Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209076 Renewal 07/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186As of today's inspection, Emmaus is not the rep payee for Individual #1. The assessment and the ISP for this individual were not consistent in indication of REP payee status. The assessment indicates the individual's grandmother is his rep payee, while his ISP reflects Emmaus as rep payee. Both ISP and assessment should reflect the same information.The home shall implement the individual plan, including revisions.Individual #1 Supports Coordinator and multidisciplinary team was sent written request by the CFOO to update Individual #1 ISP to reflect the individual's grandmother as rep payee. 09/09/2022 Implemented
SIN-00190677 Renewal 07/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual 1 did not have up to date supporting documentation indicating individual 1 refusal of a TB test.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. The individual and their team were scheduled for a meeting to occur on 9/29 to obtain proper documentation outlining the refusal of a TB test using the updated Refusal of Treatment consent and procedures (file 1). 09/29/2021 Implemented
6400.142(g)Individual 1 does not have a dental hygiene plan.A dental hygiene plan shall be rewritten at least annually. The individuals dental plan, using the new Dental plan Hygiene template, is scheduled to be completed by 10/1/21 by the Residential Manager (file 6). This plan will be retained in the individuals permanent records and updated annually as described on the template. 10/01/2021 Implemented
6400.143(a)There was no documentation to address Individual 1 refusing to go to the dentist. At the same time, there is no documentation to address Individual 1's anxiety of going to the dentist.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The Program Specialist scheduled a multidisciplinary team meeting to occur on 9/29 with the individual and his team to complete the Refusal of Treatment updated consent, offer support, education, and interventions for the individual so that dental treatment can occur. Documentation (File 1) through a sign in sheet as well as a summary of the meeting will be maintained in the individual permanent records and noted on the updated individual's Annual Assessment. 09/29/2021 Implemented
6400.144The medical (MAR) was reviewed for individual 1. The PRN medication (Acetaminophen Tylenol) was not documented or located in the MAR.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The COO and Residential Manager verified that the PRN medication of the individual was not a current RX and it was properly disposed of on 7/27/21. The COO created a Medication Management Policy on 9/13/21 that outlines proper storage of medications, disposal of medications, and proper recording of medications on an Individuals MAR. 12/31/2021 Implemented
SIN-00170042 Renewal 01/30/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were Various cleaning and personal hygiene products left unlocked throughout home, there was laundry detergent on top of the dryer, cleaning agents and personal hygiene products were under the sink in both kitchen and upper level bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals. The individuals' ISP was updated to reflect that the individual's safety or health are not at risk around poisonous materials and that the individual can have access to these items. The individual is aware of poisonous materials and recognizes words such as "poison" and "danger". However, the Individual Rights, Choices, and Services Policy was modified so that the organization ensures appropriate poison material storage and safety. Moreover, a monthly on-site audit tool was created for the compliance manager to audit each location to ensure compliance and appropriate homes. 03/12/2020 Implemented
6400.62(c)During inspection, cleaning agents were observed not in their original containers. In the kitchen there was a spray bottle with the words "basic G cleaner" written on the bottle. In the second floor bathroom under the sink there was an unlabeled spray bottle containing an undetermined solution.Poisonous materials shall be stored in their original, labeled containers. An appropriate label was put on the Basic G bottles. The Individual Rights, Choices, and Services policy was updated to reflect that the organization ensures proper handling of poisonous materials, including ensuring proper storage as well as labels. 03/12/2020 Implemented
6400.112(c)The fire drill records for this home did not document the exits used for the months of February 2019, March 2019, August 2019, October 2019, November 2019 and December 2019.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. A new fire drill form was created and used for March 2020 fire drill for each site. This fire drill form requires the Compliance Manager's review/signature to ensure compliance. The fire drill form reflects the date, time, the amount it took for evacuation, the exit route used, problems encountered, and if the fire alarm or smoke detector was operative. 03/11/2020 Implemented
