Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00239358 Renewal 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At 11:30AM, the outdoor light at the back of the home was not operable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. KACS CEO has replaced the light bulb in the back of the home and it is now operable. 03/15/2024 Implemented
6400.46(b)Program Specialist #1 was trained in fire safety on 8-1-22 and then again on 10-18-23.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).KACS CEO will ensure that Program Specialist #1 is fire safety trained again on or before 10-18-24 10/19/2024 Implemented
SIN-00220852 Renewal 02/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186Individual #1's individual support plan, last updated 1/19/2023, states chimes are on all windows and both doors and the behavior support component of the plan states the residential setting should have bells and alarms on all doors and windows. On 2/28/2023 the chimes on all doors and windows were inoperable.The home shall implement the individual plan, including revisions.KACS operations manager will call the service company that provides chimes for the doors and windows to have a technician come out to the home and service the chime system to regain compliance with this regulation. 04/28/2023 Implemented
SIN-00217169 Unannounced Monitoring 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1's December 2022 financial record did not include a receipt for Pizza Bellagio purchased 12/29/2022 in the amount of $26.30. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Program Specialist reviewed transactions with Erica on her biweekly visit and got a written note stating that she did make the purchase. 03/01/2023 Implemented
SIN-00214991 Unannounced Monitoring 11/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(d)Individual #1's Enterprise Incident Management incident # 9116320, confirmed that only Program Specialist #1 was supervising the individual for the 3:00 PM to 11:00PM on 11/05/2022. Individual #1's individual service plan, last updated 10/13/2022 states the individual should have 2 staff supervision during awake hours.The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ).KACS management will deepen hiring efforts to ensure that the company is fully staffed and in compliance with all individuals ISPs by the use of temp agencies while continuing to look for and hire permanent staff. 12/28/2022 Implemented
SIN-00192931 Unannounced Monitoring 09/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)During the inspection on 9/08/21 Individual #1's financial record did not include the following receipts: a purchase made 7/31/21 at Sam's Club in the amount of 17.78, a purchase made 7/30/21 at Hair Masters in the amount of $33.13, and a purchase made 7/10/21 at Walmart in the amount of $20.25. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. The Director will ensure that financial records are accurate by having a financial log in the home available for direct care workers, house supervisor, and program specialist to mark down any spending by the individual. 10/21/2021 Implemented
6400.62(a)During the inspection on 9/08/21 at approximately 10:39am, Lysol Toilet Bowl Cleaner 32fl/oz, with instructions to contact poison control if swallowed, was found unlocked in the laundry area closet on the third floor. Individual #1's most recent restrictive procedure plan, completed 7/01/21, states that all poisonous substances and materials are always locked up.Poisonous materials shall be kept locked or made inaccessible to individuals. The director will ensure that poisonous materials will be locked in a closet that the individual does not have access to. This will be done by having staff trained by the company trainer on how to properly store poisonous materials. The company trainer will provide a Crossover Checklist that all staff will be responsible to mark off at the beginning and each of each shift. 10/21/2021 Implemented
6400.77(b)During the inspection on 9/08/21 the first aid kit did not contain the following items: scissors, tweezers, and tape. 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. The director will ensure that the house supervisor adds all items needed to first aid kit. 10/21/2021 Implemented
6400.186Individual #1's individual service plan, last updated 8/30/21, states that due to elopement attempts there needs to be chimes on all windows and doors. At 10:07am upon entrance for the inspection on 9/08/21, the alarm system was disarmed and the chimes were inoperable. The window in the dining room, to the left of the back door, did not have a chime.The home shall implement the individual plan, including revisions.The director will ensure that the proper monitoring systems are placed on all windows and doors. 10/21/2021 Implemented
