Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225835 Renewal 06/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The Cabinet was dirty with food particles under sink where pots are located.Clean and sanitary conditions shall be maintained in the home. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Leads WHAT: We need to ensure that the homes are maintained in a clean and sanitary condition. HOW: The house lead immediately cleaned the food particles under the sink, and her job was inspected by both the Residential Director and the Regulatory Specialist. 08/25/2023 Implemented
6400.64(a)The Broiler door on stove has debris on the door consistent with old food and grease...Clean and sanitary conditions shall be maintained in the home. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Leads WHAT: We need to ensure that the homes are maintained in a clean and sanitary condition. HOW: The House lead immediately cleaned the debris on the broiler door on the stove, and her job was reviewed by the Residential Director and Regulatory Specialist. 08/25/2023 Implemented
6400.68(b)The water temperature reads 130 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Correction ¿ Immediate Cure WHO: Residential Director Regulatory Specialist House Leads WHAT: We need to ensure that the water temperature in the shower and bathtubs do not exceed 120 degrees Fahrenheit. HOW: On June 8, 2023, we reduced the water temperature so that it did not exceed 120 degrees Fahrenheit. Please note that the Individual in the home is able to temper his own water. 08/25/2023 Implemented
6400.82(f)There was no toilet paper in the bathroom.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. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Leads WHAT: We need to ensure that each bathroom and toilet area has toilet paper. HOW: We replaced the toilet paper during the licensing inspection. 08/25/2023 Implemented
SIN-00206215 Renewal 06/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The thermometer located in the first aid kit was not operational. 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. WHO: Residential Director House Manager Regulatory Specialist Staff WHAT: We need to ensure that the thermometer in the first aid kits are operational. HOW: We replaced the thermometer in the first aid kit on June 10, 2022. 08/12/2022 Implemented
6400.77(c)The First Aid Kit did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Staff WHAT: We need to ensure that each first aid kit has a manual. HOW: We replaced the manual for the first aid kit on June 10, 2022. 08/12/2022 Implemented
6400.162(b)(2)(i)Staff #1 and Staff #2 have been trained in medication administration, but their training packed is not signed by the trainer as completed.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Oral medications.Correction ¿ Immediate Cure WHO: Residential Director Regulatory Specialist WHAT: We need to ensure that all training documents are properly signed prior to filing the documents. HOW: Staff #1 and #2 have been re-trained, with the documentation properly signed as of July 20, 2022. 07/20/2022 Implemented
SIN-00188319 Renewal 05/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)Two windows in the living room and one window in the dining area lacked window screens.Windows, including windows in doors, shall be securely screened when windows or doors are open. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager, upon hire Office Manager Staff WHAT: We need to ensure that each window or door has screens, so that the home is still protected while the windows and doors are open. HOW: On May 28, 2021, we contacted the Condo Association to put window screens in the two windows in the living room and one window in the dining room. We paid for the service on June 9, 2021. The screens are scheduled to be installed on or before July 30, 2021. We also re-trained all the staff, Compliance Specialist, Office Manager and Residential Director on the 6400 regulations pertaining to physical sites, 6400.61 to 6400.86. The Office Manager, Residential Director and Compliance Specialist were re-trained on June 22, 2021. Staff were re-trained between June 17, 2021 and June 25, 2021. When we hire a House Manager, the House Manager will receive the same training. 07/30/2021 Implemented
6400.112(a)Held monthly -- Fire drills were submitted for 4/27/21 and 4/30/21 for 6100 Henry Ave. No other fire drills provided at time of inspection for this address. An unannounced fire drill shall be held at least once a month. Comment This home is an unoccupied home. There is a fire drill for April 2021, because an Individual, MF, resided there while his home was being repaired. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager, upon hire WHAT: We need to ensure that each home has a monthly fire drill. HOW: The fire drill is conducted by the Residential Director and/or House Manager, and reviewed by the Compliance Specialist. Therefore, we re-trained the Compliance Specialist and Residential Director on fire safety matters as stated in the 6400 regulations, 6400.101 to 6400.114. The training occurred on June 22, 2021. Compliance Specialist will start placing a note in the fire drill book to explain any month in which there is no fire drill due to vacancy in a home. When we hire a House Manager, the House Manager will receive the same training. 06/22/2021 Implemented
6400.112(e)It was undetermined if a sleep drill was held as the fire drill report dated 4/27/21 for 6100 Henry Ave did not indicate AM or PM.A fire drill shall be held during sleeping hours at least every 6 months. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager, upon hire WHAT: We need to ensure that a sleep drill is held at each home at least once every six months. HOW: The fire drill is conducted by the Residential Director and/or House Manager and reviewed by the Compliance Specialist. Therefore, we re-trained the Compliance Specialist and Residential Director on fire safety matters as stated in the 6400 regulations, 6400.101 to 6400.114. The training occurred on June 22, 2021. When we hire a House Manager, the House Manager will receive the same training. 06/22/2021 Implemented
