Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00205508 Unannounced Monitoring 05/16/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(3)Chief Executive Officer #1 has failed to provide a home for the safety and protection of the individuals. On 5/16/2022, the home was in such a state of uncleanliness and disrepair that the individuals living in the home were not safe to stay in the home and had to be relocated from the home.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. The CEO was hired on 3/21/22. The CEO reviewed the 6400 Regulatory Compliance Guide May 16, 2022-May 20,2022. The home was deep cleaned, treated and repairs were made to the physical site as of 5/20/22 by NHCS administration and outside entities. The CEO completed a full physical site review on 5/20/22 to ensure compliance. After an on-site inspection from ODP licensing representatives to ensure compliance, the individuals returned to their home on 5/25/22. The CEO then held a staff training on 6/1/22, incident management, daily household tasks, and chemicals were part of the training. On 6/16/22 the CEO was in-serviced on individual rights, chemicals, physical site compliance (including operable equipment, lighting, unobstructed egresses, unsafe cooking equipment), and the IM bulletin by the agency owners. The CEO in-serviced staff on 6/16/22 on physical site compliance, individual rights, IM bulletin that will be completed by 6/23/22. 06/21/2022 Not Implemented
6400.43(b)(4)Chief Executive Officer #1 has failed to comply with the Commonwealth of Pennsylvania, Pennsylvania Code, Title 55, Chapter 6400 Regulations. On 5/16/2022, the home was in such a state of uncleanliness and disrepair and unsafe conditions that the individuals living in the home had to be relocated from the home. Chief Executive Officer #1 has failed to ensure compliance with the Chapter including but not limited to regulations related to sanitary conditions, adequate lighting, unobstructed egresses, heat sources, and water temperatures.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 was hired on 3/21/22. The CEO has reviewed the 6400 regulatory compliance guide, held an in person staff training on 6/1/22, and completed a physical site review of the home on 5/20/22. The home was cleaned by 5/17/22. The light bulbs were put into sockets on 5/16/22 and the obstructed egress from the garage door was removed on 5/16/22 by NHCS administration. An outside entity was hired to fix the shower on 5/20/22 and it was repaired on 5/20/22. Water temperatures were tested on 5/20/22 and 5/20/23 by NHCS administration. 06/21/2022 Not Implemented
6400.63(a)On 5/16/2022, 2:10PM, the hot water temperature at the sink in the bathroom on the first floor of the home measured at 131.3F. On 5/16/2022, 2:19PM, the hot water temperature at the sink in the bathroom on the second floor of the home measured 132.9F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. NHCS administration contacted a plumber, and the issue was corrected on 5/20/22. NHCS administration checked the hot water temperature at each sink and shower in the home to ensure compliance on 5/20/22 and 5/23/22. 06/21/2022 Not Implemented
6400.64(a)On 5/16/2021, the following unsanitary conditions were present in the bathroom on the second floor of the home. The vanity and basin of the sink and surrounding walls were covered with various sized splatters of toothpaste, and other unidentifiable droplets. An uncovered used toothbrush and an uncapped toothpaste container oozing with toothpaste was lying near the faucet handles of the sink. A wet roll of toilet paper, also, splattered with toothpaste was atop the left side edge of the sink. The floor and bath matt in the shower were soiled with brown and black splatters and stains of what appeared to be mold, mildew, soap scum and dirt. the following unsanitary conditions were present in the kitchen of the home. The coding of the refrigerator door handle was pealing and delaminating. The inside of the microwave and the stove top were splattered with dried food particles. The interior bottom and interior door glass of the oven was coated with splattered, baked-on grease and charred remains of burnt food particles. There was a dish basin containing remnants of food particles and soap scum in the sink. Used dishes were stacked in the sink next to the basin. A sink drain strainer containing food waste was atop of the sink near the faucet handles. The following unsanitary conditions were present in the basement of the home. There were five tall kitchen bags containing trash and a discarded box approximately 5 feet long by 6 inches wide were stacked against the wall in the basement of the home. One of the bags was not sealed and there were stains on the floor under the bags from what appears to be from liquid or grease. In addition, there