Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00211838 Renewal 09/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #1's physical examination, dated 06/02/22, did not address health maintenance needs or the need for bloodwork 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. Please see enclosed our meeting agenda and Plan to correct the cited violation: Meeting Agenda: Prevention Training and Measures. ¿ Licensing findings and developing a POC. ¿ Why did this violation occur? ¿ Who is responsible for reviewing the Physical once it submitted to ensure compliance, upon admission? ¿ Health and Safety: Immediately, Send Individual to his/her PCP to get an updated Physical to comply with 6400.141 (C )11 and ensure his/her health and safety. Completed: 09/22/22 ¿ Adding additional oversite over this process to include Compliance. ¿ Prohibiting any Physical forms including MA-51 from outside entities and/or agencies. This is now a procedure update. Effective 10/01/22. It will be added to the Admission Policy on or before November 10th,2022. ¿ Updating the Admission packet directions to include, no outside physicals and no admission into NF will occur prior to packet completion. To include ¿ Submitting OUR physicals to the SC inside of the admission packet. ¿ This packet will now be submitted back to NF and reviewed prior to admission. 1st Prevention measure. We are now requiring this to be completed ( Submitting of all documents, including the Physical form ) in its entirety. Prior to being admitted into NF. ¿ Once the Packet is received and reviewed by NF Program Specialist. She will keep a copy of the packet ¿ Including the Physical and review it for accuracy. 2ND Prevention measure. ¿ 3rd measure to prevent a reoccurrence of this violation , A copy of all Admission and Annual Physicals will now be sent to the Compliance Officer and the Nurse Coordinator to ensure ongoing compliance. Quarterly reviews of all Physicals will be completed for 1 year. * This has been completed. October 3rd, 2022. By compliance. A copy of the Medical Tracker has been sent to all Team Leads and Nurse Coordinator. And available upon request. ¿ Overall responsibility for POC: Compliance and Nurse Coordinator. 11/21/2022 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 06/02/22, did not address emergency medical information pertinent to diagnosis and treatment in case of emergency. [Repeat violation 10/19/21 et. al]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Please see our training agenda and POC below: Meeting Agenda: Prevention Training and Measures. * Repeated Violation ¿ Licensing findings and developing a POC. ¿ Why did this REPEAT violation occur? ¿ Who is responsible for reviewing the Physical once it submitted to ensure compliance, upon admission? Develop a 3-step process for review. And Quarterly Audits of all Physicals including Admission Physicals. Conduct an immediate review and quarterly thereafter for 1 year. ¿ Health and Safety: Immediately, Send Individual to his/her PCP to get an updated Physical to comply with 6400.141 (C )14 and ensure his/her health and safety. Completed: 09/22/22 ¿ Adding additional oversite over this process to include Compliance. ¿ Prohibiting any Physical forms including MA-51 from outside entities and/or agencies. This is now a procedure update. Effective 10/01/22. It will be added to the Admission Policy on or before November 10th,2022. ¿ Updating the Admission packet directions to include, no outside physicals and no admission into NF will occur prior to packet completion. To include ¿ Submitting OUR physicals to the SC inside of the admission packet. ¿ This packet will now be submitted back to NF and reviewed prior to admission. 1st Prevention measure. We are now requiring this to be completed ( Submitting of all documents, including the Physical form ) in its entirety. Prior to being admitted into NF. Including but not limited to: Medical information pertinent to diagnosis. ¿ Once the Packet is received and reviewed by NF Program Specialist. She will keep a copy of the packet ¿ Including the Physical and review it for accuracy. 2ND Prevention measure. ¿ 3rd measure to prevent a reoccurrence of this violation , A copy of all Admission and Annual Physicals will now be sent to the Compliance Officer and the Nurse Coordinator to ensure ongoing compliance. Quarterly reviews of all Physicals will be completed for 1 year. * This has been completed. October 3rd, 2022. By compliance. A copy of the Medical Tracker has been sent to all Team Leads and Nurse Coordinator. And available upon request. ¿ Overall responsibility for POC: Compliance and Nurse Coordinator. 11/21/2022 Implemented
SIN-00175084 Renewal 08/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1, had a review of medications prescribed to treat symptoms of a psychiatric illness most recently completed on 4/17/20. The agency has attempted to contact the prescribing physician to complete a review on two occasions, 7/15/2020 and 7/24/2020. As of 8/5/20, the physician has not responded to the request.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.Individual/ Staff : Individual #1 Regulation # 6400.165 (g) Immediate actions taken: NFHCS has finally received, after multiple requests , Due to COVID-19 Psych Review. Dated 07/10/20 ( Enclosed) Administration Training: Enclosed is the Administration Training agenda, with signature page ( Enclosed) Plan to Correct and prevent a reoccurrence/ similar violation in the future: Due to Covid- 19, and after multiple attempts, we have received Individual #1's Psych Review dated 07/10/20 * Enclosed is the Psych Review Form. Requested: Individual #1's next psych appointment is scheduled for 10/02/20 @ 11:30 AM. Person(s) Responsible: Nurse Coordinator) Date to be Corrected: Corrected: August 10, 2020 08/10/2020 Implemented