SIN-00176321 Renewal 09/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a sticky substance consistent with grease on the surface of the oven, surrounding cabinets, and the side of the refrigerator.Clean and sanitary conditions shall be maintained in the home. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager Staff WHAT: We need to ensure that the home is in clean and sanitary conditions. HOW: For the oven, we cleaned the surface and inside the oven. We also cleaned the outside and inside of the refrigerator. Rather than simply re-train the managers, we retrained each staff during the staff¿s shift, between September 15, 2020 and October 30, 2020. We then completed a site inspection with House Manager and Residential Director so that both of them would know the items to review during the weekly inspection. The training occurred on September 18, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection ¿ the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency ¿ All homes must be inspected at least once per week. The Executive Director will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity ¿ Prevention of Reoccurrence Though the Residential Director and the House Manager will continue to split the weekly inspection to ensure that they pay more attention to each home, we now require one joint and simultaneous review weekly, with random homes selected by the Compliance Specialist. 10/30/2020 Implemented
6400.66The light in the foyer of the apartment was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager WHAT: We need to ensure that all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are properly lighted. HOW: We fixed the light in the foyer. We re-trained the Residential Director and trained the House Manager to pay closer attention to the homes. We then completed a site inspection with House Manager and Residential Director so that both of them would know the items to review during the weekly inspection. We also reviewed the procedures for the maintenance hotline. The training occurred on September 18, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection ¿ the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency ¿ All homes must be inspected at least once per week. The Executive Director will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity ¿ Prevention of Reoccurrence Though the Residential Director and the House Manager will continue to split the weekly inspection to ensure that they pay more attention to each home, we now require one joint and simultaneous review weekly, with random homes selected by the Compliance Specialist. 09/18/2020 Implemented
6400.67(a)The covering on the handle in the bathroom for the hot water faucet came off when the handle was moved to the on position.Floors, walls, ceilings and other surfaces shall be in good repair. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager WHAT: We need to ensure that the floors, walls ceilings and other surfaces are in good repair. HOW: We replaced the faucet handle for the hot water. We completed a site inspection with House Manager and Residential Director so that both of them would know the items to review during the weekly inspection. We also reviewed the maintenance hotline with the manger and residential director. The training occurred on September 18, 2020. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. Weekly Site Inspection ¿ the weekly site inspection will be conducted by Residential Director and House Manager. Weekly Site Inspection Frequency ¿ All homes must be inspected at least once per week. The Executive Director will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity ¿ Prevention of Reoccurrence Though the Residential Director and the House Manager will continue to split the weekly inspection to ensure that they pay more attention to each home, we now require one joint and simultaneous review weekly, with random homes selected by the Compliance Specialist. 09/18/2020 Implemented
6400.68(b)The water temperature in the home was checked and found to be 139.5. Hot water temperatures in bathtubs and showers may not exceed 120°F. Response: ODP has repeatedly acknowledged the difficulty in regulating the water temperature in apartment units that are not owed by the provider. As such, it has accepted the provider¿s efforts to ensure that the water temperature does not exceed 120 degrees Fahrenheit at the time the Consumer uses the water. We instituted the Hot Water Compliance form in our last Plan of Correction, submitted on or about December 9, 2019. We have said documentation for the home. Correction ¿ Immediate Cure WHO: Executive Director Residential Director WHAT: We need to ensure that the hot water temperature in the bathtubs and showers do not exceed 120 degrees Fahrenheit. HOW: We worked with the Condo to have the water reduced to less than 118 degrees Fahrenheit. However, we are continuing to use the Hot Water Compliance form for each Consumer. The Hot Water Compliance form requires the staff to test the water before the Consumer takes a shower. Correction Activity ¿ Prevention of Reoccurrence Prior to renting a home, the Executive Director will ensure that the apartment complex agrees to, and actually, reduces the water to less than 120 degrees Fahrenheit. 09/29/2020 Implemented
