disease. Update not dated or signed on copy submitted to department on 11/11/9.(DPOC by AES,HSLS on 11/18/19)] 11/11/2019 Implemented
SIN-00141373 Renewal 09/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The monthly fire drills between 9/16/17 and 8/16/18 were held on the 16th of each month. An unannounced fire drill shall be held at least once a month. An unannounced Fire Drill at all Residential sites was done on September 20, 2018. The Residential Manager, the House Manager, and the Program specialist were all retrained on Fire Safety to include Chapter 6400.112 regulation.A Fire Drill Schedule was made and will be implemented by the House Manager starting in October 2018. The House Manager will be responsible for calling each house on the date specified on the schedule to to ensure that unannounced fire drills will occur each month.House Manager will be responsible for doing a monthly review of the Fire Drills performed, and the Residential Manager will be responsible to oversee and review the Fire Drills on a quarterly basis to ensure they are completed correctly. 09/20/2018 Implemented
6400.112(e)A fire drill was not held during sleeping hours between 9/16/17 and 3/16/18.A fire drill shall be held during sleeping hours at least every 6 months. A Fire Drill during sleeping hours between at all Residential sites was done on September 20, 2018. The Residential Manager, the House Manager, and the Program specialist were all retrained on Fire Safety to include Chapter 6400.112 regulation.A Fire Drill Schedule was made and will be implemented by the House Manager starting in October 2018.House Manager will be responsible for doing a monthly review of the Fire Drills performed, and the Residential Manager will be responsible to oversee and review the Fire Drills on a quarterly basis to ensure a fire drill during sleeping hours at least every 6 months. 09/20/2018 Implemented
6400.113(a)Individual #1 was most recently instructed in fire safety on 7/5/17. Individual #2 was most recently instructed in fire safety on 6/5/17. 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. Both Individual #1 and #2 were instructed in Fire Safety on September 20, 2018. All individuals' records were reviewed to ensure they all have had their annual Fire Safety.The Residential Manager will be responsible for ensuring each Individual's Fire Safety trainings are completed upon admission and reinstructed annually and will include 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. Individuals' Fire Safety Training Agenda's will be kept in the Fire Safety Binder, (same place as the fire drills) so that they are Reviewed by House Manager when reviewing the Fire Drills performed, and the Residential Manager when reviewing the Fire Drills on a quarterly basis to ensure they are completed correctly. 09/19/2018 Implemented
6400.141(c)(6)Individual #2 had Tuberculin skin testing completed 10/7/15 and then again 5/4/18.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. All individuals' Psychiatric Medication Review forms were checked to ensure TB's were completed and up-to-date The Program Specialist, Residential Manager, and House Manager were retrained in Individual Health/Medication Overview to include 6400.141(c)(6) regulation.Program Specialist will be responsible to review the documentation after appointments to ensure all information was filled out and completed correctly, and individual records will be checked on a quarterly basis, to ensure records are up-to-date. The Program Specialist will be responsible for doing these reviews, as the PS does the individual's Quarterly Reviews. 09/19/2018 Implemented
6400.141(c)(13)Individual #1's physical examination completed 5/29/18 did not include allergies. Individual #2's physical examination completed 10/23/17 did not include allergies.The physical examination shall include: Allergies or contraindicated medications.The Physical Examination form that is used for Individual's yearly physicals was changed immediately, to include allergies. The Program Specialist, Residential Manager, and House Manager were retrained in Individual Health/Medication Overview to include 6400.141(c)(13) regulation.This form will be used for future physical examination's, and the Program Specialist will be responsible to review the documentation after appointments to ensure all information was filled out and completed correctly, and individual records will be checked on a quarterly basis, to ensure records are up-to-date. The Program Specialist will be responsible for doing these reviews, as the PS does the individual's Quarterly Reviews. 09/19/2018 Implemented
6400.163(c)The psychiatric medication reviews completed 7/19/18, 4/26/18, and 11/6/17 for Individual #2 did not include the reason for prescribing the medication. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Psychiatric Medication Review form was updated and will be used for future Psychiatric Medication Reviews. All individuals' Psychiatric Medication Review forms were checked to ensure they included the Reason for Prescribing the Medication.The Program Specialist, Residential Manager, and House Manager were retrained in Individual Health/Medication Overview to include 6400.163(c) regulation.Program Specialist will be responsible to review the documentation after appointments to ensure all information was filled out and completed correctly, and individual records will be checked on a quarterly basis, to ensure records are up-to-date. The Program Specialist will be responsible for doing these reviews, as the PS does the individual's Quarterly Reviews. 09/19/2018 Implemented