SIN-00165511 Unannounced Monitoring 10/24/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)On 10/24/19 at 3:00PM, there was a three inch crack on the bottom left side of the bathtub in the bathroom on the first floor of the home causing the bathtub to be unusable.Floors, walls, ceilings and other surfaces shall be in good repair. Violation: On 10/24/19 at 3:00PM, there was a three-inch crack on the bottom left side of the bathtub in the bathroom on the first floor of the home causing the bathtub to be unusable. Correction Required: Floors, walls, ceilings and other surfaces shall be in good repair. Immediate Action: To prevent further damage to the bathtub, Bids were requested to replace the cited bathtub, and convert into a walk- in shower. This will ensure surfaces (bathtub) remains in good repair and usable. (Update) The contractor has completed the work at the Green Tree first floor bathroom. Photos has been submitted, to licensing. The shower is operable and working accordingly. Training/ Re- Education: The Greentree staff are in the process of being trained on, but not limited to: This updated plan, observation of the shower chair while in use. (This is what caused the 3-inch hole inside of the tub), Ensuring surfaces, are in good repair. Reporting any maintenance issue, to the House Lead/ Executive Director. (including damage to surfaces, floor etc.) A copy of the training will be submitted to licensing Actions steps to correct violation/ prevent a reoccurrence 1. The cited tub has been replaced with a walk- in shower. On November 22,2019 2. Every shift, DCS will continue to utilize the Daily Checklist, which list any maintenance issues. (enclosed) When maintence issues arise, (inoperable equipment, tubs, sinks, damage to surface) Staff will document on the checklist and notify their House Leads. House leads will notify the Executive Director. To ensure follow-through. (Some maintenance issues may require an outside contractor. And will need Executive approval.) Once, repairs are made, The House leads will inform their staff, to ensure follow-through. Documentation of the checklists will be kept. 3. Monthly, ADM staff will continue to complete our Site- audits. (including the Greentree location) To ensure compliance with identified maintenance issues. Person Responsible: The House leads, are responsible for reviewing the checklists. And following- up on maintenance requests. Correction Date; This plan will be fully implemented by December 9th ,2019 12/09/2019 Implemented
6400.82(c)Individual #1 requires the use of a shower chair when bathing. Since 10/10/19, Individual #1 has not been able to bath in the home due to the bathtub that accommodates the use of a shower chair being unusable due to a crack in the bathtub. Beginning on 10/10/19, Individual #1 has had to bath at an unlicensed home that is rented by the agency located approximately a quarter mile from Individual #1's home.(c) For homes serving one or more individuals who have physical disabilities, at least one sink, one toilet and one tub or shower shall be adapted so that individuals who have physical disabilities have easy access and use. Violation: Individual #1 requires the use of a shower chair when bathing. Since 10/10/19, Individual #1 has not been able to bath in the home due to the bathtub that accommodates the use of a shower chair being unusable due to a crack in the bathtub. Beginning on 10/10/19, Individual #1 has had to bath at an unlicensed home that is rented by the agency located approximately a quarter mile from Individual #1's home. Correction Required: For homes serving one or more individuals who have physical disabilities, at least one sink, one toilet and one tub or shower shall be adapted so that individuals who have physical disabilities have easy access and use. Immediate Action: Individual # 1 shower chair, caused the crack inside of the tub. To prevent further damage to the bathtub and ensure Individual #1 can bath in the home. Bids were requested to replace the cited bathtub and convert into a walk- in shower. This will allow for easy access and use, for any indiduals with a physical disability. (Update) The contractor has completed the work at the Green Tree first floor bathroom. Photos has been submitted, to licensing. The shower and shower chair are operable and working accordingly. Training/ Re- Training: The Greentree staff are in the process of being trained on, but not limited to: This updated plan, observation of the shower chair while in use. (This is what caused the 3-inch hole inside of the tub) Reporting any maintenance issue, to the House Lead/ Executive Director. (Ensuring at least one sink, one toilet and one tub or shower is adapted so that individuals who have physical disabilities have easy access and use) A copy of the training will be submitted to licensing. Actions steps to correct violation/ prevent a reoccurrence. 1. The cited tub has been replaced with a walk-in shower, on November 22,2019. The shower and shower chair are operable and working accordingly. 2. Every shift, DCS will continue to utilize the Daily Checklist which list any maintenance issues. (enclosed) When maintence issues arise, (inoperable equipment, tubs, sinks etc.) Staff will document on the checklist, and notify their House Leads. House Leads will notify the Executive Director. To ensure follow-through. (Some maintenance issues may require an outside contractor, and will need Executive approval) Once, repairs are made, The Team leads will inform their staff, to ensure follow-through and compliance. Documentation of the checklists will be kept. Monthly, an ADM staff will continue to complete Site- audits. (including the Greentree location) To ensure compliance with identified maintenance issues. 3. Should a situation arise, were any equipment (including bathtubs) couldn¿t accommodate our resident(s) physical disability. NFHCS will initiate our emergency relocation plan. Person Responsible: The House leads, are responsible for reviewing the checklist. And following- up on maintenance requests. Correction Date; This plan will be fully implemented by December 9th,2019 [Immediately, the CEO or designee shall develop and implement policies and procedures to ensure individual who have a physical disability shall have at least one sink, one toilet and one tub or shower adapted so that individuals who have physical disabilities have easy access and use to include the implementation of the relocation policy if required easy access and use is unavailable. Within 30 days of completion of the aforementioned policy and procedures, the CEO or designee shall educate all staff person on the aforementioned policy and procedures and relocation policy. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/18/19)] 12/09/2019 Not Implemented
