Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225836 Renewal 06/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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 was 123 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. 08/25/2023 Implemented
6400.165(a)The A and d ointment was not listed on the MAR but is being used as part of individual 1's prescriptions. There is no prescription for A and D ointment at the time of inspection.A prescription medication shall be prescribed in writing by an authorized prescriber.Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Leads Therap Specialist WHAT: We need to ensure that all medications in the medication box have the correct label so that the reviewer can easily identify the authorizing prescriber. We also need to ensure that all medications are listed on the MAR. HOW: We immediately had the pharmacy print a document showing the name of the authorizing prescriber. We also had the correct label affixed to the A and D ointment, and listed on the MAR. A copy of the documents and a picture of the label was sent to the ODP licensing inspectors. 08/25/2023 Implemented
SIN-00206216 Renewal 06/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The Fire department notice was not provided / completed.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. COMMENT: The fire department notice referenced under 55 PA Code Chapter 6400.104 is only applicable for new sites or when a new Individual moves into an exiting site. This home was opened in October 2018, and no new individual has moved into the home since 2019. There has been two inspections during which the documents were provided. The documents were not provided during the 2022 inspection because (1) it was not applicable, and (2) it was not requested by the inspectors. Correction ¿ Immediate Cure WHO: Regulatory Specialist Executive Director WHAT: We need to ensure that the fire department has the exact location the bedrooms in our homes, along with our address, the number of people residing in the home, and the type of assistance needed. HOW: We re-sent the fire department notice to the fire department on July 27, 2022. 08/12/2022 Implemented
6400.141(c)(6)The individual #2 TB test is past due. It was last completed 10/24/19.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Nurse WHAT: We need to ensure that each Individual receives a TB test at least once every two years. HOW: Individual # 2 received his TB shot on July 27, 2022. The Nurse, Residential Director and House Manager have been re-trained so that they will ensure that each Individual gets a TB test at least once every two years. 08/12/2022 Implemented
6400.141(c)(9)Individual #2 prostate exam is past due. The last one was completed June 2020The physical examination shall include: A prostate examination for men 40 years of age or older. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Nurse WHAT: We need to ensure that male Individuals over the age 40 receive a prostate examination as recommend by their physician. HOW: Individual # 2 received a prostate exam from his primary care provider on July 15, 2022. The Nurse, Residential Director and House Manager have been re-trained so that they will ensure that all male individuals aged 40 and over receive a prostate examination as recommend by their physician. 08/12/2022 Implemented
6400.142(a)There is no available documentation of the individual's last dental visitAn individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Nurse WHAT: We need to ensure that all Individuals receives a dental examination on an annual basis. HOW: Individual # 2 has a dental appointment on August 3, 2022. The Nurse, Residential Director and House Manager have been re-trained so that they will ensure dental examinations are completed on annual basis. 08/12/2022 Implemented
6400.144Agency staff is documenting on Individual #2 MAR on 06/01/2022 thru 06/08/2022 that medication (OLANZAPINE 5mg) is being administered daily at 8pm. (This medication based on the script was discontinued on 06/02/2022).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: Regulatory Specialist Residential Director House Manager Nurse WHAT: We need to ensure all discontinued medications are discontinued in the MAR. HOW: All discontinued have been removed from the medication box and discontinued on the MAR. The Nurse, Residential Director and House Manager have been re-trained so that the regulatory duties regarding medication administration. 08/12/2022 Implemented
6400.181(d)individual #2 current assessment is not signed/dated by the program specialistThe program specialist shall sign and date the assessment. Correction ¿ Immediate Cure WHO: Program Specialist Regulatory Specialist WHAT: We need to ensure all individual assessments are completed and signed as required by regulations. HOW: The Program Specialist reviewed all assessments for accuracy and completion. She also signed all assessments. She was re-trained on regulatory requirements of assessments on June 11, 2022. 08/15/2022 Implemented