SIN-00189705 Unannounced Monitoring 06/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 6/24/21 the agency did not provide the Department access to following items requested: a current staff list, Individual #1's current Restrictive Procedure Plan, the most recent HRT meeting minutes for Individual #1's Restrictive Procedure Plan, and Individual #1's rep payee documentation. On 6/28/21 the agency did not provide the Department access to the certified investigation for the misuse of funds incident #8852301 discovered on 5/20/21.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The Director currently overseeing the training for executive staff and staff with supervisory roles to ensure that authorized agents of the Department have full access to the facility or agency and its records during both announced and unannounced inspections, to include, providing the opportunity for authorized agents of the Department to privately interview staff and clients. 09/01/2021 Implemented
6400.72(b)During the inspection on 6/16/2021 at 1:05pm, the window in Individual #1's bedroom that was located to the right of the entrance had a diagonal crack approximately the 18 inches in length and a horizontal crack approximately 8 inches in length., Screens, windows and doors shall be in good repair. The Director has hired a new training staff member, who will oversee and review all new hires and current staff¿s training needs including house items oversight. The trainer will ensure all staff members are properly trained and confirm they are capable of providing the proper care for the individual they serve. The director has trained personnel on the new policy/policies and required weekly house monitoring of the facility by all staff members. 09/01/2021 Implemented
6400.18(h)(7)The agency did not provide Individual #1's certified investigation for the misuse of funds incident #8852301, requested on 6/28/21; therefore, compliance could not be measured.A Department-certified incident investigator shall conduct the investigation of the following incidents: Theft or misuse of individual funds.The Director will ensure a Department-certified incident investigation be provided in a timely manner as requested. The director has trained the general manager and operation manager on the agency record keeping system that allows for the retrieval of the required certified completed investigations. 09/01/2021 Implemented
6400.45(c)On 6/24/21 during onsite inspection by the Department Individual #1 went to shower at approximately 11:30am. During this time, staff did not check on the individual for approximately 20 minutes. Individual #1's support plan last updated 5/18/21, states " individual requires monitoring every 5 minutes while in the bathroom to prevent self injury."An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual plan, as an outcome which requires the achievement of a higher level of independence.The Director has hired a new training staff member, who will oversee and review all new hires and current staff¿s training needs. The trainer will ensure all staff members are properly trained and confirm they are capable of providing the proper care for the individual they serve. The director has trained personnel on the new policy or policies. 09/01/2021 Implemented
6400.166(a)(8)Individual #1 is prescribed Vitamin D3 2000 unit softgel, take 1 capsule daily in the morning; the Medication administration record for June 2021 did not include the route of administration. Individual #1 is prescribed Chlorpromazine 50mg tablet, take 1 tablet 2 times a day; the Medication administration record for June 2021 did not include the route of administration. Individual #1 is prescribed Metformin HCL 500mg tablet, take 2 tablets 2 times per day; the Medication administration record for June 2021 did not include the route of administration. Individual #1 is prescribed Risperidone 3mg tablet, take 2 tablets at bedtime; the Medication administration record for June 2021 did not include the route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The Director has hired a new training staff member who will ensure all Direct Care Staff workers are trained and capable of operating The Electronic Mar System through Therap. 09/01/2021 Implemented
6400.166(a)(13).During inspection on 6/24/21, Direct Service Worker #1 stated they was working the day of June 23rd from 7:00am to 3:00pm and had administered all off Individual #1's 8:00am medications. Individual #1's June 2021 medication administration record shows Chlorpromazine 50mg tablet, take 1 tablet 2 times a day, administered on 6/23/21 at 8:00am and initialed by "SM". The agency did not provide a current staff list so the initials could not be identified but was not the administering staff.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The Director has hired a new training staff member who will ensure all Direct Care Staff workers are trained and capable of operating The Electronic MAR System through Therap. The Program specialist and house supervisor have been tasked with reviewing the MAR weekly. 09/01/2021 Implemented
6400.195(b)Documentation of a human rights team review meeting was not provided for Individual #1's restrictive procedure; therefore compliance could not be measured.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The Director has tasked the Program Specialist with ensuring that a meeting is held to review the status of the individual¿s restrictive procedure plan every 4 months, ensuring that a review is conducted going forward at a minimum of 6 months between reviews. 09/01/2021 Implemented