SIN-00165281 Unannounced Monitoring 10/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(a)(5)On 9/18/19, Individual #1 was left unsupervised for approximately 45 minutes after she was transported from a grocery store to her home by the police after Direct Service Worker #2 experienced a medical episode. An incident of neglect for Individual #1 was entered into the Enterprise Incident Management system on 9/26/19.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. Policy Violation: 6400.18 (a) (5) Violation: On 9/18/19, Individual #1 was left unsupervised for approximately 45 minutes after she was transported from a grocery store to her home by the police after Direct Service Worker #2 experienced a medical episode. An incident of neglect for Individual #1 was entered into the Enterprise Incident Management system on 9/26/19. Correction Required: The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. Immediate Action: On 09/18/19, Individual #1, called a staff of NFHCS. NFHCS Residential Liaison received a call from the said staff. And immediately went to the home, to ensure Individual # 1 safety. Per Incident Manager, she was informed of the event (The medical episode). But wasn¿t aware that due to Direct Service Worker #2 medical episode, it required an Incident of neglect to be filed into EIM. Once notified of the incident. She submitted the Incident into EIM. This occurred on 09/26/19 (Update) This incident has been investigated, submitted, and approved in EIM. Currently awaiting County Management review. Please see EIM report (Enclosed) Plan to correct/ prevent a reoccurrence/ Re- train staff and evaluate for effectiveness; 1. To prevent a reoccurrence of 6400.18 (a) (5). Bi- weekly, both NFHCS IM Manager and NFHCS Contracted Compliance Officer meet to review incidents. (This includes timely submission of Incidents) A copy of our latest meeting agenda is enclosed. 2. The Incident Manager has been trained in the POC for this Incident. She also attended the annual training which included an Incident Management. 3. A copy of the training(s) Meeting agenda will be kept. Person(s) Responsible ¿ NFHCS Incident Manager Angelique King. Correction Date: 11/06/2019 11/06/2019 Implemented
6400.32(h)On 9/13/19, at an unemployment hearing for Staff Person/Nurse #1, documentation belonging to Individual #1, including bank statements and a room and board contract were in the possession of Staff Person/Nurse #1. Staff Person/Nurse #1 terminated employment with the agency on 7/13/19.An individual has the right to privacy of person and possessions.Policy Violation: 6400.32(h) Violation: 9/13/19, at an unemployment hearing for Staff Person/Nurse #1, documentation belonging to Individual #1, including bank statements and a room and board contract were in the possession of Staff Person/Nurse #1. Staff Person/Nurse #1 terminated employment with the agency on 7/13/19. Correction Required: An individual has the right to privacy of person and possessions. Immediate Action: While here on site, NFHCS disclosed to the licensing surveyors, what had happened at a recent unemployment hearing, with Staff Person/Nurse #1 (Resigned). A full review of Individual#1 record was conducted. This review included all Bank statements and Room & Board contract and relative program documents were enclosed. NFHCS also reviewed, additional residential records to ensure no records were removed from NFHCS. In addition NFHCS conducted a review, of the property delivered from the former staff¿s Attorney. An incident was submitted into EIM on 9/13/19. (Update) This incident has been investigated and is currently closed. Effective 12/04/19. (Enclosed EIM Report) Plan to correct/ prevent a reoccurrence; ¿ To prevent a reoccurrence of 6400.32 (H) A review of the Residential individual(s) records is being completed quarterly. The last review was completed in November, by NFHCS Contracted Compliance Officer Josie Wiley and Residential Liaison Rickeya Giles. (Documentation (dates) of reviews are listed on the cover sheet of LIS) ¿ Monthly the Program Specialist, will review Residential individual(s) Program records. This will include (Room & Board Contracts and Banking information, and relative program documentation is enclosed. Please see training sheet enclosed. ¿ (Monthly) Documentation of reviews, will be kept and housed inside of the program binder. ¿ Quarterly Record review documentation will be placed on the LIS Data sheet. Person(s) Responsible ¿ NFHCS Program Specialist (Monthly) ¿ Quarterly NFHCS Contract Compliance Officer & Residential Liaison. Correction Date: This violation is corrected and ongoing 12/12/2019 Implemented
SIN-00161563 Renewal 08/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill conducted on 04/29/19 did not include the amount of time it took for evacuation.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. Violation: 6400.112 (c) Fire Drill Immediately: Violation has been corrected. Please see the enclosed August Fire Drill (Green Tree Location) with our New Fire Safety Checklist (Enclosed) Education / Training: An all Staff Mandatory training will be conducted at Our Drop in Center location. 454 Montgomery Ave. Bridgeville, PA 15107. On September 11th at 10:00AM. The staff will be trained on 6400.112 Violation Report. Our new Fire Safety Checklist, their responsibilities, and Incident Management. (A copy of the staff training sign in sheet, will be submitted to the Department) Plan to correct and Prevent: In order to prevent a reoccurrence of this violation. Monthly, The DC Staff completing the Fire Drill and Our New Fire Safety Checklist will have to review and sign off on the form. Using the checklist which outlines all regulatory compliance for 6400.112 (Fire Drill), They will then submit a copy of the completed drill and the checklist to our P.S. (M.P.) Once reviewed by our P.S and signed off. A copy of the checklist and drill will be sent to our Residential Liaison (R.G.) to review and sign off. Once completed, the checklist and fire drill will be housed inside of our Inspection Binder and scanned to our internal Server. Person Responsible: DCS, PS and Residential Liaison. To be fully Implemented by: This violation is corrected. And will be monitored ongoing. [Fire drill held in August and September, 2019 were held and documented as required. Upon hire, at least quarterly for 1 year and prior to conducting fire drill, the CEO or designee shall educate all staff persons responsible for conducting fire drill of the requirements of fire drills. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/14/2020)] 09/13/2019 Implemented