6400.165(b)PRN Medication (ACETAMINOPHEN 325mg) expired on 03/09/2021 and remained in individual's #2 med box.A prescription order shall be kept current.Correction ¿ Immediate Cure WHO: Residential Director House Manager Regulatory Specialist WHAT: We need to ensure all expired medications are removed from the medication box and discarded. Before expiration of PRN medication, new PRN medication will be obtained and placed in the medication box. HOW: All expired medications have been removed from the medication box and properly discarded. The Nurse, Residential Director and House Manager have been re-trained regarding their responsibilities under medication administration. 06/17/2022 Implemented
6400.167(a)(1)Medication (SERTRALINE 25mg) for Individual #2 was not administered as prescribed; the pill was still in the blister pack.Medication errors include the following: Failure to administer a medication.Correction ¿ Immediate Cure WHO: Residential Director House Manager Regulatory Specialist Staff Executive Director WHAT: We need to ensure all individual medications are administered at the prescribed date and time. HOW: We re-trained all managerial staff regarding the regulatory requirements during our post licensing meeting the week of June 13, 2022. We re-trained all staff on the issues of the Five Rights between June 15, 2022 and June 22, 2022. 08/12/2022 Implemented
6400.181(f)There is no documentation confirming that the assessment was sent to the team 30days prior to the individual's plan meetingThe program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Correction ¿ Immediate Cure WHO: Program Specialist Regulatory Specialist WHAT: We need to ensure that all assessments are sent to the team 30 days prior to the individual¿s plan meeting. HOW: We re-trained all managerial staff regarding the regulatory requirements during our post licensing meeting the week of June 13, 2022. On June 11, 2022, the Program Specialist was re-trained so that she understands her responsibilities under the 6400 regulations. The training specified that the assessment must be forwarded to the team at least 30 days prior to the plan meeting. 08/12/2022 Implemented
SIN-00188320 Renewal 05/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The window in Individual 1's bedroom lacked a window screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. Correction ¿ Immediate Cure (Exhibit I and II) WHO: Residential Director Office Manager Compliance Specialist (House Manager, upon hire) WHAT: We need to ensure that each window, including windows in doors, are securely screened so that there is a protective net when the window or net is opened. HOW: On May 28, 2021, we contacted the apartment, and requested that the maintenance office window screens in Individual #1¿s bedroom. The screens are scheduled to be installed on or before July 15, 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. 07/15/2021 Implemented
6400.112(d)Fire drill dated 3/20/21 for 7901 Henry Ave indicated the evacuation time exceeded the allowable time. Evacuation took 4 minutes. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Correction ¿ Immediate Cure (Exhibit III) WHO: Residential Director (House Manager, upon hire) Compliance Specialist WHAT: We need to ensure that evacuation time is less than two and a half minutes for each fire drill. If there is a situation in which it falls outside the two and half minute mark, then we need a protocol that includes conducting another fire drill, with the same staff, and requesting ISP meeting(s), if needed. HOW: Fire drills are conducted by the House Manager and Residential Director, 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-00176323 Renewal 09/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were many poisons left out around the apartment including but not limited to mouthwash, soaps, deodorant, colognes and cleaning fluids.Poisonous materials shall be kept locked or made inaccessible to individuals. Response: The home was reported in EIM, Incident Number 8726435, as vacant and under renovation due to destruction by a Consumer. Thus, all the items were bunched up together in different corners and surfaces. 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
6400.62(d)The closet located in the living room had chemicals and food/drink products stored in it. Some of these included Gain Laundry detergent, Avistat, Scrubbing Bubbles, and Thick It Apple Juice.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Response: The home was reported in EIM, Incident Number 8726435, as vacant and under renovation due to destruction by a Consumer. Thus, all the items were bunched up together in different corners and surfaces. Correction ¿ Immediate Cure WHO: Residential Director House Manager WHAT: We need to ensure that poisonous materials are kept separate from food. HOW: We threw out all the food in the home after the renovations were completed. We purchased new food that are separated from poisonous chemicals. 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. We also posted the list of flammable and combustible items on the door. 10/31/2020 Implemented