was an area in the corner where dried leaves and other outside debris had accumulated.Clean and sanitary conditions shall be maintained in the home. The vanity and basin of the sink were cleaned on 5/16/22 by NHCS administration. New toothbrushes and toothbrush holders were purchased on 5/16/22 by NHCS administration. The toilet paper was discarded, a toilet paper holder was purchased, and new toilet paper was placed on the holder on 5/16/22 by NHCS administration. The stove, refrigerator and microwave were cleaned on 5/16/22. The dishes were washed, dried, and put away by NHCS administration. The trash was removed from the site on 5/16/22 by NHCS administration. The spill and leaves were cleaned up on 5/16/22 by NHCS administration. 06/21/2022 Not Implemented
6400.64(e)On 5/16/2022, at 2:03PM, the trash receptacle with a height of 19 inches in the bathroom on the first floor of the home did not have a lid.Trash receptacles over 18 inches high shall have lids. The trash can was replaced on 5/16/22 by NHCS administration. NHCS administration checked the home to ensure that all trash cans over 18 inches have lids on 5/16/22. 06/21/2022 Not Implemented
6400.66On 5/16/2022, at 2:18PM, the three lights fixtures above the mirror in the bathroom on the second floor of the home were inoperable. There is not another source of light in this area. At 2:19pm, the two lighting fixtures in the hallway on the second floor of the home were inoperable. There is not another source of light in this area. At 2:37pm, there is not a source of light at the interior stairway leading from the first floor to the basement.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulbs were placed in the fixtures above the bathroom mirror and in the upstairs hallway on 5/16/22 by NHCS administration. Lights were purchased and placed going down the basement steps on 5/16/22 by NHCS administration. NHCS reviewed the physical site to ensure that all areas of the home have adequate lighting on 5/20/22. 06/21/2022 Not Implemented
6400.67(a)On 5/16/2022, at 2:16PM, there is a twenty-inch-high by eighteen-inch-wide hole in the wall next to the toilet in the bathroom on the second floor of the home.Floors, walls, ceilings and other surfaces shall be in good repair. The hole in wall next to the toilet was repaired on 5/17/22 by NHCS administration. NHCS administration completed a physical site review on 5/20/22 to ensure no other holes were in the walls at the site. 06/21/2022 Not Implemented
6400.68(a)On 5/16/2022, 2:27PM, the water temperature at the shower in the bathroom on the second floor of the home measured 93.9F.A home shall have hot and cold running water under pressure. The agency reached out to a plumber and the issue was corrected on 5/20/22. The agency checked the hot water temperature at each sink and shower in the home on 5/20/22 and on 5/23/22 to ensure it was under 120 degrees. ODP licensing representatives came on site on 5/25/22 and verified the issue was corrected 06/21/2022 Not Implemented
6400.72(a)On 5/16/2022, at 2:37PM, the bottom section of the storm door in the basement of the home did not contain a screen or tempered glass.Windows, including windows in doors, shall be securely screened when windows or doors are open. The storm door was removed from the frame on 5/17/22 by NHCS. The outside door is in place and has an operable lock. NHCS reviewed the physical site to ensure that all doors were in good repair. 06/21/2022 Not Implemented
6400.72(b)On 5/16/2022, at 2:37PM, the storm door in the basement of the home does not fit the door frame, leaving a one-to-two-inch gap between the door and the bottom of the door frame. In addition, the storm door spring closing mechanism is missing causing the door to not close as designed by the manufacture and freely swing away from the door frame. Screens, windows and doors shall be in good repair. The storm door was removed from the frame on 5/17/22. The outside door is present and in good repair. NHCS administration reviewed the physical site to ensure that all doors were in good repair on 5/20/22 06/21/2022 Not Implemented
6400.76(a)On 5/16/2022, at 2:16PM, the toilet in the bathroom on the second floor of the home bathroom toilet was not properly secured to the floor as it was missing the appropriate hardware. The toilet roll paper holder in the bathroom on the second floor of the home was missing the roll bar. The toilet paper roll was atop the side of the sink. At 2:30pm, the dining room table is not sturdy, and wobbles at least one inch in every direction. Furniture and equipment shall be nonhazardous, clean and sturdy. A toilet paper holder was placed in the bathroom on 5/17/22 by NHCS. The dining room table was removed and a new table was purchased on 5/19/22 by NHCS. The CEO completed a physical site review to ensure that all furniture was nonhazardous, clean and sturdy on 5/20/22. 06/21/2022 Not Implemented