6400.32(c)On 08/05/19, at approximately 1:45PM, Direct Service Worker #1 and Direct Service Worker #2 were arguing and directing profanity at one another in front of Individual #1 at the home. As the argument escalated, Direct Service Worker #1 began screaming at Direct Service Worker #2. When Individual #1 asked Direct Service Worker #1 to calm down, Direct Service Worker #1 replied, "Shut the fuck up! I'm not talking to you!" Direct Service Worker #2 and Individual #1 went for a walk. Individual #1 does not feel safe with Direct Service Worker #1 working in the home as a result of the incident.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Violation: 6400. 32(c) Verbal Abuse Immediately: Violation has been corrected/ Investigated. Please see the EIM Report Education / Training: An all Staff Mandatory training will be conducted at Our Drop in Center location. 454 Montgomery Ave. Bridgeville, PA 15107. On September 11th at 10:00AM. The staff will be trained on 6400.112 Violation Report. Our new Fire Safety Checklist, their responsibilities, and Incident Management with an emphasis on Verbal Abuse. (A copy of the staff training sign in sheet, will be submitted to the Department) Plan to correct and Prevent: In order to prevent a reoccurrence of this violation. A staff Re-training is scheduled (Please see above Education/ Training). With all staff and Individuals including (J.S.). Our DCS staff (A.T.) was the one who reported the incident, based on her training. One of the staff have been removed from the home, and only works in this home, one shifts a week. The CI had spoken to (J.S) who had stated she wasn¿t/ isn¿t fearful. And likes both staff. (And wants staff A.T.) to continue working with her. Staff has been separated from working together in order to prevent like incidents from occurring. Staff was informed not to engage in this type of behavior. Please see Attachment #2..Staff are not to engage in confrontation behavior in front of NFHCS participants. Person Responsible: All incidents are reported to our Incident Manager) A.K. To be fully Implemented by: This violation is corrected. And will be monitored quarterly ongoing. [At least quarterly for 1 year, all staff persons shall be educated on abuse to include but not limited to definitions, preventions, reporting of abuse and positive approaches. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/14/2020)] 09/13/2019 Implemented
SIN-00139298 Unannounced Monitoring 07/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The smoke detector in the basement of home was not operable when tested at 2:08PM. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Person Responsible-House Manager Action- Smoke Detector was sync in with other smoke detectors by contractor on 8/10/2018 and is fully operable Protocol- HM will perform a quarterly check to make sure there¿s a minimum of one operable automatic smoke detector on each floor, including the basement and attic. HM will notify his direct supervision of any problems and will immediately fixed the problem. Next inspection will be 8/31/2018. Not Forgotten Staff working in the home shall notify Program Specialist if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [Immediately and continuing at least weekly, a designated staff person shall test all smoke detectors in all community homes to ensure there is minimum of one operable automatic smoke detector on each floor, including the basement and attic. Documentation of the tests shall be kept. (DPOC by AES,HSLS on 8/30/18)] 08/10/2018 Implemented
SIN-00131637 Unannounced Monitoring 03/22/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At approximately 11:00 AM, a 19 fluid ounce spray can of Lysol disinfectant and an aerosol spray can of glass cleaner with warning instructions to contact poison control or doctor if in eyes were unlocked, unattended, and accessible to the right of the washing machine in the laundry area. The individuals living in the home are not assessed safe with poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. Person Responsible-House Manager Action-Poisonous materials shall be kept locked or made inaccessible to individuals will be locked at all time. All staff will be trained by 4/16/2018. Proof of training sheets will be submitted to Not Forgotten 6400 liaison by the end of 4/16 to ensure all staff are trained, when training occur. House Manager will train all Staff. Protocol-Executive Director, Compliance Officer or Program Coordinator will perform unannounced checks to ensure regulations are being done. Program Manager will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, HM will notify his direct supervision of any problems and will immediately fixed the problem. If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. Next inspection will be by 5/11/2018. [Immediately and at least monthly, a designated staff person trained in the physical site requirements as per 6400.64-86 shall complete onsite audits of all community homes to ensure the physical site requirements as per 6400.64-86 are met at all of the community homes. Documentation of the audits shall be kept. Immediately, the CEO or designee shall educate all staff persons that poisonous materials shall be kept locked or made inaccessible to individuals and to monitor throughout the course of their daily duties. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons on the agency's procedures for reporting, replacing and repairing physical site issues that are beyond the staff persons immediate ability to correct. Documentation of trainings shall be kept. (AS 4/25/18)] 04/17/2018 Not Implemented