6400.67(a)- There was a broken cabinet door in the kitchen that was wood and the piece was push through. - The walls throughout the living room and dinning room area had various size holes in them. - The blinds in the living room covering the sliding doors were broken and many were missing.Floors, walls, ceilings and other surfaces shall be in good repair. Response: The home was reported in EIM, Incident Number 8726435, as vacant and under renovation due to destruction by a Consumer. 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: The kitchen cabinet doors were fixed with the rest of the home. 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. 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. 10/31/2020 Implemented
6400.67(b)There were small pieces of glass on the patio and on the living room rug consistent with there being a broken window in the apartment. Floors, walls, ceilings and other surfaces shall be free of hazards.Response: The home was reported in EIM, Incident Number 8726435, as vacant and under renovation due to destruction by a Consumer. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager WHAT: We need to ensure that the floors, walls, ceilings and other surfaces are free of hazards. HOW: The broken windows were fixed with the rest of the home. The glass were also cleaned after the renovation. 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. 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. 10/31/2020 Implemented
6400.68(b)The water temperature in the apartment was checked and found to be 133.5. 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 obtained a reasonable accommodation approval from the apartment complex. The water is now scheduled to be reduced before November 19, 2020. 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. 11/19/2020 Implemented
6400.77(b)The first aid kit did not contain a thermometer, scissors, anti-septic 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. Response: The home was reported in EIM, Incident Number 8726435, as vacant and under renovation due to destruction by a Consumer. Thus, all the items were bunched up together in different corners and surfaces. Correction ¿ Immediate Cure WHO: Residential Director Compliance Specialist House Manager WHAT: We need to ensure that the first aid kit contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac. HOW: We purchased a first aid kit that contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac. 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. 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. 10/31/2020 Implemented
6400.112(e)A fire drill was not held during sleeping hours at least every 6 months.A fire drill shall be held during sleeping hours at least every 6 months. Correction ¿ Immediate Cure WHO: Residential Director House Manager WHAT: We need to ensure that there is an overnight fire drill at lease once every six months. HOW: The house manager and residential director were re-trained on the fire drill policy on September 18, 2020. A fire drill schedule was given to them on October 21, 2020. Correction Activity ¿ Prevention of Reoccurrence We created a fire drill schedule that assists the house manager and residential director with understanding when an overnight drill is needed. 10/21/2020 Implemented
SIN-00172548 Unannounced Monitoring 03/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling tile in the kitchen was stained and needs to be replaced. [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. The problem here is that there was a leak upstairs that was fixed. The apartment complex was supposed to fix the ceiling afterwards, but they deemed it a non-emergency work. HOW: 1. We contacted our own personal maintenance person to fix the ceiling since the apartment complex did not deem it an emergency need. The replacement tile has been ordered, and 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
6400.68(b)The Water temperature was 139.4 degrees Fahrenheit in the bathroom. [REPEATED VIOLATION 11/22/19] 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: Elvira Berry, Executive Director Anthony Okonkwo, CFO/Residential Director Esther Brinson, Administrative Assistant Staff WHAT: We need to ensure that the hot water temperature in the bathtubs and showers do not exceed 120 degrees Fahrenheit. HOW: 1. We put in an emergency request to have the hot water reduced to less than 120 degrees Fahrenheit on March 17, 2020. 2. 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. On the form, it states, ¿Staff is required to check the water temperature of the bathroom before each Resident takes a shower. The water temperature CANNOT exceed 120 degrees Fahrenheit. The form then has space for each staff to put the temperature of the water. We have now modified the form to also state that ¿Residents cannot take a bath with water that is more than 120 degrees Fahrenheit, and all such occurrences should be reported to the Residential Director immediately, and also reported to the Maintenance Hotline.¿ 3. Staff re-training for Hot Water Compliance Form: Residential Director- March 16, 2020 to March 27, 2020 4. Hot Water Compliance Form and Maintenance Hotline re-training for Administrative Assistant ¿ March 16, 2020 Correction Activity ¿ Prevention of Reoccurrence We will now forward copies of the Hot Water Compliance Form 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
