Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225837 Renewal 06/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The bedroom closet door was off the track in individual 2 bedroom, which can pose a hazard and the door can fall to the floor. Floors, walls, ceilings and other surfaces shall be free of hazards.Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Leads WHAT: We need to ensure that closet doors are well maintained and on track so that they do not pose fall risk. HOW: We replaced the closet door with curtains to eliminate the need to worry about the door falling off the tracks. We chose this action after talking to the Individual and staff in the home. They stated that the Individual did not like having to manipulate closet doors. 08/25/2023 Implemented
SIN-00206217 Renewal 06/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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
6400.141(c)(14)Individual #1's physical did not include pertinent medical information in the event of an emergencyThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. COMMENT: This citation was wrongfully issued. The word, ¿N/A¿, is clearly written under the sentence, ¿Information pertinent to diagnosis and treatment in case of emergency¿. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Nurse Staff WHAT: We need to ensure that all physicals have medical information pertinent to diagnosis and treatment in case of an emergency. HOW: Individual #1 is scheduled for another physical on August 8, 2022. The Nurse, Residential Director and House Manager have been re-trained so that they will continue to ensure that each Individual¿s doctor completes the annual physical forms in its entirety. 08/15/2022 Implemented
6400.141(c)(15)Individual #1's physical did not include instructions for the individual's dietThe physical examination shall include:Special instructions for the individual's diet. COMMENT: This citation was wrongfully issued. The word, ¿N/A¿, is clearly written under the sentence, ¿Recommended diet and special instructions, include specifics for medical diet (for example low salt) and/or for food/liquid modifications (for example: mechanical soft with nectar thick liquids)¿. Thus, confirming that the Individual did not have any recommended or special dietary needs. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Nurse WHAT: We need to ensure that all physicals have medical information pertinent to special diets and special instructions related to the recommendation. HOW: Individual #1 is scheduled for another physical on August 8, 2022. The Nurse, Residential Director and House Manager have been re-trained so that they will continue to ensure that each Individual¿s doctor completes the annual physical forms in its entirety. 08/15/2022 Implemented
6400.144Medication was not administered for Individual #1 on 05/28/2022 for the 8:00am dosage. The medication remained in the blister pack and no documentation was recorded. (Individual stated staff didn't give it to her, when asked by management) Management clarified she refused the medication, but did not have documentation of the refusal and education of the refusal.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. COMMENT: This citation was wrongfully issued. For May 28, 2022, the staff clearly marked the letters, M/R, on the Medication Administration Record, clearly recording that the Individual missed her medications because she refused to take the medication at 8:00 A.M., on May 28, 2022. Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Staff WHAT: We need to ensure that all medication activities are recorded on the Medication Administration Record, thus confirming the activities that occurred during the medication administration. HOW: All the MAR has been reviewed to ensure that all medication are properly documented. 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. 06/22/2022 Implemented
6400.181(d)Individual #1 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 Executive Director WHAT: We need to ensure that the assessments are signed by the program specialist prior to being forwarded to other people. HOW: The assessment was signed by the Program Specialist on June 11, 2022. The Program Specialist has been re-trained so that she understands her responsibilities under the 6400 regulations. 06/22/2022 Implemented
6400.63(b)The floor leading to the kitchen where the rug meets the tile was coming up and damaged. (Individual #1 stated it hurts her feet when walking over it)Heat sources do not require guards or insulation if all indviduals living in the home understand the danger of heat sources and have the ability to sense and move away from the heat source quickly. Documentation of each individual's understanding and ability shall be in each individual's assesment.Correction ¿ Immediate Cure WHO: Residential Director Regulatory Specialist House Manager WHAT: We need to ensure that the floors are in good repair. HOW: On July 27, 2022, we fixed the floor leading to the kitchen so that the rug and tile are in alignment and not damaged. 08/12/2022 Implemented
