Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217690 Renewal 01/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, dated 3/24/2022, did not address 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. Provider has updated their physical form to mirror the state recommended form that was revised on 1/10/23 and emailed to all providers. This change will make it easier for doctors to complete the physical form in its entirety. 01/23/2023 Implemented
6400.181(e)(4)Individual #1's assessment, completed 3/11/2022, states the individual can have up to 2 hours unsupervised per week, but the Individual Support Plan (ISP), last updated 1/05/2023, states the individual can be left alone for 4 hours. The assessment must include the following information: The individual's need for supervision. The Provider will immediately review both the ISP and assessment for any discrepancies and areas of clarification. In addition, the Provider will meet with the entire interagency team including the individual to ensure that all informations correct. The Provider will ensure both the ISP and assessment are accurate. 03/05/2023 Implemented
6400.182(c)Individual #1's assessment, completed 3/11/2022, states the individual can evacuate within 2.5 minutes with verbal prompts; however, the individual support plan, last updated 1/05/2023, states the individual would not require any assistance evacuating in the event of a fire. The Individual Support Plan for Individual #1, last updated 1/05/2023, states the individual has a behavior support plan. Chief Executive Officer #1 states the individual does not currently have a behavior support plan.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Provider will immediately review both the ISP and assessment for any discrepancies and areas of clarification. In addition, the Provider will meet with the entire interagency team including the individual to ensure that all informations correct. The Provider will ensure both the ISP and assessment are accurate. 03/05/2023 Implemented
SIN-00183942 Renewal 02/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 2/26/2021 at 11:02AM, the hot water temperature in the sink in the bathroom in the hallway of the home measured 125.8°FHeat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. March 1, 2021, EHC in conjunction with the property manager and owner installed a protective guard to prevent to prevent individuals from coming in contact with heat sources exceeding 120°F. Specifically, the bathroom sink had a temperature control valve placed on it that prevents the facet from being turned all the way to the left and regulates the temperature of the hot water pipes. Effective immediately, EHC will ensure all program specialists (or designated EHC staff) are trained to the requirements regarding regulating heat sources such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, to prevent individuals from coming in contact with such heat sources. Monthly, the program specialist (along with the program director) will continue to monitor and document the monitoring of heat sources such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces. The program specialists or designated EHC staff will ensure procedures regarding this regulation are implemented. Effective immediately, on a monthly basis, the program director will monitor the program specialists (or designated EHC staff) and verify the monitoring of heat sources such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, to prevent individuals from coming in contact with such heat sources. The program director, in conjunction with EHC administrative staff, will conduct quarterly reviews of the heat source monitoring and documentation of the monitoring in order to demonstrate compliance with Chapter 6400 regulations. EHC QMP will include quarterly reporting of the heat source monitoring. [On 3/19/21, the Executive Administrator for the agency provided to the Department a water temperature check document recording that the water temperature on 3/1/21 at the sink measured 106.3 Degrees. (AES,HSLS on 3/22/21)] 02/01/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 3/17/2020. The rights document did not include the following rights: 6400.32e, the right to make choices and accept risks; 6400.32f, to refuse to participate in activities and services; 6400.32g, to control his own schedule and activities; 6400.32h, to control his own schedule and activities; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.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.Effective February 26, 2021, EHC revised the "Rights of the Individual" to include: (e) An individual has the right to make choices and accept risks; (f) An individual has the right to refuse to participate in activities and services; (g) An individual has the right to control the individual's own schedule and activities; (h) An individual has the right to privacy of person and possessions; (p) An individual has the right to choose persons with whom to share a bedroom; (q) An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home (relating to negotiation of choices); (t) An individual has the right to access food at any time; (u) An individual has the right to make health care decisions; and (v) An individual's rights may only be modified (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. EHC has developed and implemented a plan to remain compliant regarding Department policy and procedure updates, compliance with Chapter 6400 and agency bulletins as of February 26, 2021. As of March 1, 2021, EHC trained the administrative and designated EHC staff to review Department policies and bulletins on a monthly basis. As of February 26, 2021, EHC informed and explained individual rights and the process to report a rights violation to the individual, and persons designated by the individual. Annually these rights will be reviewed with individuals residing in EHC's community homes. Effective immediately, EHC will ensure all program specialists (or designated EHC staff) are trained to the requirements regarding all elements of individual rights. The program specialist or (designated EHC staff) will ensure procedures regarding this regulation are implemented in compliance with Chapter 6400. Effective immediately, the program director will monitor the program specialist (or designated EHC staff) to ensure that all individuals in the home have been informed and explained all elements of their individual rights, to include persons designated by the individual upon admission and annually. Effective immediately, the program director, in conjunction with EHC administrative staff, will conduct quarterly reviews to report compliance with this regulation on the QMP quarterly reports. Effective immediately, EHC will ensure the policy is reviewed annually. 