Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235693 Renewal 12/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Poisons are not kept in their original containers. At the time of inspection in the hallway closet there was a clear bottle containing a green liquid. The bottle had "fabric softener" written on the it. It is unclear what the liquid in the bottle was as it was not labeled.Poisonous materials shall be stored in their original, labeled containers. Upon discovery, the unlabeled poisonous material was discarded. 12/07/2023 Implemented
6400.77(b)The first aid kit did not have a thermometer at the time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer was immediately placed in the First Aid Kit. 12/08/2023 Implemented
SIN-00199093 Renewal 12/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The garbage can in the bathroom on the lower level of the home was covered in rust.Floors, walls, ceilings and other surfaces shall be in good repair. Garbage can replaced. Program Director to complete monthly walk through's each home to ensure all items with in the home are within good repair. 02/28/2022 Implemented
6400.106The furnace has not been inspected annually. There is no documentation of any inspections of the furnace.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. Furnaces throughout Eihab homes have begun to be serviced and will be completed by 2/28/22 02/28/2022 Implemented
6400.141(a)Individual #1's admission date is 12/13/21. Individual; #1 did not have a physical examination completed within 12 months prior to placement. Documentation of an exam that was completed on 11/2/21 was provided; however, this did not include all requirements of the physical including: A review of previous medical history, 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, Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician, Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204, 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, 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, Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals, an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals, physical limitations of the individual, allergies or contraindicated medications, medical information pertinent to diagnosis and treatment in case of an emergency and special instructions for the individual's diet.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Agency nurse will receive all medical documentation and will review to ensure completion prior to filing in the individual's medical record. 02/28/2022 Implemented
6400.213(1)(i)Individual #3's record did not contain a current, dated photograph.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.All agency individual's photographs to be updated, dated and added to the individuals record by 3.15.22. 03/15/2022 Implemented
SIN-00191680 Unannounced Monitoring 08/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Fire drills are not unannounced. There is a calendar in the back of the fire safety book that had the scheduled times and dates of fire drills through the month of October. An unannounced fire drill shall be held at least once a month. In compliance with 6400.112 (A) all fire drills are unannounced list found during this monitoring has been removed. 08/26/2021 Implemented
6400.141(a)Eihab emailed a copy of Individual #1's most current physical exam. This physical exam is dated 7/2/2020. His next physical exam is scheduled for 9/28/2021, which exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Upon discovery of this issue individual #1 was assisted in accessing medical service to complete his annual exam due to lack of availability of his PCP 08/07/2021 Implemented
6400.214(b)The following required documents were not kept on-site at this location for Individual #1: Physical exam, dental exam, and assessment. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Residential Books have been updated to include all current annual documentation, these books will be maintained in the program. 08/26/2021 Implemented
6400.166(a)(11)Individual #1 is prescribed Famotidine 20mg (2 tabs) QD at 8am and 8pm. The purpose or diagnosis for this medication is not listed on his Medication Administration Record. ((Repeat Violation: 1/19/2021, 5/12/2021, 7/16/2021))A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Program Managers are monitoring Medication Administration Records daily with Medical Coordinators auditing weekly. Staff have undergone retraining to follow ODP Medication Administration protocols. Medical coordinators and Program Specialists have met with Pharmacy Administrators to review with them our regulatory needs related to the MAR. 08/26/1921 Implemented
SIN-00186547 Unannounced Monitoring 04/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(c)The agency neglected Individual #6 by not implementing Individual #6's hours of supervision according to the Individual Support Plan(ISP). The ISP states that they have 14 hours of home supervision, they require staff to be within the home. Individual #6 has 10 hours of independent time per day. On 4/13/21, The Supports Coordinator for Individual #6 conducted an unannounced visit to the home and discovered supervision was not being provided. Staffing scheduled for the home show that staffing is being provided only from 11pm to 7am. Staffing is not being provided in excess of the 10 hours of supervision Individual #6 can safely maintain.(Repeat Violation: 1/22/2021)An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Since the time of the survey the schedule has been reassigned from the Program Operations Administration/Management to the Quality Assurance Director to ensure that all individuals are not abused or neglected due to staffing. In addition an incident has been filed in EIM to report an allegation of neglect due to staffing levels of supervision. 06/15/2021 Implemented