6400.82(f)On 5/16/2022, at 2:16pm, the bathroom on the second-floor of the home did not have clean paper or cloth towels.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. A paper towel holder and paper towels were placed in the bathroom on 5/16/22 by NHCS administration. NHCS ensured that each sink at the home had paper towels on 5/16/22. 06/21/2022 Not Implemented
6400.83(c)On 5/16/2022, at 2:11PM, used unwashed plates and bowls were in the sink in the kitchen of the home.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.The dishes were washed and put away on 5/16/22 by NHCS administration. The agency conducted a staff training on 6/1/22 and implemented a staff shift cleaning checklist. 06/21/2022 Not Implemented
6400.101On 5/16/2022, at 2:37PM, the inside the door leading from the basement to the garage of the home has a two inch by eight inch piece of wood nailed to the wall which hangs approximately six inches over the door obstructing egress from the garage into the basement and entrapment in the garage. There is not a man door in the garage of the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The piece of wood was removed from the wall on 5/16/22 by NHCS administration. NHCS reviewed the physical site to ensure there were no obstructions to the exits on 5/16/22 06/21/2022 Not Implemented
6400.32(c)On 5/16/2022, the home was in such a state of uncleanliness and disrepair that the individuals living in the home had to be relocated from the home. The Individuals in the home did not have hot water to shower, were exposed to the risk of scalding, clean equipment to prepare food, sanitary condition for personal hygiene and inadequate lighting and obstructed egresses to safely move and evacuate the home.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.The home was cleaned, and repairs were made to the physical site as of 5/20/22 by NHCS administration and outside entities. Lightbulbs were placed throughout the home by NHCS administration on 5/16/22. The obstruction to the garage door egress was removed on 5/16/22 by NHCS administration. The shower was fixed by an outside entity on 5/20/22. Water temperatures were tested to ensure compliance on 5/20/22 and on 5/23/22 to ensure compliance. All new personal hygiene were purchased for the individuals on 5/16/22 and were placed in sanitary conditions. 06/21/2022 Not Implemented
6400.32(d)On 5/16/2022, the home was in such a state of uncleanliness and disrepair that the individuals living in the home had to be relocated from the home. The Individuals in the home did not have hot water to shower, were exposed to the risk of scalding, clean equipment to prepare food, sanitary condition for personal hygiene and inadequate lighting and obstructed egresses to safely move and evacuate the home.An individual shall be treated with dignity and respect.The home was cleaned, and repairs were made to the physical site as of 5/20/22 by NHCS administration and contractors. Lightbulbs were placed throughout the home by NHCS administration on 5/16/22. The obstruction to the garage door egress was removed on 5/16/22 by NHCS administration. The shower was fixed by a contractor on 5/20/22. Water temperatures were tested to ensure compliance on 5/20/22 and on 5/23/22 to ensure compliance. All new personal hygiene were purchased for the individuals on 5/16/22 and were placed in sanitary conditions. 06/21/2022 Not Implemented
SIN-00201826 Renewal 03/15/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At 11:08AM, the outside light at the exit from the door at the basement of the home was inoperable. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Owner replaced inoperable outside light 3/17/22 03/17/2022 Not Implemented
6400.81(i)The two windows in Individual #1's bedroom did not have drapes, curtains, shades, blinds or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Owner purchased curtains to place in individuals window. Staff have been instructed to remind individual that curtains and/or blinds must remain in the window and that it should not be taken down 03/16/2022 Not Implemented
6400.166(a)(13)Individual #1's March 2022 Medication Administration Record did not include a master key of names and initials of staff administering medication.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.CEO went to the home and replaced master key signature page with MAR. Staff have been instructed to notify CEO immediately if master key signature page is discovered not to be present and that this page should always remain with MAR. 03/16/2022 Implemented