6400.213(1)(i)Individual #1's record did not include 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. Both Individual records were fixed immediately to include hair color and identifying marks. All individuals' records were checked for the following information: the name, sex, admission date, birth-date and social security number, 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, the race, height, weight, color of hair, color of eyes and identifying marks, the religious affiliation, the next of kin, and a current, dated photograph, Documentation was correct as needed. All individual records will be checked on a quarterly basis, to insure records are up-to-date. The Program Specialist will be responsible for doing these reviews, as the PS does the individual's Quarterly Reviews. 09/13/2018 Implemented
SIN-00121752 Renewal 09/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door of the home was used as the exit route in the monthly fire drills held between August 2016 and August 2017. Alternate exit routes shall be used during fire drills. House Manager will review Fire Drills Quarterly to make sure they follow 55 Pa Code Chapter 6400.112 regulations. [Immediately, the CEO shall train all staff persons responsible for conducting fire drills on the requirements of completing and documenting fire drill as per 6400.112(a)-(I). Documentation of trainings shall be kept. At least monthly for 1 year and then continuing quarterly, the CEO or designee shall audit all fire drill records at all community homes to ensure fire drills are conducted and documented at required. Documentation of audits shall be kept. (AS 10/10/17)] 10/06/2017 Implemented
6400.141(a)Individual #1's most recent physical examination was completed 10-27-16, and the previous examination was completed 10-05-15.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Yearly physicals will be scheduled in advanced to meet 55 PA Code Chapter 6400.141 requirements. Also documentation of any appointments cancelled/rescheduled by the doctor's office will be in individual's file.[Immediately, the CEO shall develop and implement a tracking system to ensure that individuals have physical examinations completed, timely and are following physicians orders which shall be kept. (AS 10/10/17)] 10/06/2017 Implemented
SIN-00102520 Renewal 10/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The medication reviews for Individual #2 were completed on 10/1/15 and then again on 2/3/16. The medication reviews for Individual #2, completed on 2/3/16 and 4/25/16 did not include the necessary dosage of the prescribed medications. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Prior to licensing the Psychiatric Care Form was updated to include a Medication Review which includes the reason for prescribing the medication, the need to continue the medication and necessary dosage. Moving forward the Program Specialist will review all documentation following the Psychiatric Review to ensure all required information has been completed [Immediately, the Director of Operations shall develop and implement procedures to include a tracking system and a review process to ensure all Individuals' medication reviews are completed with all required information and timely. Within 30 days of receipt of the plan of correction the Director of Operations shall train all staff responsible for ensure accurate and timely completion of the medication reviews on the aforementioned procedures. Documentation of reviews and tracking system shall be kept and reviewed by the Director of Operations to ensure completion. (AS 11/15/16)] 11/08/2016 Implemented
6400.181(f)The program specialist provided Individual #1's assessment completed 5/7/16 the Supports Coordinator on 5/10/16 for the ISP meeting which was held on 6/7/16.(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). Attached documentation (copy of email) that showed the Program specialist attempted to send the Service Coordinator a copy of assessment of 5/7/2016, which would have been 30 days prior to the ISP meeting. Due to Program Specialist not receiving emails for this Service Coordinator prior Program Specialist email was unable to be delivered. Prior to licensing this issue has been resolved. Program Specialist has also been retrained on regulations relating to development, annual update and revision of the ISP [The program specialist provided Individual #1's assessment to the supports coordinator on 10/12/16. Immediately, the Director of Operations shall develop and implement a tracking system to ensure the program specialist provides all Individuals' assessments to all plan team members within the required timeframes. Within 30 days of receipt of the plan of correction the Director of Operations shall train the Program specialist on the policies and procedures. Documentation of correspondence and tracking system shall be kept and reviewed by the Director of Operations to ensure completion. (AS 11/15/16)] 11/08/2016 Implemented