02/26/2021 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 4/2/2020 to the individual plan team members on 4/16/2020 for the individual plan meeting on 4/16/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.March 1, 2021, EHC developed and implemented a plan to remain compliant regarding Department policy and procedure compliance with Chapter 6400 regarding ensuring the program specialist (or designated EHC staff) shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. Effective immediately, EHC will ensure all program specialists (or designated EHC staff) are trained to the requirements regarding all elements of the service plan including providing the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. The program specialist will ensure procedures regarding this regulation are implemented. Effective immediately, the program director will monitor the program specialist (or designated EHC staff) to ensure that all individual plan team members receive the assessment at least 30 calendar days prior to an individual plan meeting. The program director, in conjunction with EHC administrative staff, will conduct quarterly reviews of individual files in order to demonstrate compliance with Chapter 6400 regulations. EHC QMP will include quarterly reporting of the individual file reviews. 03/01/2021 Implemented
SIN-00164149 Renewal 10/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned on 5/24/18 and then again on 9/17/19.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. On October 9, 2019, the Executive Director created a database to monitor all furnace inspections. The Executive Director will collaborate with the property owner to ensure that the furnace meets regulation 6400.106. The furnace shall be inspected and cleaned by a professional furnace cleaning company at least annually. 10/09/2019 Implemented
6400.166(d)Individual #1 was prescribed Ibuprofen 600 mg tablets with the instructions "take 1 tablet by mouth twice a day for 7 days." Individual #1 was administered the first dose on 9/30/19. The last dose of the medication should have been given at 8:00 AM on 10/6/19. Individual #1 continued to be administered Ibuprofen 600 mg tablets on 10/6/19 at 8:00 PM, 10/7/19 at 8:00 AM and 8:00 PM, 10/8/19 at 8:00 AM and 8:00 PM, and 10/9/19 at 8:00 AM.The directions of the prescriber shall be followed.On October 26, 2019, all staff was retrained on as needed (PRN) medication administration. Staff was advised to read and follow instructions as written on each medication label. Also, the Medication Administrator Trainer will provide resource material upon initial training of all staff and reviewed quarterly. The program specialist will provide immediate notification to all staff of any new medications prescribed. In addition, a medication check review will be conducted weekly. [Additional Medication training shall continue based on medication reviews to ensure medications are administered as prescribed. Documentation of all medication trainings and all medication reviews shall be kept. (DPOC by AES,HSLS on 10/30/19)] 10/26/2019 Implemented
6400.213(1)(i)The record for Individual #1, date of admission 3/20/19, does not include identifying marks. The record for Individual #2, date of admission 7/5/19, does not include identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate, Social Security number, race, height, weight, color of hair, color of eyes and identifying marks.Following the inspection, the Emergency Information Sheet was immediately corrected on October 9, 2019. On October 26, 2019, staff was trained on Regulation 6400.213 Contents of record. In addition, staff was trained on completing all required line items and/or sections on documentation of all individual forms. Furthermore, the agency revised orientation training to include chapter 6400.213 and it will be implemented into annual training for all staff. [At least quarterly and upon admission, the CEO or designee shall audit all individuals' records to ensure all required information is included. Documentation of record audits shall be kept. (DPOC by AES,HSLS on 10/30/19)] 10/09/2019 Implemented
SIN-00144042 Initial review 10/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The door to the laundry room has a locking mechanism that prevents egress from inside the laundry room when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The landlord of the apartment complex had a key lock on the doorknob to the laundry room door on the morning of the initial inspection of a new residential home with no participants. Landlord was contacted during the inspection and was put on speaker phone which then advised the inspector and the owner that he would contact the maintenance guy to have it removed within the next couple of days. Inspector advised the owner of Exceptional Home Care to email her pictures of the correction by Monday, October 29, 2018 by 8:00am so that she can attach the pictures of the correction to the report so that a plan would not be requested. The maintenance man removed the lock on the same day of the inspection at approximately 6:00pm on Friday, October 26, 2018. An email was sent to the inspector on October 26, 2018 at 9:37pm with attachment of pictures of the laundry room doorknob showing that the lock had been removed and correction made.The lock has been removed and replaced with a handle that does not lock making the door accessible from both sides of the door. The door cannot be locked and therefore the egress is no longer blocked.The Owner, Executive Director and Program Specialist were counseled on importance of keeping exits unobstructed. The Program Specialist is responsible for conducting monthly site audits, which include ensuring that all doorways are unobstructed. Chapter 6400.101 Unobstructed egress will be implemented into orientation training for all new hires (currently there are no staff hired for the new residential home because it is not licensed to operate as of yet). Additionally, the Executive Director will conduct unannounced spot checks/site audits of the home on a quarterly basis to ensure unobstructed doorways. Chapter 6400.101 Unobstructed egress will be implemented into annual training for all staff. [Documentation of the training shall be kept. (DPOC by AES,HSLS on 11/2/18)] 10/26/2018 Implemented
SIN-00236483 Renewal 12/19/2023 Compliant - Finalized
SIN-00199289 Renewal 02/01/2022 Compliant - Finalized