SIN-00186007 Renewal 04/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(4)Individual #2 is prescribed Fiber-Lax, Lorazepam, Clonazepam, Metformin, and Divalproex. On 4/9/2021, these medications were not present in the home to be administered to Individual #2. Chief Executive Officer #1 failed to ensure that the medication administration record for Individual #2 accurately reflected the medications that the Individual is prescribed. As of 4/26/21 there were no incident reports entered into the into the Department's information management system since discovery of the Medication Administration Errors on 4/9/2021. Chief Executive Officer #1 failed to ensure the compliance with this chapter as the Medication Administration Records did not accurately reflect prescribed medications, all prescribed medications were not being administered, and incident reports were not completed for the medication errors.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. Owner had a meeting with program CEO to address failure to ensure MAR accurately reflects medications and the responsibilities of the program and home as well as a review of regulations. CEO has been directed to always use monitoring tools put into place to monitor compliance and to review regulations monthly. Immediate action, Program specialist obtained medication list on 4/12/21 from doctor and pharmacy documentation was provided during inspection process. Owner and program specialist reviewed prescribed meds and MAR to ensure accuracy. Program specialist will review CEO's entries of medications against MAR to ensure accuracy and owner will monitor for six months. Owner had a meeting with staff regarding the importance of paying attention to meds and MAR staff has been directed to inform CEO or program specialist if necessary if an error is noticed. Incident report has been entered based on medications not being visible during remote inspection. 04/26/2021 Implemented
6400.77(b)On 4/9/2021 there was no Scissors in the First Aid Kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. 4/9/21 owner purchased new first aid kit and label was created to place inside kit to warn staff to always place scissors back into the kit. Regulations regarding first aid kits were reviewed with staff 4/9/21. 04/09/2021 Implemented
6400.77(c)On 4/9/2021 there was no First Aid Manual in the First Aid Kit. A first aid manual shall be kept with the first aid kit.4/9/21 owner purchased new first aid kit and label was created to place inside kit to warn staff that manual should remain in the kit. Regulations regarding first aid kits were reviewed with staff 4/9/21. 04/09/2021 Implemented
6400.82(e)On 4/9/2021 the bathtub in the bathroom, located in the first door on the left at the top of the stairs did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Corrected 4/9/21 owner purchased new mat. Regulations were reviewed with staff regarding nonslip surfaces inside on bathtub and to inform CEO or program specialist if a new mat is needed. 04/09/2021 Implemented
6400.82(f)On 4/9/2021 there was no trash receptacle in the bathroom, located in the first door on the left at the top of the stairs.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. 4/9/21 owner purchased new trash can. Regulations were reviewed with staff regarding trash cans and to inform CEO or program specialist if a new one is needed. 04/09/2021 Implemented
6400.106The furnace was inspected and cleaned by a professional furnace cleaning company on 2/5/2020 and again on 3/22/2021.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. Immediately, owner will ensure that furnace inspections are completed within the annual timeframe. 04/09/2021 Implemented
6400.110(a)On 4/9/2021 there was no smoke detector located on the basement of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Violation was corrected 4/9/21. Owner purchased new smoke detector and performed a test to ensure interconnected. Owner has directed staff and individuals to never remove a smoke detector. 04/09/2021 Implemented
6400.141(c)(3)The most recent Tetanus immunization for Individual #1 was 3/23/09.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Owner reviewed regulations with Program Specialist and program CEO concerning Immunizations. 4/12/21 program specialist contacted individual #1 doctor to discuss tetanus immunization. Doctor agreed to review records and provide a schedule of when immunizations should take place. PS will develop a system to track Immunizations and follow up with doctors yearly to ensure immunizations are up to date. 04/12/2021 Implemented