6400.62(b)There were various poisons left out around the apartment such as mouth wash, soaps and colognes.Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment.Correction ¿ Immediate Cure WHO: Residential Director House Manager Staff WHAT: We need to ensure that poisonous materials are kept locked. HOW: We updated our Flammable and Combustible Policy and we then re-trained the staff, residential director, house manager and compliance specialist on the new policy. The training occurred between September 15, 2020 and October 30, 2020. Correction Activity ¿ Prevention of Reoccurrence We highlighted the portion about locking up potentially poisonous items on the weekly checklist, but we also included mouth wash, soaps and colognes. We also posted the list of flammable and combustible items on the door. 10/31/2020 Implemented
SIN-00172550 Unannounced Monitoring 03/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There was no ventilation in the bathroom. The vent was taped and covered, staff reports a leakage over the weekend. Documentation requested for work order but not provided at inspection. [REPEATED VIOLATION 11/22/19]Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Response There was an active work order for this vent at the time of the inspection. The plastic was taped over the cover the front of the vent because the upstairs tenant had a leak in his or her bathroom. At the time, the staff called the maintenance hotline, and the maintenance man came out to place the plastic cover over the vent, pending permanent stoppage of the leak. Correction ¿ Immediate Cure (Exhibit II) WHO: Elvira Berry, Executive Director Anthony Okonkwo, CFO/Residential Director Esther Brinson, Administrative Assistant WHAT: We need to ensure that there is ventilation by at least one operable window or mechanical ventilation in the living areas, recreation areas, dining areas, individual bedrooms, kitchen and bathrooms. HOW: 1. The leak was dried out, and the vent screen/face plate has been replaced. 2. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. 3. Weekly Site Inspection ¿ the weekly site inspection will be conducted by Mr. Anthony Okonkwo, Residential Manager. 4. Weekly Site Inspection Frequency ¿ All homes must be inspected at least once per week. 5. Weekly Site Inspection Checklist Training ¿ Mr. Okonkwo was trained by Elvira Berry on March 18, 2020. 6. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Okonkwo is required to call the maintenance hotline to report any maintenance related issues. Mr. Okonkwo was trained on the Maintenance Hotline on March 18, 2020. 7. Maintenance Hotline Training, Office- The Administrative Assistant, Esther Brinson, was re-trained on the Maintenance Hotline on March 17, 2020. 8. Weekly Site Inspection Audit ¿ Elvira Berry, Executive Director, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity ¿ Prevention of Reoccurrence We will now forward copies of the Weekly Site Inspection document, applicable work orders and proof of completion to ODP on a bi-weekly basis during the provisional licensing period, as proof that this task is being completed. The documents will be sent to ODP on April 3, 2020, April 17, 2020, May 1, 2020, May 15, 2020, May 29, 2020, June 12, 2020, June 26, 2020, July 10, 2020, July 24, 2020 and August 7, 2020. 04/03/2020 Implemented
6400.67(a)All the walls in the home were scuffed or not clean at the surface. The walls throughout the home needs to be cleaned and painted. [REPEATED VIOLATION 11/22/19]Floors, walls, ceilings and other surfaces shall be in good repair. Correction ¿ Immediate Cure (Exhibit II) WHO: Elvira Berry, Executive Director Anthony Okonkwo, CFO/Residential Director Esther Brinson, Administrative Assistant WHAT: We need to ensure that the floors, walls, ceilings and other surfaces are in good repair. HOW: 1. The entire apartment has been repainted, with a new carpet installed. 2. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. 3. Weekly Site Inspection ¿ the weekly site inspection will be conducted by Mr. Anthony Okonkwo, Residential Manager. 4. Weekly Site Inspection Frequency ¿ All homes must be inspected at least once per week. 5. Weekly Site Inspection Checklist Training ¿ Mr. Okonkwo was trained by Elvira Berry on March 18, 2020. 6. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Okonkwo is required to call the maintenance hotline to report any maintenance related issues. Mr. Okonkwo was trained on the Maintenance Hotline on March 18, 2020. 7. Maintenance Hotline Training, Office- The Administrative Assistant, Esther Brinson, was re-trained on the Maintenance Hotline on March 17, 2020. 8. Weekly Site Inspection Audit ¿ Elvira Berry, Executive Director, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity ¿ Prevention of Reoccurrence We will now forward copies of the Weekly Site Inspection document, applicable work orders and proof of completion to ODP on a bi-weekly basis during the provisional licensing period, as proof that this task is being completed. The documents will be sent to ODP on April 3, 2020, April 17, 2020, May 1, 2020, May 15, 2020, May 29, 2020, June 12, 2020, June 26, 2020, July 10, 2020, July 24, 2020 and August 7, 2020. 04/03/2020 Implemented