SIN-00187296 Renewal 04/22/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)The provider is representative payee for Individual #1 and has no record of financial resources, including dates and amounts of deposits and withdrawals. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Director has updated the financial record storage procedures. The individual has agreed to give the provider access to the monthly bank statement and a paper leger has been placed in the residence to log any cash on hand. The individual and staff have been informed to store all receipts in the folder which is stored with the cash on hand leger. 05/17/2021 Not Implemented
6400.181(e)(1)Individual #1's assessment completed 1/05/2021 did not include functional strengths, needs and preferences of the individual. This section was left blank. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The Program Special has been tasked with correcting and completing all assessments to include: Functional strengths, needs, and preferences of the individual. Director has updated the responsibility of the PS and is currently training additional Program Specials to assist with all required documentation. 05/17/2021 Not Implemented
6400.181(e)(12)Individual #1's assessment completed 1/05/2021 did not include recommendations for specific areas of training, programming and services. This section was left blank.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Program Special has been tasked with correcting and completing all assessments to include: Recommendations for specific areas of training, programming, and services. Director has updated the responsibility of the PS and is currently training additional Program Specials to assist with all required documentation. 05/17/2021 Not Implemented
6400.165(g)Individual #1 had a psychiatric medication review completed 10/06/2020 and then again 1/19/2021{repeat violation 3/10/2020}.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Program Special has been tasked with scheduling and documenting all required appointments. Director has updated the responsibility of the PS and is currently training additional Program Specials to assist with all required documentation. 05/17/2021 Not Implemented
6400.166(a)(7)Individual #1 is prescribed Sertraline HCL 100mg tablet with instructions to take 1 tablet once daily. The April 2021 medication administration record states Sertraline HCL 100mg tablet, with instructions to take 1 and 1/2 tablets once daily.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The induvial medication documentation error was corrected. 05/17/2021 Not Implemented
6400.166(a)(15)Individual #1 is prescribed Adult Multi-Vitamin Gummies 200mcg with instructions to chew and swallow 1 gummy by mouth daily. The April 2021 medication administration record did not include the special precautions to chew and swallow by mouth.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.The induvial medication documentation error was corrected. 05/17/2021 Not Implemented
6400.186The restrictive procedure plan for Individual #1 effective 1/02/2021 states the home shall have chimes on the front door, back door, and all windows. On 4/23/2021 during the physical site inspection, it was observed that the windows in the home did not have chimes.The home shall implement the individual plan, including revisions.The subscripted home security company has been notified and will ensure all windows are checked and ensure the window chimes function property. 05/17/2021 Not Implemented
SIN-00181042 Renewal 12/21/2020 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed on 12/08/2020, was not fully completed; sections 6400.42 through 6400.275 were left blank. In addition, the agency use a self-assessment tool, modified 6/2018 that did not include the current 55 Pa. Code Chapter 6400 Regulations for Community Homes for Individuals with intellectual Disabilities or Autism from February 3, 2020.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Keliser Adult Care Services will ensure that all self-assessments are completed for all homes at least 3-6 months prior to the expiration date of the agency¿s certificate of compliance in order to measure and record compliance. The Director will cross reference all assessments to ensure they are completed correctly and in a timely manner.[Immediately, the CEO or designated management staff will train all staff responsible for completing self-assessments on the requirements of the chapter. Immediately, the CEO or designated management staff will develop a system to track the completion of self-assessment and corrections for any areas that are identified as noncompliant. The CEO or designee will audit all self-assessments and ensure corrections are made. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] 01/15/2021 Not Implemented