6400.165(c)Individual #2 is prescribed Fiber-Lax 625 mg, take 1 tablet by mouth daily; Lorazepam 1 mg, take 1 tablet by mouth daily; Clonazepam 1 mg, take 1 & 1/2 tablets by mouth 3 times a day; Metformin 1000 mg, take 1 tablet by mouth twice a day; and Divalproex DR 500 mg, take 1 tablet by mouth 3 times a day. During the on-site inspection on 4/9/2021 at 2:30PM, these medications were not present in the home to be administered to Individual #2.A prescription medication shall be administered as prescribed.Owner had a meeting with program CEO 4/26/21 to address failure to ensure MAR accurately reflects medications and the responsibilities of the program and home as well as a review of regulations. CEO has been directed to always use monitoring tools put into place to monitor compliance and to review regulations monthly. Immediate action, Program specialist obtained medication list on 4/12/21 from doctor and pharmacy documentation was provided during inspection process. Owner and program specialist reviewed prescribed meds and MAR to ensure accuracy. Program specialist will review CEO's entries of medications against MAR to ensure accuracy and owner will monitor for six months. Owner had a meeting with staff regarding the importance of paying attention to meds and MAR staff has been directed to inform CEO or program specialist if necessary if an error is noticed. 04/26/2021 Implemented
6400.166(a)(7)Individual #2 is prescribed Divalproex DR 500 mg, take 1 tablet by mouth 3 times a day. The Medication Administration Record for April 2021 states that Individual #2 should be administered Divalproex DR 500 mg, take 2 tablets by mouth 2 times a day. Individual #2 is prescribed Calcium/D3 315mg, 250iu, take 2 tablets by mouth daily. The Medication Administration Record for April 2021 states that Individual #2 should be administered Calcium/D3 600-5, take 1 tablet by mouth daily.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Owner had a meeting with program CEO to address failure to ensure MAR accurately reflects medications and the responsibilities of the program and home as well as a review of regulations. CEO has been directed to always use monitoring tools put into place to monitor compliance and to review regulations monthly. Immediate action, Program specialist obtained medication list on 4/12/21 from doctor and pharmacy documentation was provided during inspection process. Program specialist will review CEO's entries of medications against MAR to ensure accuracy and owner will monitor for six months. Owner had a meeting with staff regarding the importance of paying attention to meds and MAR staff has been directed to inform CEO or program specialist if necessary if an error is noticed. 04/26/2021 Implemented
6400.167(c)As of 4/26/2021, the medication errors discovered during the on-site inspection on 4/9/2021 resulting from the failure to administer the prescribed medications Fiber-Lax, Lorazepam, Clonazepam, Metformin, Divalproex for Individual #2 were not reported as an incident through the Department's information management system.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Program specialist obtained current medication list from doctors. Medications in question were located that same day. Incident report was entered due to medication not being visible during remote inspection. There was no medication missed for Metformin. Lorazepam was discontinued 4/14/21. 05/01/2021 Implemented
SIN-00172036 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(2)The mattresses and box springs in the bedrooms belonging to Individual #1 and Individual #2 were on the floor.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Program Specialist placed mattresses back onto box springs 2/28/20. A second mattress was added to Individual #2 box spring to support weight. CEO had a conversation with both individuals regarding the importance of not removing mattress off of box spring. [In addition to the aforementioned compliance checks, the CEO or program specialist shall interview the individuals to ensure individuals are comfortable with the provided mattress and foundation. (DPOC by AES,HSLS on 5/6/20)] 03/28/2020 Implemented
6400.142(e)Individual #2 had a dental appointment on 8/7/19, with instructions for a follow up examination and cleaning in six months, as of 2/27/20, the follow up appointment has not been completed.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Individual #2¿s non- compliance was due to having dental surgery 2/25/20. Follow-up /cleaning was re-scheduled 3/17/20 for 4/1/20 by program specialist. Future date to be determined after COVID-19 mandate is lifted. [Immediately, the CEO shall develop and implement a tracking and scheduling system to include documentation of changes in appointment scheduling or appointments as needed. Within 30 days or receipt of the plan of correction, all staff persons responsible for ensuring timely completion of individuals' medical appointments shall be educated on the tracking and procedures. Documentation of trainings shall be kept. Documentation of aforementioned quarterly reviews by the CEO shall be kept. (DPOC by AES,HSLS on 5/6/20)] 03/17/2020 Implemented