6400.76(a)The blinds in the dining room are bent and need to be replaced. [REPEATED VIOLATION 11/22/19] Furniture and equipment shall be nonhazardous, clean and sturdy. Correction ¿ Immediate Cure (Exhibit II) WHO: Elvira Berry, Executive Director Anthony Okonkwo, CFO/Residential Director Esther Brinson, Administrative Assistant WHAT: We need to ensure that the furniture and equipment are non-hazardous, clean and sturdy. HOW: 1. We ordered new blinds for the entire apartment. The new blinds will be installed before April 3, 2020. 2. We will continue to conduct the Weekly Site Inspection check, implemented with our POC submitted on or about December 9, 2020, to identify deficiencies that need to be fixed. 3. Weekly Site Inspection ¿ the weekly site inspection will be conducted by Mr. Anthony Okonkwo, Residential Manager. 4. Weekly Site Inspection Frequency ¿ All homes must be inspected at least once per week. 5. Weekly Site Inspection Checklist Training ¿ Mr. Okonkwo was trained by Elvira Berry on March 18, 2020. 6. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Okonkwo is required to call the maintenance hotline to report any maintenance related issues. Mr. Okonkwo was trained on the Maintenance Hotline on March 18, 2020. 7. Maintenance Hotline Training, Office- The Administrative Assistant, Esther Brinson, was re-trained on the Maintenance Hotline on March 17, 2020. 8. Weekly Site Inspection Audit ¿ Elvira Berry, Executive Director, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Correction Activity ¿ Prevention of Reoccurrence We will now forward copies of the Weekly Site Inspection document, applicable work orders and proof of completion to ODP on a bi-weekly basis during the provisional licensing period, as proof that this task is being completed. The documents will be sent to ODP on April 3, 2020, April 17, 2020, May 1, 2020, May 15, 2020, May 29, 2020, June 12, 2020, June 26, 2020, July 10, 2020, July 24, 2020 and August 7, 2020. 04/03/2020 Implemented
6400.77(b)There was no tape or antiseptic found in the first aid kit. 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. Response The home had three first aid kit, all of which together had the required items. However, the concern raised by the Inspector is that in the case of an emergency, staff would need to consult up to three first aid kits to get the needed item to address the emergency. Correction ¿ Immediate Cure (Exhibit II) WHO: Elvira Berry, Executive Director Anthony Okonkwo, CFO/Residential Director Agnes Todo, Registered Nurse WHAT: Ensure that each first aid kit has 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. HOW: 1. We consolidated the first aid kits, so that all items are in one bag. 2. We moved the first aid kit review from monthly to weekly review by the Residential Director. 3. The Nurse will audit the first aid kit on a bi-weekly basis to ensure that all required items are present. 4. First Aid Kit requirement training ¿ The Residential Director was trained on the requirements of the first aid kit on March 17, 2020. He has until March 31, 2020, to ensure that there is only one first aid kit in the home, and the kit has all the items. 5. First Aid Kit Assignment to Nurse ¿ March 23, 2020 Correction Activity ¿ Prevention of Reoccurrence We changed the First Aid Kit inspection to a weekly inspection instead of a monthly inspection with the Fire Drill. The review of the First Aid Kit is now assigned to the Residential Director. The Nurse will audit the Residential Director¿s work on a bi-weekly basis. 04/03/2020 Implemented
6400.165(c)Individual #1's medication log on March 6,7,and 8, showed that no medications were given, and no documentation or explanation provided for the blank spaces on the Medication Administration Record. Visine eye drops 8am dose not administered on 3/12/2020. Albuterol inhaler in medication box, but not on the medication log. It could no be determined at inspection if administered as prescribed. Glycolax powder was not given at 8am on March 7th, 8th, 11th, and 12th, there was no documentation/explanation provided at inspection. Pantoprazole sod 1 tablet by mouth daily before 1 meal at 8am not in blister pack for 3/12/2020, and not signed out on med log. It could not be determined if this medication was administered as prescribed.A prescription medication shall be administered as prescribed.Response: Individual I went to her parent¿s house from March 6, 2020 to March 8, 2020. The Glycolax Powder was given on March 11 and 12, but was not entered into the MAR. the Pantorazole was given at 8AM, but was not entered into the MAR by the staff who was still on shift. The staff will no longer give medication until she has been re-trained on Medication Administration. The Albuterol Inhaler was dropped off by the pharmacy, but was not yet entered in the MAR at the time of the inspection. Per the Plan of Correction (POC), submitted on or about December 9, 2019, Medication Administration Records (MAR) will be audited by the nurse on Fridays and Saturdays. This audit process was instituted to ensure that the House Manager¿s task of reviewing the MAR is completed in a manner that is in compliance with the regulatory requirement. The unannounced licensing inspection was conducted on Thursday, March 12, 2020, a day before the nurse¿s audit. The lesson here is that we need more frequency in our audit. Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Anthony Okonkwo, Residential Director, Pharmacist Agnes Todo, Registered Nurse Staff WHAT: We need to ensure that there is an adequate system for accurately accounting for each medication so that it is clear that the needed medical, nursing, pharmaceutical, dental, dietary and psychological services are arranged for and/or provided. HOW: 1. Staff - Staff was re-trained on the Medication Administration Policy/Checklist from March 21, 2020 to April 3, 2020. 2. Nurse will pick up medications and enter it into the MAR instead of having the medications delivered. 3. MAR Duties ¿ Anthony Okonkwo, Residential Director, is also a Pharmacist. He will be in charge of checking the MAR for each Consumer and comparing it to the blister packs. He will also be in charging of making sure that the right codes are used for any issues of non-compliance such hospitalization, refusal, etc. This check will be conducted daily. 4. MAR Auditing ¿ Agnes Todo, Nurse will audit the MAR at least two times per week. 5. MAR Duties Training ¿ Mr. Okonkwo received trained on his MAR duties on March 17, 2020. The nurse, Agnes Todo received re-training on MAR duties on March 17, 2020. Correction Activity ¿ Prevention of Reoccurrence The Nurse and Residential Director are now in charge of the MAR. Medication can only be picked up by Nurse so that it can be entered immediately. The new nurse is a Registered Nurse. The Nurse will now audit the MAR at least two times per week. 04/03/2020 Implemented