6400.110(e)On 12/21/2020 at 11:18AM the smoke detector located in the garage at the basement level, was not interconnected with the smoke detectors on the 2nd and 3rd floors.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Keliser Adult Care Services will ensure all smoke detectors are interconnected. Keliser Adult Care Services consulted with ABC fire company to come in and ensure all smoke detectors are interconnected. Moving forward the agency will continue services with ABC Fire Company to ensure all residential sites are compliant according to regulations at least twice annually.[The department viewed the smoke detector to be operable and interconnected on 2/4/21. At least quarterly for one year, the CEO or designee will test all smoke detectors in all homes to ensure they are working and interconnected if needed per the requirements of the chapter. Immediately, the CEO or designated management staff will train all staff on the agencies inoperable alarm policy. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] 01/15/2021 Not Implemented
6400.112(a)The fire drills held from April 2020 to December 2020 were all conducted on the first of the month; 4/01/2020, 5/01/2020, 6/01/2020, 7/01/2020, 8/01/2020, 9/01/2020, 10/01/2020, 11/01/2020 and 12/01/2020. An unannounced fire drill shall be held at least once a month. Keliser adult care services will ensure that all fire drills are done monthly, unannounced and alternate routes are used. According to PA code 55 chapter 6400.112 (a) and 6400.112(f) The House Supervisor will cross reference all fire drills to ensure they are completed unannounced and using alternate routes.[A fire drill was conducted on 1/10/21. At least monthly for one year then continuing quarterly, the CEO or designee will audit all fire drill records to ensure fire drills are conducted on different days of each month. Immediately, the CEO or designated management staff will train all staff responsible for conducting fire drills on the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] 01/15/2021 Not Implemented
6400.112(f)The fire drills held on 4/01/2020, 5/01/2020, 6/01/2020, 7/01/2020, 8/01/2020, 9/01/2020, 10/01/2020, 11/01/2020 and 12/01/2020 used the back door as the exit route.Alternate exit routes shall be used during fire drills. Keliser adult care services will ensure that all fire drills are done monthly, unannounced and alternate routes are used. According to PA code 55 chapter 6400.112 (a) and 6400.112(f) The House Supervisor will cross reference all fire drills to ensure they are completed unannounced and using alternate routes.[The fire drill conducted on 1/10/21 at the home also used the back door as the exit. Immediately, the CEO or designee shall run a fire drill using another exit of the home. At least monthly for one year then continuing quarterly, the CEO or designee will audit all fire drills to ensure that alternate exits are being used for fire drills. Immediately, the CEO or designated management staff will train all staff responsible for conducting fire drills on the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] 01/15/2021 Not Implemented
6400.18(a)(8)On 5/08/20, Individual #1 called 911 and law enforcement responded. The agency reported the law enforcement activity incident (8693578) in the Department's information management system, Enterprise Incident Management Systems on 5/20/2020.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual. Keliser Adult Care Services LLC will ensure that incidents will be reported within 24 hours of discovery. The team has also hired a designated EIM person to handle and complete all incidents. The Director will cross reference all incidents to ensure they are completed in a timely manner.[Immediately, the CEO or designated management staff will train all staff on reporting requirements of the chapter. At least monthly for 6 months and then continuing at least quarterly, the CEO or designated management staff shall audit and analyze incidents to ensure all are reported, investigated, reviewed and analyzed as required as per 6400.18-6400.20. Upon completion of quarterly reviews training for any areas of noncompliance shall be completed as needed. Documentation of trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] 01/15/2021 Not Implemented
SIN-00172282 Renewal 03/10/2020 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 2:09PM, a 30-fluid oz. bottle of Original Clorox Bathroom Bleach Foamer was unlocked, unattended, and accessible under the kitchen sink. Individual #1's assessment, dated 11/29/2019, indicates that the individual cannot use or avoid poisons independently.Poisonous materials shall be kept locked or made inaccessible to individuals. Keliser Adult Care Services already has a policy in place that keeps all poisonous materials locked away from individuals. All staff was retrained on hazardous materials policy and management will check to ensure all poisonous materials are kept and remain locked up. [On 6/25/20, there were not any poisonous materials accessible to individuals. Poisonous materials were locked in a closet. Weekly checks of the homes for poisonous materials is being kept. (DPOC by AES,HSLS on 7/6/20)] 04/15/2020 Implemented