6400.166(a)(5)The Medication (TRAZODONE) is being administered to Individual#1 the strength of the medication on the individuals MAR states 50mg, on the pharmacy label the strength is listed as 100mg. The Script was requested.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Correction ¿ Immediate Cure WHO: Regulatory Specialist Residential Director House Manager Therap Specalist Staff WHAT: We need to ensure all medication are recorded as prescribed in the MAR, thus ensuring that the prescription orders are current. HOW: The medication was taken to the pharmacy for clearer instructions. 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. 06/22/2022 Implemented
6400.181(f)There is no documentation confirming that the assessment was sent to the team 30days prior to the individual's plan meeting.The 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 Executive Director WHAT: We need to ensure that the assessments are sent to the team at least thirty days before an Individual¿s ISP meeting. HOW: The Program Specialist has been re-trained so that she understands her responsibilities under the 6400 regulations. 06/22/2022 Implemented
6400.182(d)There was no documentation provided that confirmed that notice was sent to the ISP team 30days prior to the ISP meetingThe individual and persons designated by the individual shall be involved and supported in the initial development and revisions of the individual plan.Plan of Correction COMMENT: This citation is vague and appears to be applicable to the Support Coordinator Organization who are responsible for setting up the ISP meeting. Correction ¿ Immediate Cure WHO: Program Specialist Regulatory Specialist Executive Director WHAT: We need to ensure that all internal relevant team members participate in the ISP development and meetings. HOW: We re-trained all managerial staff regarding the regulatory requirements during our post licensing meeting the week of June 13, 2022. The Program Specialist has been re-trained so that she understands her responsibilities under the 6400 regulations on June 11, 2022. 08/12/2022 Implemented
SIN-00188321 Renewal 05/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)The 4/21/21 physical exam for Individual #1 did not include a gynecological exam.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Response: Individual #1¿s gynecological exam is administered by another physician, and was scheduled for June 8, 2021. Correction ¿ Immediate Cure (Exhibit I, II) WHO: Residential Director Compliance Specialist Nurse House Manager, upon hire WHAT: We need to ensure that each female Individual receives gynecological exam, as neeed, but at least once per year. HOW: Individual #1 received her gynecological exam on June 8, 2021. We re-trained the Residential Director, Nurse and Compliance Specialist so that they are more aware of the timing for necessary medical appointments. The training was completed on June 22, 2021. The House Manager will receive the same training upon hire. 07/05/2021 Implemented
6400.32(e)There was only one fork freely accessible for Individual 1's immediate use in the kitchen. The rest of the eating utensils in the home, including forks, knives, and spoons, were all locked in a closet made inaccessible to Individual 1. Staff on site explained that eating utensils were locked as a safety precaution due to Individual 1's history of self-injurious behaviors and physical aggression. The most recent copies of Individual 1's Individual Support Plan (ISP) dated 05/26/2021, Behavioral Support Plan (BSP) dated 06/30/2021, and Annual Assessment dated 09/30/2020 were reviewed; these documents do not explicitly mention the locking of eating utensils, inclusive of knives, as a safety precaution due to Individual 1's behavioral concerns. In the absence of such documentation, Individual 1 should be able to freely access and utilize any and all utensils in the home and assess the risks--if any--on their own.An individual has the right to make choices and accept risks.Correction ¿ Immediate Cure (Exhibit III, IV) WHO: Residential Director House Manager, upon hire Staff Compliance Specialist WHAT: We need to ensure that all staff are adhering to the Individual Rights policy, thus giving the Individuals the opportunity to make choices and accept risks. HOW: All staff were re-trained on Individual Rights between June 17, 2021 and June 25, 2021. The Residential Director and Compliance Specialist were re-trained on Individual Rights and site inspections on June 22, 2021. The House Manager will receive the same training upon hire. 06/26/2021 Implemented
6400.162(a)Staff #1 did not have an up to date medication training at the time of inspection and is administering medication to individuals. The last medication training for this staff was completed on 4/21/20 and is required to be renewed annually to remain valid.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Comment Staff #1¿s medication administration certificate annual renewal occurred on April 16, 2021, but was mistakenly omitted. Correction ¿ Immediate Cure (Exhibit V, VI) WHO: Compliance Specialist Human Resources Director Nurse WHAT: We need to ensure that all the medication administration certified staff are renewed annually so that their certificate will remain valid. HOW: Staff #1 was given an entirely new medication administration class on June 18, 2021. The Nurse, Compliance Specialist and Human Resources Director were re-trained on documentation maintenance. The training occurred on June 22, 2021. 07/05/2021 Implemented