SIN-00162746 Renewal 09/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no operational light in the kitchen of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager Naeemah Johnson, Office Manager WHAT: We need to ensure that there is sufficient lighting in the home, which includes rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes. This will involve changing the way in which we currently conduct our weekly home inspections. WHEN: Monthly Home Inspection Checklist Re-Training for Program Specialist- September 25, 2019 Change the light in the kitchen ¿ September 20, 2019 Maintenance Hotline Training for Office Manager ¿ October 21, 2019 Weekly Home Inspection Checklist Training- October 28, 2019 Thursday Round Ups Agenda Updated ¿ November 14, 2019 HOW: We changed the light in the kitchen. The Program Specialist was re-trained on the Monthly Home Inspection Checklist on September 25, 2019. The Office Manager was trained on the use of the Maintenance Hotline on October 21, 2019. A new House Manager was hired, and she was trained on the weekly Home Inspection Checklist on October 28, 2019. The weekly Home Inspections were included as a topic for the weekly meeting. Correction Activity ¿ Prevention of Reoccurrence We changed the receipt notification for the Maintenance Hotline so that the notice went to the Office Manager¿s email. This change will eliminate the need for the Office Manager to have to check a voicemail to get the maintenance requests. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 11/15/2019 Implemented
6400.67(a)There was a cabinet in the kitchen that was loose from where the hinges keeps the door on.Floors, walls, ceilings and other surfaces shall be in good repair. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager Naeemah Johnson, Office Manager WHAT: We need to ensure that all floors, walls, ceilings and other surfaces are in good repair. This will involve changing the way in which we currently conduct our weekly home inspections. WHEN: Monthly Home Inspection Checklist Re-Training for Program Specialist- September 25, 2019 Fix hinges on the kitchen cabinet ¿ September 20, 2019 Maintenance Hotline Training for Office Manager ¿ October 21, 2019 Weekly Home Inspection Checklist Training- October 28, 2019 Thursday Round Ups Agenda Updated ¿ November 14, 2019 HOW: We fixed the hinges on the kitchen cabinet. The Program Specialist was re-trained on the Monthly Home Inspection Checklist on September 25, 2019. The Office Manager was trained on the use of the Maintenance Hotline on October 21, 2019. A new House Manager was hired, and she was trained on the weekly Home Inspection Checklist on October 28, 2019. The weekly Home Inspections were included as a topic for the weekly meeting. Correction Activity ¿ Prevention of Reoccurrence We changed the receipt notification for the Maintenance Hotline so that the notice went to the Office Manager¿s email. This change will eliminate the need for the Office Manager to have to check a voicemail to get the maintenance requests. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 11/15/2019 Implemented
6400.67(b)The rugs in the foyer of the apartment were pulled away from the tack strips which were now uncovered with nails sticking up from them. This presents a hazard for anyone walking into the home as they could step on the strips. The medication closet had nails sticking through the back of the door that could impale a person's hands if they were reaching into the closet. [Repeated non-compliance 6/18/18.] Floors, walls, ceilings and other surfaces shall be free of hazards.Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager WHAT: We need to ensure that all floors, walls, ceilings and other surfaces are free of hazards. This will involve changing the way in which we currently conduct our weekly home inspections. HOW: 1. We replaced the carpet in the entire house on November 14, 2019. 2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager. 3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day. 4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day. 5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019. 6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019. 7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019. 8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man. Correction Activity ¿ Prevention of Reoccurrence We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 12/26/2019 Implemented
6400.104The notification to the fire department dated 1/26/18 was not current and did not include the exact location of the individual's bedroom.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Rachael Cohen, Compliance Specialist WHAT: We need to ensure that the notification to the fire department contains information related to the exact location of each Individual¿s bedroom. WHEN: Fire Department Notification Policy ¿ September 23, 2019 Fire Department Notification Policy training for the Compliance Specialist ¿ September 25, 2019 Fire Department Notification Policy training for the Program Specialist ¿ September 25, 2019 New Notifications Sent to Fire Department ¿ September 20, 2019 to November 19, 2019 HOW: We drafted a Fire Department Notification Policy and conducted training on the policy. We also re-sent the letters to the fire department. Correction Activity ¿ Prevention of Reoccurrence The policy was initially part of the admission process, and assigned to the Program Specialist. We created a separate Fire Department Notification policy, and assigned it to the Program Specialist and Compliance Specialist. In the policy, there are sample letters to send for notification. 11/20/2019 Implemented