6400.68(b)At 2:28PM, the hot water temperature at the bathtub in the bathroom next to bedroom on the second floor of the home measured 123.8F. [Repeat violation 3/19/19, et. al. and 4/17/18]. Hot water temperatures in bathtubs and showers may not exceed 120°F. Keliser Adult Care Services will ensure that all hot water temperatures do not exceed 120F.Keliser Adult Care Services has secured maintenance services to ensure water temperature is compliant. In the event it is not, maintenance has been instructed to install temperature regulator to ensure accurate and comfortable water temperature.68b [On 6/25/20, at 12:41PM the water temperature at the shower was 118°F, displayed on the digital water regulator. Immediately, the CEO or designee shall develop and implement and train staff on a plan to monitor and document hot water temperature at all locations accessible to the individual to ensure the hot water does not exceed 120°F. (AES,HSLS on 7/6/20)] 04/15/2020 Implemented
6400.106There was no written documentation of the inspection and cleaning of the furnace for the home by a professional cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Keliser Adult Care Services will ensure that furnaces are inspected and cleaned annually. Keliser Adult Care Services has secured services to ensure proper functionality and inspection twice a year. [Immediately, the CEO or designee shall develop and implement a policy and procedure to ensure timely scheduling, completion and documentation of furnace inspections and cleanings by a professional furnace cleaning company. (DPOC by AES,HSLS 7/6/2020)] 04/15/2020 Not Implemented
6400.112(i)The fire drill conducted 1/13/2020 at 4:30 PM did not include the use of at least one smoke detector, the fire drill form states a cellular phone for the type of alarm used. The fire drill conducted 2/10/2020 at 9:00 PM did not include the use of at least one smoke detector, the fire drill form states "verbal" for the type of alarm used. The fire drill conducted 3/2/2020 at 6:08 PM did not include the use of at least one smoke detector, the fire drill form states "verbal" for the type of alarm used. A fire alarm or smoke detector shall be set off during each fire drill.Keliser Adult Care Services retrained staff on the fire drill policy. The executive team will monitor house supervisor during drills to ensure the smoke detector and or fire alarm is used as the alarm type and all documentation is completed correctly to reflect proper execution. [The fire drills held in April, May and June 2020 used the fire alarm in each of the fire drills. Immediately, the CEO or designee shall train all staff persons responsible for conducting, participating and observing fire drills of the requirements of fire drills as per 6400.112a-112h. Documentation of the trainings shall be kept. At least monthly for 1 year, and continuing at least quarterly, the CEO or designee shall audit all fire drill records to ensure fire drills are held and documented as required. (DPOC by AES,HSLS on 7/6/20)] 04/15/2020 Implemented
6400.163(h)The first aid kit contained Aspirin Pain Reliever and Fever Reducer 325 mg with an expiration date of 4/1/2019.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Keliser Adult Care Services will complete monthly medication checks to ensure that all prescription medications that are discontinued or expired will be destroyed in a safe manner according to federal and state regulations. [On 6/25/20, the first aid kit did not contain medications. Documentation of aforementioned monthly medication checks shall be kept. Immediately and upon hire, the CEO or designee shall educate all staff persons of the location and requirements of first aid kits and storage procedures for medications. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 7/6/20)] 04/15/2020 Implemented
SIN-00158408 Unannounced Monitoring 07/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34At 9:00AM, authorized agents of the Department [the Department] arrived at the home for an unannounced inspection and then proceeded to knock and ring the doorbell. They did not receive a response. At 9:02AM, the Department called Program Specialist #2, who reported to the Department that s/he would attempt to reach the Chief Executive Officer #1. At 9:16 AM, the Program Specialist #2 returned a call to the Department stating she was in Canada and the Chief Executive Officer #1 could not be reached. At 9:32AM, the Department requested to complete onsite inspections at the agency's other licensed community living homes. At 10:10AM, Program Specialist #2 called the Department stated that no one was available to meet the the Department to gain access to the licensed community living homes. At 10:25AM, the Department departed without gaining access to the agency's licensed community living homes.