6400.143(a)Individual #1 refused the PPD on the physical dated 12/16/19 and there was no documentation of attempts to train or counsel the individual.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual #1 received counseling on the importance of routine medical examination and treatment. The individual, the counselor, and the individual's guardian signed off on this form. A chart audit tool was modified to reflect this counseling form. A medical refusal policy was developed, which provides all staff steps to take in an individual refuses medical or dental examination or treatment. 03/12/2020 Implemented
6400.166(b)Individual #1 prescribed medication Lamictal tablet 200 mg was administered, per staff, on January 9, 2020 at 10 pm, however the medication log was not signed immediately after use as being administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff person received a re-review/training on medication administration documentation. The organization developed a weekly medication audit tool to ensure proper documentation and administration of medications. 03/11/2020 Implemented
SIN-00148046 Renewal 12/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(d)Individual #1's 1:1 staff on 11/8/18 at the 3pm-7pm shift was not present in the home through review of time sheets.The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). The house manager, who completes scheduling, will ensure that all ratios are kept. He will alert CEO immediately for a back up. He will record anyitme ratio is not in compliance with resident's isp. 01/18/2019 Implemented
6400.62(a)The bathroom had unlocked cleaning products.Poisonous materials shall be kept locked or made inaccessible to individuals. The poisons were locked during the inspection. The house manager will ensure that all cleaning products and poisons will be locked in the closet in the basement. 01/18/2019 Implemented
6400.64(f)The trash can in the back yard does not have a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.A new trash can was purchased with a lid. The lids that tend to blow off, have been bungy-corded to the can to prevent this. 01/25/2019 Implemented
6400.66The light fixture at the back door did not have a bulb. The basement exit did not have a light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. 6400.66 The light bulbs have been replaced by the landlord. The house manager will be responsible for checking for future stains. (photo has been emailed) 01/18/2019 Implemented
6400.67(a)The ceiling located in the basement had water stains.Floors, walls, ceilings and other surfaces shall be in good repair. 6400.67 The ceiling tiles have been replaced by the landlord. The house manager will be responsible for checking for future stains. (photo has been emailed) 01/18/2019 Implemented
6400.70The telephone in the basement was inaccessible for the individuals living in the home.A home shall have an operable, non coin-operated telephone with an outside line that is easily accessible to individuals and staff persons.A contractor has moved the landline up to the kitchen for greater accessibility. A photo will be sent via email upon completion.0 02/05/2019 Implemented
6400.81(k)(1)In individual #2's bedroom, the mattress was on the floor.In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. A platform bed frame will be purchased so that resident cannot move it, thus causing possible injury to himself. The CEO will approve and purchase this. 02/18/2019 Implemented
6400.111(f)The fire extinguisher in the kitchen does not have an inspection tag. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. 6400.111 The fire extinguisher was taken to General Fire Company to be recharged. ( A photo was emailed). The house manager will check these yearly. 01/18/2019 Implemented
6400.112(d)Individual #1 refused to evacuate during fire drills on 10/20/18 and 8/14/18. 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. The house manager will ensure that each core member eggresses under 2..5 minutes for the monthly fire drill. The CEO will check on the monthly fire drills. 01/18/2019 Implemented
6400.112(h)The fire drill records did not have documentation of the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.6t400.112 A new form was created that shows a meeting place area for sign in. (photo was emailed) 01/18/2019 Implemented
6400.141(c)(10)Individual #2's annual Physical Exam dated 6/27/2018 does not indicate if they are free of Communicable DiseasesThe physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Upon admission into the program or homes, The Program Specialist will review the participants' physicals to ensure that the Free of Communicable Disease" section is checked off. If not, then remediation will be utilized, such as not accepting the individual into the program. 01/18/2019 Implemented
6400.181(d)Individual #2's annual assessment Date 1/11/18 the program specialist signed, but did not date the assessment.The program specialist shall sign and date the assessment. 6400.216 The Program Specialist will be advised by the CEO to sign and date assessments that she writes. CEO will read the assessments after the Program Specialist writes them. 01/19/2019 Implemented