6400.110(f)Individual #1's bedroom was not equipped with a bed shaker or a strobe light. Both individual #1 and the staff are deaf. [Repeated Non-Compliance 6/18/18] If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager Naeemah Johnson, Office Manager WHAT: We need to ensure to ensure that there is a reliable smoke detector mechanism for Individual 1¿s bedroom. WHEN: Monthly Home Inspection Checklist Re-Training for Program Specialist- September 25, 2019 Install a strobe light in the bedroom ¿ September 21, 2019 Thursday Round Ups Agenda Updated ¿ November 14, 2019 Maintenance Hotline Training for Office Manager ¿ October 21, 2019 Weekly Home Inspection Checklist Training- October 28, 2019 HOW: We previously purchased a bed shaker for Individual 1¿s bed since she did not want a strobe light in her room. However, Individual 1 does not like it when the bed vibrates during fire drills. After talking to Individual 1, and addressing the concerns raised during licensing, Individual 1 agreed to have a strobe light in her room, in addition to the bed shaker. The strove light has been installed. The Program Specialist was re-trained on the Monthly Home Inspection Checklist on September 25, 2019. The Office Manager was trained on the use of the Maintenance Hotline on October 21, 2019. A new House Manager was hired, and she was trained on the weekly Home Inspection Checklist on October 28, 2019. The weekly Home Inspections were included as a topic for the weekly meeting. Correction Activity ¿ Prevention of Reoccurrence We previously purchased a bed shaker for Individual 1¿s bed since she did not want a strobe light in her room. However, Individual 1 does not like it when the bed vibrates during fire drills. After talking to Individual 1, and addressing the concerns raised during licensing, Individual 1 agreed to have a strobe light in her room, in addition to the bed shaker. The strove light has been installed. We changed the receipt notification for the Maintenance Hotline so that the notice went to the Office Manager¿s email. This change will eliminate the need for the Office Manager to have to check a voicemail to get the maintenance requests. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. 11/14/2019 Implemented
6400.112(e)The time of day (AM/PM) was not indicated on the following fire drills; 3/2019, 4/2019 and 5/2019. It could not be determined if a second sleep drill was held.A fire drill shall be held during sleeping hours at least every 6 months. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Tanya Carter, House Manager WHAT: We need to ensure that there is a clear indication on the Fire Drill form of when the fire drill was conducted, so that we can tell whether there has been a fire drill conducted during sleeping hours within the last 6 months. WHEN: Fire Drill Form Updated ¿ September 23, 2019 Fire Drill Form training for Program Specialist ¿ September 24, 2019 Fire Drill Form training for House Manager ¿ October 29, 2019 HOW: The Fire Drill form was updated, and a training was conducted for the Program Specialist and House Manager on September 24, 2019 and October 29, 2019. Correction Activity ¿ Prevention of Reoccurrence We changed our Fire Drill form to have a mandatory option to check off for AM/PM instead of leaving the option of providing the information up to staff. We also changed the assignee for the task. Rather than the task being completed by the staff, then reviewed by the House Manager, the task can only be completed by the House Manager, then reviewed by the Program Specialist. 10/29/2019 Implemented
6400.144Individual #1's medication Lidocaine patches were not on site.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. Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist (Medication Administration Train the Trainer) Iris West, Nurse Al Williams, House Manager Staff WHAT: We need to ensure that there is an adequate system for accurately accounting for each medication so that it is clear that the needed medical, nursing, pharmaceutical, dental, dietary and psychological services are arranged for and/or provided. HOW: 1. Staff - Staff was re-trained on November 26 and 27, 2019. For the practicum, we separated the employees into two days to ensure that they understand their responsibilities. Staff received training on the updated the Medication Administration Policy/Checklist on November 21 and 22, 2019. 2. MAR Duties - Al Williams, House Manager, will be in charge of checking the MAR for each Consumer and comparing it to the blister packs. He will also be in charging of making sure that the right codes are used for any issues of non-compliance such hospitalization, refusal, etc. 3. MAR Duties Training ¿ Mr. Williams was trained on his MAR duties on November 29, 2019 by the nurse, Iris West. The duties were explained to Mr. Williams by Elvira Berry, Executive Director on December 2, 2019 and December 19, 2019. 4. MAR Duties Frequency ¿ Mr. Williams will check the MAR for each home at least three times per week. 5. MAR Duties Auditing ¿ Iris West, Nurse will audit the MAR at least once per week. Correction Activity ¿ Prevention of Reoccurrence The Nurse is now in charge of Medication Administration Record (MAR). She has designated Fridays and Saturdays as her review days for the MARs. She will audit Mr. Williams¿ work, and make updates as needed. We will continue to ensure that Staff are up to date on their practicum, by having the Program Specialist check the practicum observation due dates for each staff at least once a month. We posted the revised Medication Administration Policy/Checklist at each home, above the table on which the Medication Administration book is kept. We also put the Medication Administration Policy/Checklist inside the Medication Administration book. 12/19/2019 Implemented