6400.45(e)Individual #6's alone time was being used at the convenience of the home due to staff shortages. It was reported by individual #6's Supports Coordinator that on 4/13/21 when they conducted an unannounced visit this occurred as well as other times, but exact dates are unknown. Staffing schedules for the home indicate that staffing is being provided only from 11pm to 7am. (Repeat Violation 2/22/2021).An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.Since the time of the survey the schedule has been reassigned from the Program Operations to the Quality Assurance Director to ensure that all individuals are not abused or neglected due to staffing. In addition an incident has been filed in EIM to report an allegation of neglect due to staffing levels of supervision. 06/15/2021 Implemented
6400.186The agency is not implementing Individual #6's hours of supervision according to the Individual Support Plan(ISP). Their ISP states that they have 14 hours of home supervision, they require staff to be within the home. Individual #6 has 10 hours of independent time per day. On 4/13/21, The Supports Coordinator for Individual #6 conducted an unannounced visit to the home and discovered supervision was not being provided. Staffing scheduled for the home show that staffing is being provided only from 11pm to 7am. (Repeat Violation: 1/22/2021)The home shall implement the individual plan, including revisions.Since the time of the survey the schedule has been reassigned from the Program Operations to the Quality Assurance Director to ensure that all individuals are not abused or neglected due to staffing. 06/15/2021 Implemented
SIN-00183781 Unannounced Monitoring 01/25/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(e)Individual #2's alone time was being used at the convenience of the home due to staff shortages. Several staff reported coming onto different shifts and there being no staff on duty due call offs or not having enough staff to cover shifts. Exact dates are unknown, but it was reported this has occurred several times in recent months.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.Program administration meets on a weekly basis to review the staffing schedule and that individuals are not left unsupervised solely for the convenience of the staff or the agency. On a weekly basis, the facility is scheduled with 24-hour coverage. Staff will be retrained by March 15, 2021 to notify management in the event (and follow the chain of command) in the event they arrived for their shift and there is no staff on duty due to call off or an emergency. In the event of an emergency and/or the scheduled staff cannot or fail to arrive on shift, management staff will expedite to arrange coverage for the shift. Staff will be mandated to ensure individual #2's needs are met and that individuals are not left unsupervised solely for the convenience of the staff shortage or program needs. Administrative staff are currently working on a designated per diem list and a staffing agency to assist with on-call emergency staffing needs in the facilities. 03/15/2021 Not Implemented
SIN-00181630 Renewal 01/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Staff #1 was hired on 12/4/2020. She did not receive fire safety training until 1/11/2021. According to staff schedules, Staff #1 was working in the houses prior to receiving 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.Since the time of survey Staff #1 is no longer employed with the agency. The new hire orientation training process has been revised to include new staff will not work on shift in ratio until all required training has occurred. The Training Director will provide an approval to the Program Specialist and the HR Department to indicate employees has passed all required training and can work in ratio on shift. that staff will only shadow and no in ratio. Agency and ODP required training will be conducted under the Training Coordinator or designee facilitation. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine training record reviews. The training record reviews will consist of ensuring orientation includes all required areas including the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. The Training Coordinator will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.51(a)(3)Orientation must be completed prior to working alone with individuals and within 30 days after hire. Staff #1 was hired on 12/4/2020. The following orientation areas were not completed until after 30 days: Person-centered practices, individual choice and supporting individuals to develop and maintain relationships (1/12/2021); prevention, detection and reporting of abuse, suspected abuse and alleged abuse (1/11/2021); recognizing and reporting incidents (1/10/2021); and job related skills & knowledge such as ISP training (1/11/2021). According to staff schedules, Staff #1 was working in the houses prior to completing these areas of training.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.Since the time of survey Staff #1 is no longer employed with the agency. The new hire orientation training process has been revised to include new staff will not work on shift in ratio until all required training has occurred. The Training Director will provide an approval to the Program Specialist and the HR Department to indicate employees has passed all required training and can work in ratio on shift. that staff will only shadow and no in ratio. Agency and ODP required training will be conducted under the Training Coordinator or designee facilitation. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine training record reviews. The training record reviews will consist of ensuring orientation includes all required areas including the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. The Training Coordinator will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
SIN-00204263 Unannounced Monitoring 04/20/2022 Compliant - Finalized