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The violation that occurred on July 10, 2019 related to timing. The agents arrived at an empty consumer home and contacted the Program Specialist. The site where agents arrived was not the office where consumer records were housed, yet it was the preferred meeting location of the auditor. The agents arrived during transport of the individuals for both houses. The agents were given permission to access all residential homes but were unwilling to wait for DCS, to return to the home for access. The agent informed the Program Specialist that they would receive a violation for denied access. While the CEO and Program Specialist were not present within the hour, the agents could have accessed the consumer homes if they were willing to wait for staff to return from transport to day programs and school. The CEO and Program Specialist met immediately to discuss the violation that occurred and designed a policy and a specific role to fulfill prevent future occurrences of this violation. Keliser Adult Care Services has created an ¿ON CALL¿ position to serve as a back-up, for instances where the CEO and Director are unavailable. This individual has keys to all provider homes and office space and will give any authorized agents of the department, access to all licensed sites within the hour.¿The Program Specialist will conduct ¿drills¿ every 30 days to ensure the on-call is prepared in case of unannounced inspection.[Immediately, the CEO or designee shall educate all staff persons on their responsibilities to ensure access to the agency and the records is provided. Documentation of trainings and the aforementioned drills shall be kept. (DPOC by AES,HSLS on 9/24/19)] 07/15/2019 Implemented
6400.43(b)(4)At 9:00AM, authorized agents of the Department [the Department] arrived at the home for an unannounced inspection and departed at 10:25AM after access to agency's community living homes was not made available to the Department. The Chief Executive Officer #1 was unable to be contacted by agency staff or the Department. Access to the licensed community living homes by the Department as required by Chapter 6400.11. the requirements specified in Chapter 20 (relating to licensure or approval of facilities and agencies) shall be met; was denied.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. The CEO retrained the Program Specialist on the 6400 regulations and implemented a position and policy to prevent future occurrences of not only this violation, but violations of any kind. The CEO made sure that all contact information is accurate and up to date. CEO instructed Program Specialist to do practice drills every 30 days to ensure the on-call person will be at the licensed sites within an hour at the most. The Program Specialist retrained direct care workers on company policies and procedures and made sure they understand that agents are able to access all licensed sites upon arrival. [Documentation of aforementioned trainings and drills shall be kept. (DPOC by AES,HSLS on 9/24/19)] 07/15/2019 Implemented
SIN-00152055 Renewal 03/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Direct Service Worker #2, date of hire 9/21/17, had 22 hours of training for the training year from 1/1/18 to12/31/18.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. The director updated the current training policy requiring all employee's to calculate their hours quarterly and annually. The director trained the Program Specialist and all the staff on the new policy requirement's. The Program Specialist will review the training logs quarterly and annually with staff. [Documentation of the audits of training records shall be kept. (DPOC by AES,HSLS on 8/8/19)] 05/13/2018 Implemented
6400.46(e)Direct Service Worker #1, date of hire 10/8/18, did not have training in in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. [repeat violation-4/17/18]Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. The Director updated the current policy that require a initial training to be completed prior to the start date to included training in the areas of intellectual disability. The current policy did not have intellectual disability requirement within the 30 calendar days, but within the calendar year. The director trained the Program Specialist and all the employee's on the updated policy requirement's. [Within 30 days of hire and at least quarterly, the program specialist shall audit staff persons training records to ensure all required trainings are completed, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/8/19)] 05/14/2019 Implemented
6400.151(a)Direct Service Worker #1, date of hire 10/8/18, did not have a physical examination prior to employment. [repeat violation-4/17/18] A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Direct Service Worker #1 physical was complete prior to hired date, but physical was not available at the time of the audit. A copy of the completed physical has been provided. The Director have updated the current policy and trained the new Program Specialist to make 3 copies of each employee physical keeping in thier files and a office copy[Immediately, upon hire and at least annually, the CEO or designee shall audit all staff persons' current physical examination to ensure completion, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 8/8/19)] 05/03/2018 Implemented
SIN-00199916 Unannounced Monitoring 02/07/2022 Compliant - Finalized
SIN-00177123 Unannounced Monitoring 09/28/2020 Compliant - Finalized