6400.165Individual#1's medication Polyeth Glycol was not available on 9/16, 9/17 and 9/18/19 8 am dose. Staff marked the medication administration record with a "0". No record of action was available. Individual #1's medication Ovar Redihal was not available on 9/11, 9/12 and 9/13/19 for the 8am and 8pm dose.Documentation of medication errors and follow-up action taken shall be kept. Correction ¿ Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist (Medication Administration Train the Trainer) Iris West, Nurse Al Williams, House Manager Staff WHAT: We need to ensure that medication are properly discontinued with sufficient documentation, and that documentation for medication errors and follow-up actions are kept. HOW: 1. Staff - Staff was re-trained on November 26 and 27, 2019. For the practicum, we separated the employees into two days to ensure that they understand their responsibilities. Staff received training on the updated the Medication Administration Policy/Checklist on November 21 and 22, 2019. 2. MAR Duties - Al Williams, House Manager, will be in charge of checking the MAR for each Consumer and comparing it to the blister packs. He will also be in charging of making sure that the right codes are used for any issues of non-compliance such hospitalization, refusal, etc. 3. MAR Duties Training ¿ Mr. Williams was trained on his MAR duties on November 29, 2019 by the nurse, Iris West. The duties were explained to Mr. Williams by Elvira Berry, Executive Director on December 2, 2019 and December 19, 2019. 4. MAR Duties Frequency ¿ Mr. Williams will check the MAR for each home at least three times per week. 5. MAR Duties Auditing ¿ Iris West, Nurse will audit the MAR at least once per week. Correction Activity ¿ Prevention of Reoccurrence The Nurse is now in charge of Medication Administration Record (MAR). She has designated Fridays and Saturdays as her review days for the MARs. She will audit Mr. Williams¿ work, and make updates as needed. We will continue to ensure that Staff are up to date on their practicum, by having the Program Specialist check the practicum observation due dates for each staff at least once a month. We posted the revised Medication Administration Policy/Checklist at each home, above the table on which the Medication Administration book is kept. We also put the Medication Administration Policy/Checklist inside the Medication Administration book. 12/19/2019 Implemented
6400.168(c)It could not be determined if the medication trainer was certified as the training was completed at another agency prior to employment, and they did not have the certificate. Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. Correction ¿ Immediate Cure WHO: Adekunle Baruwa, Program Specialist Rachael Cohen, Compliance Specialist Iris West, Nurse Shavell Gordine, Staff WHAT: We need to ensure that medical administration training is only conducted by qualified Providence Corporation staff, so that we can ensure that we have the trainer¿s certification. 1. Medication Administration Class for Staff 1 ¿ September 20, 2019 2. Update Training Policy ¿ September 23, 2019 3. Training Policy training for Program Specialist ¿ September 24, 2019 4. Training Policy training for Compliance Specialist ¿ September 24, 2019 5. Assign medication administration eligibility/clearance for Direct Care Staff to Nurse ¿ November 29, 2019 6. Check all staffs¿ training record to ensure that all staff were trained by approved Providence Corporation trainer ¿ December 26, 2019 Correction Activity ¿ Prevention of Reoccurrence We changed our Training Policy so that employees can only receive medication administration training from a qualified Providence Corporation staff. The Compliance Specialist is responsible reviewing pre-employment documents from new employees. The Compliance Specialist shall not accept any outside medication administration documentation from any new employee. 12/26/2019 Implemented
Article X.1007Providence Corporation is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1 did not have documentation of a declination if they had lived in Pennsylvania for the past 2 years. Staff person #2 did not have documentation of a declination if they had lived in Pennsylvania for the past 2 years.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Correction ¿ Immediate Cure WHO: Rachael Cohen, Compliance Specialist WHAT: We need to ensure that the residency requirement is conspicuous on the Background Check form, so that the form¿s goal will be served. This requires updating the form and re-training the responsible employee on the new form. WHEN: Background Check Form Update ¿ September 20, 2019 Hiring Policy re-training ¿ September 24, 2019 Background Check Form re-training ¿ September 24, 2019 Review of Personnel Files for Background Check only ¿ October 23, 2019 HOW: The Compliance Specialist was re-trained on the hiring requirements and the updated background check form. The Compliance Specialist then checked all the personnel files to ensure that the files are in compliance with the residency requirement. Correction Activity ¿ Prevention of Reoccurrence We updated the Background Check Form, with the section asking about the residency highlighted in red. This update will ensure that the assigned staff will pay attention to whether the employee answered the question. 10/23/2019 Implemented