6400.165(b)Individual 1 was prescribed Chlorpromazine 200mg Tablets on 02/10/2021 with instructions to take two tablets per day, a reduction from the previous prescription of "Take 1 tablet by mouth daily at 8am, 12pm, and 4pm and two tablets at 8pm." The March 2021 Medication Administration Record (MAR) still listed the previous entry with four doses daily, but this was crossed out and appropriately discontinued. A handwritten entry with the correct administration instructions appears at the bottom of the March 2021 MAR, and staff initials suggest that the medication was administered per these instructions during March. In Individual 1's April 2021 MAR, an entry for Chlorpromazine 200mg appears with the previous instructions and four daily administration times. Staff initialed that they administered the medication per these incorrect instructions on ten occasions, as follows: 04/01/2021 at 8am, 4pm, and 8pm; 04/02/2021 at 8am, 4pm, and 8pm, 04/03/2021 at 8am, 4pm, and 8pm, and 04/04/2021 at 8am. After the last such administration, the entry on the MAR notes that the medication was discontinued. On another page in the MAR, there is a handwritten entry for Chlorpromazine 200mg twice daily, effective with the 8pm dose on 04/04/2021, which staff initialled from that date onward in the month of April. Supplemental prescription information supplied by the provider confirms that the Chlorpromazine 200mg prescription remained "take 1 tablet by mouth twice daily" throughout both March and April of 2021. Based on the documentation provided, it cannot be reasonably determined whether the administering staff adhered to the correct administration instructions per the then-current Cholrpromazine prescription for the aforementioned administration times from 04/01/2021 through 04/04/2021.A prescription order shall be kept current.Correction ¿ Immediate Cure (Exhibit III) WHO: Residential Director House Manager, upon hire Nurse WHAT: We need to ensure all medication are recorded as prescribed in the MAR, thus ensuring that the prescription orders are current. HOW: We re-trained the Nurse, Residential Director and Compliance Specialist so that they are more careful when entering information into the MAR, and while reviewing the MAR. The Nurse, Residential Director and Compliance Specialist were re-trained on June 22, 2021. The house manager will receive the same training upon hire. 07/05/2021 Implemented
6400.166(a)(11)All of the medications present in Individual 1's March 2021 Medication Administration Record (MAR)--excluding the three pro re nata medications in the log--lack a corresponding diagnosis or reason for prescribing the medication. All of the medications present in Individual 1's April 2021 MAR--excluding the four pro re nata medications in the log--lack a corresponding diagnosis or reason for prescribing the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Comment: We need a change in policy. The corresponding diagnosis and reason for prescription is usually memorialized on the Medication List, not the Medical Administration Record as a way to conserve space on the MAR. Correction ¿ Immediate Cure (Exhibit II) WHO: Residential Director Nurse Compliance Specialist House Manager, upon hire WHAT: We need to ensure that there is a readily available information related to the diagnosis and/or purpose of each prescribed medication. HOW: A change in recording procedure was needed. Therefore, we immediately changed the information being recorded on the MAR for all the Individuals. We now include each diagnosis and/or purpose of medication, with each recording on the MAR. The MAR is created by the Residential with supervision from the Nurse and Compliance Specialist. Therefore, we re-trained the Residential Director, Nurse and Compliance Specialist. The re-training occurred on June 22, 2021. When we hire a house manager, we will also provide the same training to the house manager. 06/22/2021 Implemented
SIN-00176324 Renewal 09/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the home was tested and found to be 132.4. 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 apartment complex to install a converter that ensures that our water always remains under 120 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. 09/30/2020 Implemented
6400.110(f)Individual #1 is deaf, and at the time of inspection there was no bed shaker on the individual's bed. 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. Response: The home is equipped with flashing smoke detectors in the rooms, hallway and kitchen. Correction ¿ Immediate Cure WHO: Residential Director House Manager WHAT: We need to ensure to ensure that there is a permanent bed shaker in the Consumer¿s room. HOW: We purchased the bed shaker, and placed it under the Consumer¿s bed. 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 The problem is that the Consumer does not like the bed shaker under her bed. Therefore, we held a meeting on September 15, 2020, during which it was addressed. The Consumer¿s mom agreed to work with the Consumer to accept the bed shaker under her bed. We also purchased four bed shakers, one bed shaker was placed under the Consumer¿s bed, with another bed shaker hidden in the home so that it can be used as a back up just in case the Consumer throws it out again. In addition, there is an extra bed shaker in the office and in the Residential Director¿s car. 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. 09/15/2020 Implemented