6400.181(e)(9)Individual #2's annual assessment Date 1/11/18 did not document individual's disability.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. 6400.216 The Program Specialist will thoroughly understand her job description per the 6400 regulations, including writing a correct assessment which includes all necessary information such as individual's disability, functional and medical limitations. The CEO will read the assessments for required information. 02/18/2019 Implemented
6400.181(e)(10)Individual #2's annual assessment Dated 1/11/18 did not include a Lifetime Medical History.The assessment must include the following information: A lifetime medical history. 6400.181 Program Specialist will complete a Lifetime Medical History each anniversary year based on the 6400 regulations. The CEO will read over this report upon completion for accuracy and compliance. 02/18/2019 Implemented
6400.181(f)Individual #2's annual assessment Dated 1/11/18 was not 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). The Program Specialist will be trained on all areas of her job description as written in the 6400 regulations, including the correct procedure of sending the assessment to the Supports Coordinator. The CEO will check that the assessments are being sent to the Supports Coordinator both initially and annually. 02/18/2019 Implemented
6400.216(a)Individuals' files in the basement were left unlocked. An individual's records shall be kept locked when unattended. 6400.216 The door knob on basement door was changed to a key lock door knob. The house manager will make sure it remains locked when the basement is not in use. The CEO will oversee the house manager. 01/18/2019 Implemented
SIN-00126489 Renewal 10/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 did not have an up to date financial record of funds received and or deposited .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. Financial records for individual #1 are held by CEO/mother who has power of attorney for individual. Going forward, each individual will have a recorded ledger with accurate accounting for receipt and deposits of individuals funds. also a record manifest of individuals property will be kept for accurate accounting of individuals property. 01/08/2018 Implemented
6400.22(d)(2)Individual #1 did not have documentation of disbursements made for them.(2) Disbursements made to or for the individual. Financial records for individual #1 are held by CEO/mother who has power of attorney for individual. Going forward, all disbursements will have documentation to evidence the distribution of funds made on the behalf of the individual for the individual. 01/08/2018 Implemented
6400.46(f)Staff person #1 did not have documentation of initial fire safety training.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Staff have been trained in Fire Safety for the home on 1-11-2018 as verified by documentation at end of scan. Going forward, all staff and Program Specialists will be trained 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, smoking safety procedures if individuals or staff persons at the home, the use of fire extinguishers, smoke detectors and fire alarms and notification of local fire department as soon as possible after a fire is discovered. 01/08/2018 Implemented
6400.68(b)The hot water in the bathtub was 130.6°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. With water temperature reading being 130.6 on day of inspection, Program Specialist adjusted heat on Water heater to under 120.0 degrees on day of inspection. Subsequent inspections done by Program Specialist and Director of Residential indicted that water temperature was being maintained under 120.0 F Director of Residential follows up with monthly inspection check and adjusts if necessary. Staff have been instructed to be aware of any water temperature change and to notify supervisor immediately of any dramatic change. Going forward, temperature of hot water in the home will not exceed 120 degrees F. temperature will be monitored on a monthly basis. 01/08/2018 Implemented
6400.76(a)There was lint the size of a golf ball in the dryer in the basement. Furniture and equipment shall be nonhazardous, clean and sturdy. Lint was removed from Dryer on October 13, 2017. Sign was placed on dryer on October 16, 2017 with Director of Residential following up with monthly inspection checks. Going forward, as a part of ongoing fire safety and maintenance, all dryer lint will be removed after each and every cycle of drying with the house clothes dryer. 01/08/2018 Implemented
6400.141(a)Individual #1's physical examination dated 9/7/16 was more than a year from the previous examination dated 8/4/15.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Going forward, all individual's are subject to a yearly physical examination with Emmaus Home approved physical forms used. 01/08/2018 Implemented