SIN-00140992 Renewal 06/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There was a broken knob on the oven which could not be closed to turn off the gas without some work. There were nails sticking through the backside of the medicine closet. Floors, walls, ceilings and other surfaces shall be free of hazards.Correction - Immediate Cure WHO: Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that the staff and Individuals (if applicable) are able to turn off the oven knob without effort. We also need to ensure that there are not hazardous conditions in the home. WHEN: Oven Knob Changed - June 21, 2018 Medicine Door repair - June 21, 2018 House Inspection Training - June 29, 2018 - Rachel Cohen House Inspection Training - July 28, 2018 - Shamaine Bennett HOW: We installed a new oven knob. We also repaired the medication door so that the nail is no longer hanging out. In addition, we re-trained the Compliance Specialist and the House Manager so that they are able to notice these non-compliance circumstances during their weekly house inspection. Correction Activity - Prevention of Reoccurrence A House Manager or Compliance Assistant could have prevented the citation by closing checking the regulations. In the past, we required either the House Manager or the Compliance Assistant to conduct a weekly house inspection. We now require the Executive Director, Compliance Assistant and House Manager to each conduct a weekly House Inspection. This means that there are three people checking the houses to ensure compliance on a weekly basis. 07/28/2018 Implemented
6400.110(f)Individual #1 who was deaf could not be alerted to the current fire system as the bed shaker did not work properly. Also, the fire alarm did not activate the strobes in the home. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Correction - Immediate Cure WHO: Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that each Individual who is unable to hear a smoke detector or fire alarm system has equipment that will alert him or her in the event of a fire. WHEN: Bed Shaker and Strobe Lights Installed - June 20, 2018 House Inspection Training - June 29, 2018 - Rachel Cohen House Inspection Training - July 28, 2018 - Shamaine Bennett HOW: We bed shaker and strobe lights were installed on June 20, 2018. They were tested during inspection on June 20, 2018. We also re-trained the Compliance Specialist and the House Manager so that they are able to notice these non-compliance circumstances during their weekly house inspection. Correction Activity - Prevention of Reoccurrence A House Manager or Compliance Assistant could have prevented the citation by closing checking the regulations. In the past, we required either the House Manager or the Compliance Assistant to conduct a weekly house inspection. We now require the Executive Director, Compliance Assistant and House Manager to each conduct a weekly House Inspection. This means that there are three people checking the houses to ensure compliance on a weekly basis. 07/28/2018 Implemented
6400.112(c)On 10/10/17 the fire drill indicated that it took 3 minutes for evacuation. On 1/27/18 and 4/11/18 the fire drill record did not indicate the exit used.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. Correction - Immediate Cure WHO: Elvira Berry, Executive Director Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that our residents and staff are able to evacuate within 2.5 minutes. WHEN: Fire Expert Training - May 24, 2018 and June 6, 2018 Fire Drill re-training - June 29, 2018 Fire Drill conducted - July 7, 2018 HOW: We already had a fire safety training by a safety expert on June 15 and 23, 2017. On June 29, 2018, we re-trained the Compliance Assistant and House Manager on the proper Fire Drill requirements. We also shared the ODP 6400 regulations requirement and emergency preparedness requirement with the supervisory personnel. They now understand that if a fire drill is conducted with an exit time of more than 2.5 minutes, they must notify the Executive Office, and they must re-do the fire drill within the month, until all the Individuals and staff are able to exit the home in less than 2.5 minutes. A fire drill was conducted on July 7, 2018 with the updated form. A copy of the fire drill updated fire drill was sent to ODP. Correction Activity - Prevention of Reoccurrence The Fire Drill Form will now be sent to the Executive Office within 48 hours of being conducted. The Executive Office must review the Fire Drill Form for compliance within 24 hours of receipt. This new review process will ensure that the supervisory personnel are held accountable for ensuring that all Individuals and staff can exit the building within 2.5 minutes. 07/07/2018 Implemented
6400.112(h)On 8/28/17 the fire drill record did not indicate 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.Correction - Immediate Cure WHO: Elvira Berry, Executive Director Rachel Cohen, Compliance Assistant Shamaine Bennett, House Manager WHAT: We need to ensure that our residents and staff are able know the designated meeting place so that there are no confusions during an emergency. Fire drills are conducted by the supervisory personnel. Therefore, we need to ensure that the supervisory personnel have the training needed to fulfill their responsibilities. WHEN: Fire Expert Training - May 24, 2018 and June 6, 2018 Fire Drill document updated - June 22, 2018 Updated Fire Drill Procedure Training - June 25, 2018 Fire Drill conducted - July 7, 2018 HOW: We already had a fire safety training by a safety expert on June 15 and 23, 2017. On June 22, 2018, we updated our Fire Drill Form so that the designated meeting place is moved up to the first line on the form. A fire drill was conducted on July 7, 2018 with the updated form. A copy of the fire drill updated fire drill was sent to ODP. Correction Activity - Prevention of Reoccurrence On the old Fire Drill document, the designated meeting place blended in with the document, which caused the employees to miss the requested information. Therefore, we updated the form, and instituted a policy that the Fire Drill Form will only be printed on color. The different colors on the form will help employees with completing the form accurately. 07/07/2018 Implemented