Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00102823 Renewal 10/25/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)The physical examinations for Direct Service Worker #1 were completed 3/12/13 and then again on 1/26/16. 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. Each employee will have a physical completed as per regulatory time frames. This employee was not tracked properly. The Human Resource (HR) Director will be trained in regulation 6400.151(a) to ensure that physicals are completed within the regulatory time frames by 11/18/2016. Each employees¿ personnel file will be reviewed to ensure that employee physicals have been completed as per regulations by the HR Director by 11/30/2016. Ongoing, the HR Director will track and monitor for compliance using the current database of employees¿ physical due dates monthly or a similar process that will ensure compliance. 11/12/2016 Implemented
6400.151(c)(2)The Tuberculin skin testings for Direct Service Worker #1 were completed 3/12/13 and then again on 1/26/16. 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. Each employee will have Tuberculin skin testing by Mantoux method completed as per regulatory time frames. This employee was not tracked properly. The Human Resource (HR) Director will be trained in regulation 6400.151(c)(2) to ensure that Tuberculin skin testing by Mantoux method are completed within the regulatory time frames by 11/18/2016. Each employees¿ personnel file will be reviewed to ensure that employee Tuberculin skin testing by Mantoux method have been completed as per regulations by the HR Director by 11/30/2016. Ongoing, the HR Director will track and monitor for compliance using the current database of employees¿ physical due dates monthly or a similar process that will ensure compliance. 11/12/2016 Implemented
SIN-00085760 Renewal 10/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The interior basement stairs and the back porch outside steps did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Nonskid surfaces / strips will be added to the interior basement stairs and the exterior deck steps. All Program Specialists will be trained in the regulation to ensure future compliance. All other surfaces have been inspected and are in compliance. [CEO or designee will complete on site visits of each home at least quarterly to ensure steps and/or stairs have non skid surfaces. (AS 12/8/15) 11/25/2015 Implemented
6400.141(c)(7)The physical examination completed on 10/13/14 for Individual #1, date of birth 3/15/54 did not include a gynecological examination. 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. Records for other female consumers have been checked and are in compliance regarding this regulation. Upon admission this individual's next of kin did not feel the examination was appropriate. At a meeting in spring 2015, the next of kin understood the need for the examination and options in the future. The individual did have a gynecological examination in June 2015. To prevent this citation from occurring in the future, the Program Specialists have all been trained in this regulation. Further, a process has been established that utilizes a shared calendar with the Program Director. The Program Director will monitor appointments with the Program Specialists to ensure appointments are occurring as regulated / in a timely manner. 11/20/2015 Implemented
6400.141(c)(8)Individual #1, date of birth 3/15/54, had a mammogram completed on 4/17/14 and then again on 6/11/15.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Records for other female consumers have been checked and are in compliance regarding this regulation. To prevent this citation from occurring in the future, the Program Specialists have all been trained in this regulation. Further, a process has been established that utilizes a shared calendar with the Program Director. The Program Director will monitor appointments with the Program Specialists to ensure appointments are occurring as regulated / in a timely manner. 11/20/2015 Implemented
6400.186(d)Individual #1's 3 month ISP reviews completed on 11/14/14, 2/14/15, 5/12/15 and 8/12/15, were not sent to all plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. To immediately correct this citation, the 3-month ISP Reviews will be sent to the day program for the individual. Records for other individuals have been checked and are in compliance. To ensure future compliance: All Program Specialists will be trained in the regulation. The ISP Review Document has been updated to add a list of team members for the individual. All activities listed will be completed by 11/20/2016.[Immediately, Program directors and program specialists will review each individuals' ISPs, invitation letters and other documentation to ensure the entire team is included in receiving ISP reviews as required. (AS 12/8/15) 11/20/2015 Implemented
6400.213(1)(i)The record for Individual #1, date of admission 11/3/14, 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.Records for other individuals have been checked and are in compliance. To ensure future compliance: All Program Specialists will be trained in the regulation. The Pertinent Information Form is used to document ¿identifying marks¿. The Program Specialist erroneously left the area blank. The Program Specialist has updated the form. [CEO or designee will review a 25% sample of all individual records at least quarterly for the next 6 months to ensure all required personal information including identifying marks is present. (AS 12/8/15) 11/20/2015 Implemented
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