6400.71There were no emergency numbers on or near the outside telephone line in the dining area. [REPEATED VIOLATION 11/22/19]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. Response The emergency numbers were posted on a poster board above the phone. However, there were other papers posted around it. We need to make it more visible. 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 telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are posted on or by each telephone in the home with an outside line. HOW: 1. We printed the emergency numbers in red to make it more visible, then reposted it on the poster board above the phone. 2. We will continue to conduct the Weekly Site Inspection check to identify deficiencies that need to be fixed. 3. Weekly Site Inspection ¿ a 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 and work orders 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 found in the first aid kit. This was replaced during the inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. 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
6400.81(k)(6)There were no mirrors found in individual #1 or #2's bedrooms. [REPEATED VIOLATION 11/22/19]In bedrooms, each individual shall have the following: A mirror. 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 each room has a mirror. HOW: 1. We replaced the mirrors each bedroom. 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
6400.82(f)There was no toilet paper in the bathroom. [REPEATED VIOLATION 11/22/19]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. Response Individual II did not have toilet paper in his bathroom because he uses wipes. However, we have now placed toilet paper in the bathroom. 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 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. HOW: 1. We placed a toilet paper in the bathroom. 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
6400.46(a)During the physical site inspection, staff member #3 was not able to operate the smoke detector during the test.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Response Per the regulations, Direct Service Workers and Program Specialist shall be trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms. Our employees are trained as required. However, per the Fire Drill policy submitted as part of our Plan of Correction, on or about December 9, 2020, the fire drills are only conducted by the managerial staff. This means that every month, the managerial staff goes to the home, activates the fire drill, and the staff proceeds to carry out his or her duty. The staff are never required to activate the smoke detector because it is not their role and it is not required by the regulation. Correction ¿ Immediate Cure (Exhibit II) WHO: Elvira Berry, Executive Director Anthony Okonkwo, CFO/Residential Director Staff - Emmanuel Oitamong Staff WHAT: Ensure that ensure that direct care workers are trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms. HOW: Staff, Emmanuel Oitamong, was trained on how to activate the smoke detector on March 17, 2020. In our last POC, we indicated that we will show the direct care staff the manner in which they activate the smoke detector. We have been doing it, but not by observation, instead of having them do it themselves. We have now changed it so that each employee actually activates the smoke detector. The training is from March 17, 2020 to April 3, 2020. Correction Activity ¿ Prevention of Reoccurrence We changed our training format so that staff activates the smoke detector during their training instead of watching the instructor activate the smoke detector. 04/03/2020 Implemented
6400.169(a)Staff member#1 documented as completed annual medication training on 9/6/19 had a score of 89, which needs a 90 to pass. Staff #2 administered 8am medications on 3/12/2020, and has no current medication training provided, last annual practicum completed on 12/30/2017.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Response Staff I was not a current employee at the time of the inspection or now. Staff I¿s employment ended more than a week before the inspection occurred on March 12, 2020. Correction ¿ Immediate Cure (Exhibit I) WHO: Elvira Berry, Executive Director WHAT: We need to ensure that staff has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). HOW: We changed our medication administration vendor since such mistake should not have occurred. Correction Activity ¿ Prevention of Reoccurrence All vendor¿s work (related to medication administration) will be reviewed by Elvira Berry prior to payment. 03/31/2020 Implemented