6400.65The mechanical ventilation in the bathroom off of the Individual #3's bedroom on the middle floor of the home was inoperable. The bathroom does not have a window or another method of ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Person Responsible-House Manager/Maintenance Facilitator Action-Currently individuals #3 room is empty. Not Forgotten has place a call to house rental agency to fix the problem. Not Forgotten will send a picture and receipt that the mechanical ventilation was properly fixed no later to 6400 liaison by 4/20. Protocol-Executive Director, Compliance Officer or Program Coordinator will perform unannounced checks to ensure regulations are being done. Program Manager will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. Next inspection will be by 5/11/2018. [Aforementioned supporting documentation shall be immediately sent to the Department. Immediately and at least monthly, a designated staff person trained in the physical site requirements as per 6400.64-86 shall complete onsite audits of all community homes to ensure the physical site requirements as per 6400.64-86 are met at all of the community homes including that living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms are ventilated by at least one operable window or by mechanical ventilation. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons on the agency's procedures for reporting, replacing and repairing physical site issues that are beyond the staff persons immediate ability to correct. Documentation of trainings shall be kept. (AS 4/25/18)] 04/20/2018 Not Implemented
6400.66The ceiling fan/light fixture in the second bedroom to the right of the hallway on the home's main floor had two empty light sockets and an inoperable light bulb. The only alternate source of light in the room was on the opposite side of the room on a table surrounded by clothing and other miscellaneous items.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. House Manager Action-Light bulbs were added to the ceiling fan/light fixture in the second bedroom to the right of the hallway on the home's main floor had two empty light sockets and an inoperable light bulb. All staff will be trained by 4/16/2018 to remove trash receptacles. Proof of training sheets and receipts trash receptacle will be submitted to Not Forgotten 6400 liaison by the end of 4/16 to ensure all staff are trained, when training occur. House Manager will train all Staff. Protocol-Executive Director, Compliance Officer or Program Coordinator will perform unannounced checks to ensure regulations are being done. Program Manager will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. Next inspection will be by 5/11/2018. [Aforementioned supporting documentation shall be immediately sent to the Department. Immediately and at least monthly, a designated staff person trained in the physical site requirements as per 6400.64-86 shall complete onsite audits of all community homes to ensure the physical site requirements as per 6400.64-86 are met at all of the community homes including that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons on the agency's procedures for reporting, replacing and repairing physical site issues that are beyond the staff persons immediate ability to correct. Documentation of trainings shall be kept. (AS 4/25/18)] 04/17/2018 Not Implemented
6400.72(b)The bi-fold door to Individual #3's bedroom on the middle floor of the home required excessive force using two hands to open and close, was not anchored to the door frame, was duct tape in multiple areas and left a 1-2 inch gap between the door and doorframe when closed. Screens, windows and doors shall be in good repair. Person Responsible-Maintenance Facilitator/House Manager Action-A new bi-fold door to Individual #3's bedroom on the middle floor installed. Not Forgotten will send 6400 liaisons pictures and receipts of updates by 4/20/2018 Protocol-Executive Director, Compliance Officer or Program Coordinator will perform numerous unannounced checks to ensure Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Next inspection will be by 5/11/2018. [Aforementioned supporting documentation shall be immediately sent to the Department. Immediately and at least monthly, a designated staff person trained in the physical site requirements as per 6400.64-86 shall complete onsite audits of all community homes to ensure the physical site requirements as per 6400.64-86 are met at all of the community homes including that screens, windows and doors are in good repair. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons on the agency's procedures for reporting, replacing and repairing physical site issues that are beyond the staff persons immediate ability to correct. Documentation of trainings shall be kept. (AS 4/25/18)] 04/20/2018 Not Implemented
6400.73(a)The outside stairway from the deck on the middle floor of the home to the street level does not have a handrail. The interior stairs from the home's main floor to the laundry area had a railing that moves approximately 1 inch from side to side when used. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Person Responsible-Maintenance Facilitator/House Manager Action-The outside stairway from the deck on the middle floor of the home to the street level a handrail was installed. The interior stairs from the home's main floor to the laundry area had a railing that moves approximately 1 inch from side to side when used was reinforced. Not Forgotten will send 6400 liaisons pictures and receipts of updates by 4/20/2018 Protocol-Executive Director, Compliance Officer or Program Coordinator will perform numerous unannounced checks to ensure Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Next inspection will be by 5/11/2018. [Aforementioned supporting documentation shall be immediately sent to the Department. Immediately and at least monthly, a designated staff person trained in the physical site requirements as per 6400.64-86 shall complete onsite audits of all community homes to ensure the physical site requirements as per 6400.64-86 are met at all of the community homes including that each ramp, and interior stairway and outside steps exceeding two steps have a well-secured handrail. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons on the agency's procedures for reporting, replacing and repairing physical site issues that are beyond the staff persons immediate ability to correct. Documentation of trainings shall be kept. (AS 4/25/18)] 04/20/2018 Not Implemented