6400.151(c)(2)Staff person #1's physical examination dated 8/18/16 did not have documentation of a Tuberculin skin test. 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. Staff #1 Received documentation of the Tuberculin skin test on 2/3/18. Going forward, all staff persons physical examinations will include a Tuberculin skin test by Mantoux method with negative results every two years. See attached Emmaus Home physical form. 01/08/2018 Implemented
6400.151(c)(3)Staff person #1's physical examination dated 8/18/16 did not have a free of communicable disease statement. 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. Staff #1 had documentation of free from communicable disease on 2/3/18. Going forward, all staff physical forms contain a space to be indicated of if individual is free of communicable disease 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. 01/08/2018 Implemented
6400.186(b)Individual #1's 3 month ISP reviews dated 6/17, 3/17 and 9/17 were not signed and dated by the program specialist and the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Was corrected on October 16, 2017. Going forward, all ISP reviews will be signed and dated by the Program Specialist and consumer upon review of the ISP. 01/08/2018 Implemented
SIN-00116999 Initial review 07/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were multiple paint cans, which indicated to contact poison control if ingested, located in the basement.Poisonous materials shall be kept locked or made inaccessible to individuals.Basement closet will be have a lock installed by the landlord. A picture will be sent.[Executive Director or designee will conduct monthly physical site inspections to ensure poisonous materials are locked DS 07/19/17] 07/17/2017 Implemented
6400.67(a)There was water damage to the surface of the wood located inside the cabinet under the kitchen sink . There was rust found on the light fixture above the mirror located in the upstairs bathroom. Floors, walls, ceilings and other surfaces shall be in good repair. The piece of wood under the kitchen sink shall be replaced by a carpenter. The light fixture in bathroom will be replaced by landlord. Pictures will be sent. [Executive Director or designee will conduct monthly physical site inspections to ensure floors, ceilings, and other surfaces are in good repair DS 07/19/17] 07/16/2017 Implemented
6400.68(b)The water temperature was measured at 124.8 degrees in the shower located in the upstairs bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water was lowered to 118 degrees by the landlord. A monthly test will be conducted by house assistant. A record will be kept on site. 07/16/2017 Implemented
6400.70There was no telephone in the home.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. A landline will be installed. Anne Bradley Leopold will handle this. A photo will be sent of the telephone. 07/16/2017 Implemented
6400.71There were no emergency phone numbers posted in 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. Emergency phone numbers, including the closet hospital, police, ambulance and poison control will be listed and taped by the land line phone. This will be done by Anne Bradley Leopold, Executive Director. Evidence of this will be sent.[Executive Director or designee will conduct monthly physical site inspections to ensure emergency numbers are posted by each telephone in the home DS 07/19/17] 07/16/2017 Implemented
6400.77(a)There was no first aid kit in the home. A home shall have a first aid kit. A first aid kit will be kept in the house at all times. It contains a manual. It will be placed there and maintained by Anne Bradley Leopold, executive director. A picture has been sent.[Executive Director or designee will conduct monthly physical site inspections to ensure the first aid kit is present in the home DS 07/19/17] 07/16/2017 Implemented
6400.110(a)There was no smoke detector in the basement. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. An interactive smoke alarm system called Kidde Battery operated wireless interconnected smoke alarm will be installed by Larry Leopold. They will be tested monthly when fire drills are conducted. 07/16/2017 Implemented
6400.110(e)There are three stories in the home and the smoke detectors in the home were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. An interactive wireless smoke alarm system called Kidde will be installed by Larry Leopold on all three floors, including the second, first and basement floors. 07/16/2016 Implemented
6400.111(a)There were no fire extinguishers in the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. We will place an operable fire extinguisher with the minimum rating of 2-A on each floor, including the basement and attic. Larry Leopold, our director of operations will be the person to do this. These extinguishers will be checked monthly by him and reset yearly by General Fire Company. Records will be kept on site. 07/16/2017 Implemented
6400.111(c)There was no fire extinguisher in the kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). A 2-A 10BC rating fire extinguisher will be placed in the kitchen by Larry Leopold. It will be tested monthly by Larry Leopold and reset yearly by General Fire Company. Records will be kept on site. A report will be kept in the house. A photo will be sent. 07/16/2017 Implemented