SIN-00166808 Unannounced Monitoring 11/21/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The hall bathroom did not have ventilation. Individual #3's bathroom did not have 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. 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 each that living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. HOW: 1. We had the vent fixed on November 22, 2019 and December 5, 2019. However, it keeps tripping off. The apartment will install a new vent before December 31, 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 nuance of each home. 12/31/2019 Implemented
6400.68(b)The Water temperature in individual #3's bathroom was 143.9 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Correction - Immediate Cure WHO: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager Staff WHAT: We need to ensure that the hot water temperature in the bathtubs and showers do not exceed 120 degrees Fahrenheit. HOW: 1. We put in an emergency request to have the hot water reduced to less than 120 degrees Fahrenheit on November 22, 2019, at 4:30 P.M. The hot water was reduced on the same day. 2. We now use a 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. 3. Staff Training for Hot Water Compliance Form - The House Manager, Al Williams, was trained on the Hot Water Compliance Form on December 20, 2019. The Hot Water Compliance Form was introduced to the homes on December 20, 2019. It was revised on December 23, 2019, and Mr. Williams was trained again on December 23, 2019. The staff were trained on the Hot Water Compliance Form on December 23, 2019, December 24, 2019 and December 25, 2019. In addition: 4. Weekly Site Inspection - a weekly site inspection will be conducted by Mr. Al Williams, House Manager. 5. Weekly Site Inspection Frequency - There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day. 6. 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. 7. 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. 8. 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. 9. 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. 10. 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 nuance of each home. 12/26/2019 Not Implemented
6400.76(a)The Towel rack in individual #3's bathroom broken needs to be replaced. Furniture and equipment shall be nonhazardous, clean and sturdy. 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 the furniture and equipment are nonhazardous, clean and sturdy. HOW: 1. Replace the broken piece of the towel rack - November 22, 2019, December 5, 2019, December 27, 2019 - the rack keeps coming off. Therefore, we requested permission from the apartment complex to replace it by ourselves. The new rack will be installed on December 27, 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 nuance of each home. 12/27/2019 Implemented
6400.82(f)The hall bathroom had no trash can, and no paper towels. Individual #3's bathroom had no toilet paper, paper towels, or a trash can.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: Elvira Berry, Executive Director Barry Baruwa, Program Specialist Al Williams, House Manager NaeEmah Johnson, Office Manager WHAT: We need to ensure that 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. HOW: 1. Put new trash can, paper towel and bathmat in both bathrooms¿ November 22, 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. 12/26/2019 Implemented
6400.165(c)Individual #3's medications were not administered as prescribed for: Pantoprazole 40mg at 6am on November 1,4,5.10, and 11. The medication was still in the blister pack. Methenamine HIP 1gm at 8am on November 1, and 11. The medication was still in the blister pack. Olanzapine 5mg at 8am on November 1, and 11. The medication was still in the blister pack. Finasteride 5mg at 8am on November 1, and 11. The medication was still in the blister pack. Cerovite Tab Senior at 8am on November 1, and 11. The medication was still in the blister pack. Sertraline 25mg at 8am on November 1, and 11. The medication was still in the blister pack. Divalproex ER 500mg at 8am on November 1, and 11. The medication was still in the blister pack. Reguloid 400mg at 8am on November 13. The medication was still in the blister pack.A prescription medication shall be administered as prescribed.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. 12/19/2019 Not Implemented
6400.167(b)Individual #3's medications were not administered for: Pantoprazole 40mg at 6am on November 1,4,5.10, and 11. The medication was still in the blister pack. Methenamine HIP 1gm at 8am on November 1, and 11. The medication was still in the blister pack. Olanzapine 5mg at 8am on November 1, and 11. The medication was still in the blister pack. Finasteride 5mg at 8am on November 1, and 11. The medication was still in the blister pack. Cerovite Tab Senior at 8am on November 1, and 11. The medication was still in the blister pack. Sertraline 25mg at 8am on November 1, and 11. The medication was still in the blister pack. Divalproex ER 500mg at 8am on November 1, and 11. The medication was still in the blister pack. Reguloid 400mg at 8am on November 13. The medication was still in the blister pack. And there is no documentation for any medication errors.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.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. 12/19/2019 Not Accepted