6400.81(k)(1)At approximately 10:00AM, Individual #1's bed was equipped with a half bedrail that was engaged.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. Bunk beds are not permitted for individuals 18 years of age or older.Person Responsible-House Manager Action-Individual #1's bed was equipped with a half bedrail will be un engaged at all time. All staff will be trained by 4/16/2018. Proof of training sheets will be submitted to Not Forgotten 6400 liaison by the end of 4/16 to ensure all staff are trained, when training occur. House Manager will train the staff. Protocol-Executive Director, Compliance Officer or Program Coordinator will perform numerous unannounced checks to ensure individual's records shall be kept locked when unattended. If problems exist, HM will notify his direct supervision of any problems and will immediately fixed the problem. If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. Next inspection will be by 5/11/2018. [Aforementioned supporting documentation shall be immediately sent to the Department. Immediately, the bedrails on Individual #1's bed shall be rendered inoperable or removed unless specific medical professional orders are obtained. Immediately and continuing at least quarterly, the CEO or designee shall audit all community homes to ensure all individuals' have a bed appropriate to the needs of the individuals and medical orders pertaining to beds for individuals are implemented. Documentation of audits shall be kept. (AS 4/25/18)] 04/17/2018 Not Implemented
6400.82(f)The bathroom off of Individual #3's bedroom did not contain a trash receptacle.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. Person Responsible-House Manager Action-Each bathroom will have a trash receptacle. All staff will be trained by 4/16/2018 to remove trash receptacles. Proof of training sheets and receipts trash receptacle will be submitted to Not Forgotten 6400 liaison by the end of 4/16 to ensure all staff are trained, when training occur. House Manager will train all Staff.Protocol-Executive Director, Compliance Officer or Program Coordinator will perform unannounced checks to ensure 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. PM will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. Next inspection will be by 5/11/2018. [Immediately, the CEO or designee shall educate all staff persons that each bathroom and toilet area shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle and to monitor throughout the course of their daily duties. Immediately and at least monthly, a designated staff person trained in the physical site requirements as per 6400.64-86 shall complete onsite audits of all community homes to ensure the physical site requirements as per 6400.64-86 are met at all of the community homes. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons on the agency's procedures for reporting, replacing and repairing physical site issues that are beyond the staff persons immediate ability to correct. Documentation of trainings shall be kept. (AS 4/25/18)] 04/17/2018 Submitted
6400.101At approximately 10:30AM, the outside passageway from the middle floor of the home via the deck was obstructed by overgrown, low hanging shrubbery, several inches of snow on the walkway and steps, and a wooden gate with a sliding lock mechanism. The door leading from the home's kitchen to the garage was equipped with a key locking mechanism when engaged would prevent egress from the garage. There is not a standard door in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Person Responsible-Maintenance Facilitator/House Manager Action-The floor of the home via the deck obstructed by overgrown, low hanging shrubbery was removed. The wooden gate with a sliding lock mechanism was fixed. The door leading from the home's kitchen to the garage was equipped with a key locking mechanism when engaged would prevent egress from the garage was fixed. A standard door in the garage was added.Not Forgotten will send 6400 liaisons pictures and receipts of updates by 4/20/2018.Protocol-Executive Director, Compliance Officer or Program Coordinator will perform numerous unannounced checks to ensure Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Next inspection will be by 5/11/2018. [Aforementioned supporting documentation shall be immediately sent to the Department. Immediately, upon opening new homes and at least quarterly, the CEO or designated management staff person shall completed on site walk through of all community homes to ensure there are not locking mechanisms that are preventing egress from stairways, halls, doorways, passageways, rooms and the building. Immediately, locking mechanisms including the door from the kitchen to the garage and the outside gate from the deck to the stairs leading to the front of the home shall be corrected. Immediately and upon hire, a designated management staff person shall train all staff persons that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor and correct throughout the course of their daily duties. Documentation of trainings shall be kept. (AS 5/25/18)] 04/20/2018 Not Implemented
6400.161(b)There were two unlocked, unattended, and accessible 2-drawer black filing cabinets that contained multiple prescription medications for several individuals including the following medications prescribed for Individual #2: 28 doses of Valsartan 80 mg, 28 does of Folic Acid 1 mg, 28 doses of Latuda 40 mg, 28 doses of Zonisamide 100 mg. In addition, the was a unlocked, unattended, and accessible metal lock box on to of the black filing cabinet to the right containing Clonazepam 2mg tablets, prescribed for Individual #1.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. Person Responsible-House Manager Action-Prescription and potentially toxic nonprescription medications shall be kept in an area or container will be locked at all time. All staff will be trained by 4/16/2018. Proof of training sheets will be submitted to Not Forgotten 6400 liaison by the end of 4/16 to ensure all staff are trained, when training occur. House Manager will train the individual. Protocol-Executive Director, Compliance Officer or Program Coordinator will perform numerous unannounced checks to ensure individual's records shall be kept locked when unattended. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, HM will notify his direct supervision of any problems and will immediately fixed the problem. Next inspection will be by 5/11/2018. If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. [Immediately, the CEO or designee shall remove the 100 count boxes of acetaminophen and ibuprofen from the first aid kit and place in a area or container that is locked. Immediately and continuing at least monthly, the CEO or designee shall complete an onsite audit of all community home to ensure prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure prescription and potentially toxic nonprescription medications are kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials to include at a minimum locked locations at all homes, access of staff persons, monitoring by management and reporting of unlocked medications. Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall educate all staff persons working in all community home of the aforementioned policies and procedures. Documentation of trainings shall be kept. (AS 4/25/18)] 04/17/2018 Not Implemented
6400.216(a)The medical record including appointment forms, doctor's orders, and medication lists with diagnoses for Individual #1, Individual #2, and Individual #3 were unlocked, unattended, and accessible on the wooden cabinet under the window in the dining area of the home. An individual's records shall be kept locked when unattended. Person Responsible-House Manager Action-Individual record will be locked at all time. All staff will be trained by 4/16/2018. Proof of training sheets will be submitted to Not Forgotten 6400 liaison by the end of 4/16 to ensure all staff are trained, when training occur. House Manager will train all Staff Protocol-Executive Director, Compliance Officer or Program Coordinator will perform unannounced quarterly checks to ensure individual's records shall be kept locked when unattended. PM will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be by 5/11/2018.If founded that the issue not corrected a corrective action will be issue to staff(s). The staff that were already retrained will be placed on probation and retrained. The next step is termination. [Immediately and continuing at least monthly, the CEO or designee shall complete an onsite audit of all community home to ensure individual's records are kept locked when unattended. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure individual's records are kept locked when unattended to include at a minimum locked locations at all homes, access of staff persons, monitoring by management and reporting of unlocked records. Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall educate all staff persons working in all community home of the aforementioned policies and procedures. Documentation of trainings shall be kept. (AS 4/25/18)] 04/17/2018 Not Implemented
SIN-00126922 Renewal 12/27/2017 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature measured 126.1 °F in the bathtub in the upstairs bathroom at 1:39pm on 12/28/17. (Repeated Violation-1/9/17, et al) Hot water temperatures in bathtubs and showers may not exceed 120°F. Person Responsible- Maintenance Facilitator Action-(1) Not Forgotten has adjusted hot water temperatures in bathtubs and showers may not exceed 120°F. (2) Not Forgotten has hired a maintenance facilitator to ensure they are being monitored. (3) Not Forgotten will monitor weekly the temperatures with a weekly tracking sheet. Protocol-Residential staff will perform a weekly check to make sure of water temperatures in bathtubs and showers may not exceed 120°.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [On 3/22/18, at 10:54AM, the hot water temperature measured 123°F in the shower in the bathroom off of the individual bedroom on the middle floor of the home. Immediately, the hot water temperature in the home shall be lowered and measured to ensure the hot water does not exceed 120°F. Immediately and continuing daily until the hot water temperature does not exceed 120°F for one week and then continuing at least weekly and then continuing at least monthly, the maintenance facilitator or a staff person trained by the CEO or maintenance facilitator to accurately measure and adjust water temperatures shall measure hot water temperature at all community homes. Documentation of temperature checks shall be kept and audited by the CEO at least monthly for 1 year. Documentation of audits shall be kept. (AS 3/23/18)] 03/09/2018 Not Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center was not on or by the telephone 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. Persons Responsible-Program Specialist & Program Coordinator Action-Not Forgotten has placed 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. Protocol-Program Specialist and Program Coordinator will create checklist to make sure 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 according to regulations are covered. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection to make Not Forgotten is in compliance and will report issues and concerns to the quality management team. Next inspection will be 3/9/2018. [Within 30 days of receipt of the plan of correction and upon hire, a designated management staff person train all staff persons of the telephone numbers required by all telephones and to use if needed. Immediately and continuing at least quarterly, the CEO or designated management staff person shall completed onsite checks of all community homes to ensure all required telephone numbers are on or by each telephone with an outside line. Documentation of all checks shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
6400.77(b)The first aid kit did not contain a thermometer and tweezers. 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. Persons Responsible-Nurse Coordinator Action-Tweezers were placed in the first aid kit. Protocol-Nurse Coordinator is creating an inventory checklist and will train Residential Staff to follow daily. If an item is missing, the RS will notify NC. The NC will investigate what happen and will the protocol of her findings. The items will be replaced immediately in the first kit to make sure the health and safety of the individual is being met. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of trainings and documentation of inventory checklist to make sure Not Forgotten is in compliance and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. [Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall educate all staff persons working in community homes of the required items in first aid kits and the agency's replacement and replenishment procedures to ensure all required items are in first aid kits at all times. Documentation of trainings shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