6400.151(c)(3)Direct Service Worker #1's physical examination, completed 6/5/18 did not address communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Direct Service Worker #1, is no longer employed as of 3/10/20 . New Hires will be given agency physical form to ensure that all required information and signatures are completed. [Immediately, upon completion and annually, the CEO or designee educated in the requirements of staff person's physical examinations shall audit physical examinations to ensure all required information is included and there are not any areas of required information left blank. Documentation of audits and trainings shall be kept. (DPOC by AES,HSLS on 5/6/20)] 03/10/2020 Implemented
6400.181(e)(1)Individual #1's assessment completed 1/10/20 did not include functional strengths, needs, and preferences. Individual #2's assessment completed 1/26/20 did not include functional strengths, needs and preferences of the individual. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually. [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(2)Individual #1's assessment completed 1/10/20 did not include likes, dislikes, and interests of the individual. Individual #2's assessment completed 1/26/20 did not include likes, dislikes and interest of the individual.The assessment must include the following information: The likes, dislikes and interest of the individual. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were update on 1/25/20 to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(3)(i)Individual #1's assessment completed 1/10/20 did not include the individual's current level of performance and progress in the area of acquisition of functional skills. Individual #2's assessment completed 1/26/20 did not include the individual's current level of performance and progress in acquisition of functional skills.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(3)(iv)Individual #1's assessment completed 1/10/20 did not include the individual's current level of performance and progress in the area of personal needs with or without assistance from others. Individual #2's assessment completed 1/26/20 did not include the individual's current level of performance and progress in personal needs with or without assistance from others.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others.Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(4)Individual #1's assessment completed 1/10/20 did not include the individual's need for supervision. Individual #2's assessment completed 1/26/20 did not include the individual's need for supervision. The assessment must include the following information: The individual's need for supervision. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(5)Individual #1's assessment completed 1/10/20 did not include the individual's ability to self-administer medications. Individual #2's assessment completed 1/26/20 did not include the individual's ability to self-administer medications.The assessment must include the following information:  The individual's ability to self-administer medications.Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(6)Individual #2's assessment completed 1/26/20 did not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #2s' current assessment was updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(7)Individual #1's assessment completed on 1/10/20 did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Individual #2's assessment completed 1/26/20 did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(8)Individual #1's assessment completed 1/10/20 did not include the individual's ability to evacuate in the event of a fire. Individual #2's assessment completed 1/26/20 did not include the individual's ability to evacuate in the event of a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(9)Individual #1's assessment completed 1/10/20 did not include documentation of the individual's disability, including functional and medical limitations. Individual #2's assessment completed 1/26/20 did not include documentation of the individual's disability, including functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/29/20. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(10)Individual #1's assessment completed 1/10/20 did not include a lifetime medical history. Individual #2's assessment completed 1/26/20 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. Program Specialist completed Lifetime Medical History 4/22/20. CEO will use a monitoring tool for compliance to ensure medical history is completed upon admissions and updated as needed [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 04/22/2020 Implemented