6400.141(c)(10)Individual #1 annual physical date 1/14/2020 did not indicate communicable disease precautions.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Correction ¿ Immediate Cure WHO: Residential Director House Manager Nurse WHAT: We need to ensure that the physical examination includes information related to whether the individual has a communicable disease and ways to prevent spread of the disease to other individuals. HOW: We re-submitted our physical form to the Consumer¿s doctor so that the portion related to communicable disease is completed. The nurse trained the Residential Director and House Manager about appointments. Correction Activity ¿ Prevention of Reoccurrence The Residential Director and the House Manager will be required to go to annual physicals with the Consumers, thus ensuring that all portions of the form are completed prior to the Consumer leaving the doctor¿s office. The form will then be reviewed by the nurse before it is filed. 11/06/2020 Implemented
6400.141(c)(12)Individual #1 annual physical dated 1/14/2020 did not indicate physical limitationsThe physical examination shall include: Physical limitations of the individual. Correction ¿ Immediate Cure WHO: Residential Director House Manager Nurse WHAT: We need to ensure that the physical examination includes information related to the Consumer¿s physical limitations. HOW: We re-submitted our physical form to the Consumer¿s doctor so that the portion related to the Consumer¿s physical limitations. The nurse trained the Residential Director and House Manager about appointments. Correction Activity ¿ Prevention of Reoccurrence The Residential Director and the House Manager will be required to go to annual physicals with the Consumers, thus ensuring that all portions of the form are completed prior to the Consumer leaving the doctor¿s office. The form will then be reviewed by the nurse before it is filed. 11/06/2020 Implemented
6400.141(c)(14)Individual #1 annual physical date 1/14/2020 did not indicate information pertinent to diagnosis.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Correction ¿ Immediate Cure WHO: Residential Director House Manager Nurse WHAT: We need to ensure that the physical examination includes information pertinent to the diagnosis. HOW: We re-submitted our physical form to the Consumer¿s doctor so that the portion related to information pertinent to the Consumer¿s diagnosis is completed. The nurse trained the Residential Director and House Manager about appointments. Correction Activity ¿ Prevention of Reoccurrence The Residential Director and the House Manager will be required to go to annual physicals with the Consumers, thus ensuring that all portions of the form are completed prior to the Consumer leaving the doctor¿s office. The form will then be reviewed by the nurse before it is filed. 11/06/2020 Implemented
6400.141(c)(15)Individual #1 annual physical dated 1/14/2020 did not indicate dietary instructions.The physical examination shall include:Special instructions for the individual's diet. Correction ¿ Immediate Cure WHO: Residential Director House Manager Nurse WHAT: We need to ensure that the physical examination includes information related to the Consumer¿s dietary needs. HOW: We re-submitted our physical form to the Consumer¿s doctor so that the portion related to dietary needs is completed. The nurse trained the Residential Director and House Manager about appointments. Correction Activity ¿ Prevention of Reoccurrence The Residential Director and the House Manager will be required to go to annual physicals with the Consumers, thus ensuring that all portions of the form are completed prior to the Consumer leaving the doctor¿s office. The form will then be reviewed by the nurse before it is filed. 11/06/2020 Implemented
6400.142(f)Individual #1 record did not contain a dental hygiene planAn individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Response: The dental hygiene plan is in the nurse¿s file and the master medical records for each Consumer. Correction ¿ Immediate Cure WHO: Residential Director House Manager Nurse WHAT: We need to ensure that each Consumer has a written dental hygiene plan. HOW: We re-wrote the dental hygiene plan, and placed a copy in each home for each Consumer, along with putting it in the medical record book for each Consumer. Correction Activity ¿ Prevention of Reoccurrence The nurse will now include a copy of the dental hygiene plan in the front tab of the Consumer¿s health record book and in the health records at the homes. 10/31/2020 Implemented
SIN-00172547 Unannounced Monitoring 03/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature in the bathroom was 134.2 degrees Fahrenheit. [REPEATED VIOLATION 11/22/19} Hot water temperatures in bathtubs and showers may not exceed 120°F. Response: This home is a vacant apartment within an apartment complex. 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 do not have such documentation for this home because it is a vacant 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 16, 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