6400.101The door in the basement leading to the outside of the home had a locking mechanism which required a key to exit the home preventing egress when engaged. The door on the first floor leading to the basement had a slide lock on the first floor side that preventing egress from the basement when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. APerson Responsible-Maintenance Facilitator Action-The door leading to the basement with the locking mechanism was fixed to ensure the stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Protocol-Maintenance Facilitator will perform a quarterly check of Stairways, halls, doorways, passageways and exits from rooms and from the building to make sure there¿s no obstructions. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify Maintenance Facilitator if any area becomes obstructed. Staff is to make sure all areas are unobstructed from any movable objects. [Immediately, upon opening new homes and at least quarterly, the CEO or designated management staff person shall completed on site walk through of all community homes to ensure there are not locking mechanisms that are preventing egress from stairways, halls, doorways, passageways, rooms and the building. Immediately, locking mechanisms including the door from the kitchen to the garage and the outside gate from the deck to the stairs leading to the front of the home shall be corrected. Immediately and upon hire, a designated management staff person shall train all staff persons that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor and correct throughout the course of their daily duties. Documentation of trainings shall be kept. (AS 3/23/18)] 03/09/2018 Not Implemented
6400.110(a)The smoke detector on the first floor of the home was not operable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Person Responsible-Maintenance Facilitator Action- Smoke Detector was installed Protocol-Maintenance Facilitator will perform a quarterly check to make sure there's a minimum of one operable automatic smoke detector on each floor, including the basement and attic. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018. Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [On 3/21/18, smoke detectors were on each floor of the home, interconnected and audible throughout the home. Immediately, upon opening a new and continuing at least monthly, CEO or designated management staff person shall check the smoke detectors in all community homes to ensure there is a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Documentation of checks shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
6400.110(b)The smoke detector on the third floor was located 17 feet from the closest bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Person Responsible-Maintenance Facilitator Action-Smoke was installed on the third floor was located 17 feet from the closest bedroom door. Protocol-Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable automatic smoke detector on each floor, including the basement and attic. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [Smoke detector was 10 feet from the furthest bedroom door in the common area or hallway of the home. Immediately and upon opening new homes and at least semi-annually, designated management staff person and the maintenance facilitator shall completed an onsite check of all community homes to ensure there is an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Documentation of onsite checks shall be kept. Immediately and continuing at least monthly, the maintenance facilitator or a designated staff person trained by the CEO or maintenance facilitation to test smoke detectors shall test all smoke detectors in the community homes to ensure there is a minimum of one operable automatic smoke detector on each floor of the homes. Documentation of the checks shall be kept. (AS 3/23/18)] 02/11/2018 Implemented
6400.110(e)The home which has three floors did not have interconnected smoke detectors.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. Person Responsible-Maintenance Facilitator Action-Interconnected smoke detectors was installed on the third floors. Protocol-Maintenance Facilitator will perform a quarterly check to make sure there's a minimum of one operable automatic smoke detector on each floor, including the basement and attic.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018. Not Forgotten Staff working in the home shall notify MF if there's a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s) [On 3/22/18, smoke detectors were on each floor of the home, interconnected and audible throughout the home. Immediately, upon opening a new and continuing at least monthly, CEO or designated management staff person shall check the smoke detectors in all community homes to ensure there is a there is 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. Documentation of checks shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
6400.111(a)There was not a fire extinguisher on the first floor of 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. Person Responsible-Maintenance Facilitator Action- At least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic was added to each floor.Protocol-Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing fire extinguisher. MF will follow protocol of immediately replacing, adding fire extinguisher (s). [Immediately, upon opening new homes and at least monthly, the CEO or designated management staff person shall check fire extinguishers to ensure there is at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Documentation of checks shall be kept. (AS 3/23/18)] 03/09/2018 Implemented
SIN-00179241 Renewal 11/12/2020 Compliant - Finalized
SIN-00172878 Unannounced Monitoring 04/09/2020 Compliant - Finalized
SIN-00154988 Unannounced Monitoring 04/26/2019 Compliant - Finalized