6400.181(e)(11)Individual #1's assessment completed 1/10/20 did not include psychological evaluations. Individual #2's assessment completed 1/26/20 did not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/2920. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.181(e)(12)Individual #1's assessment completed 1/10/20 did not include recommendations for specific areas of training, programming and services. Individual #2's assessment completed 1/26/20 did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Assessment form was revised by CEO 3/10/20 to ensure that all components of assessment are clearly identified, Program Specialist completed/updated revised assessment form 3/2920. CEO will use a compliance tool for current and new individuals to monitor the completion of assessments within 60 days and annually [Individual #1 and Individual #2s' current assessments were updated to include missing information. Copies were submitted to the department on 5/4/2020. (AES,HSLS on 5/6/2020)] 03/29/2020 Implemented
6400.32(r)Individual #1's bedroom door did not have a lock. Individual #2's bedroom door did not have a lock.An individual has the right to lock the individual's bedroom door.Owner purchased locks and placed them on all bedroom doors 3/25/20. Program Specialist talked to individuals 3/23/20 regarding the new regulations and the right to lock bedroom door. Staff were made aware of this change and where the key is kept and when they should use it [At least monthly for at least 1 year, the CEO or program specialist shall interview the individuals and staff persons to ensure individual are exercising their right to lock their bedroom doors and any changes in the process need to be made. (DPOC by AES,HSLS on 5/6/20)] 03/25/2020 Implemented
6400.165(g)Individual #1's most recent review of medications prescribed to treat symptoms of psychiatric illness was completed on 5/28/19. Individual #2's most recent review of medications prescribed to treat symptoms of psychiatric illness was completed on 6/12/19.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.Program Specialist contacted Individual #1 & #2¿s physician on 2/28/20 to request medication reviews that were not readily available at the time of inspection . CEO will use a medication review tracking form to monitor medication reviews every 90 days [Individual #1 had a medication review completed 2/21/20. Individual #2 had a medication review completed 2/12/20. A blank Psych med reviews tracking form was submitted to the Department. Immediately, the CEO shall develop and implement a tracking, scheduling, record keeping and auditing procedure to ensure timely completion of psychiatric medication reviews and educate staff person responsible for supporting individuals in having psychiatric medication reviews on the aforementioned procedures. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 5/6/2020)] 02/28/2020 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 1/10/19 to the individual plan team members for an individual plan meeting on 10/10/19. The program specialist did not provide Individual #2's assessment, completed 1/26/19 to the individual plan team members for an individual plan meeting on 8/08/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.CEO will monitor program specialist assessment process. A Compliance Monitoring Tool has been implemented to ensure assessment responsibilities are in compliance. The Program Specialists will keep track of initial/annual assessments and ISP dates to ensure that assessments are completed and provided to the ISP team 30 days prior to the ISP meeting. Program Specialist shall send updated assessment to SC and keep documentation. [Individual #1 and #2's updated assessments were provided to the plan team members on 4/15/20. Documentation of aforementioned audits shall be kept. Blank audit documentation was provided to the Department. (DPOC by AES,HSLS on 5/6/20)] 03/30/2020 Implemented
SIN-00155667 Renewal 03/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home was completed on 8/21/18, more than 6 months prior to the expiration of the current Certificate of Compliance, which expired on 3/26/19.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. To avoid non-compliance an annual calendar has been created to alert of date that self-assessment for home should be completed within 3 to 6 months to the certificate of compliance expiration date, this will aid in self-assessment not being completed too early. The program specialist and CEO have access to calendar and will check the date of the completed self-assessment for compliance. [Prior to 3 months of the expiration of the current Certificate of compliance, the CEO or designee shall audit the self-assessment to ensure timely, full and accurate completion. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 7/5/19)] 03/28/2019 Implemented
6400.21(a)Direct Service Worker #1, date of hire 10/19/18, had a criminal background check completed 11/7/18.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. To avoid non-compliance criminal background checks will be performed prior to date of hire. Direct Service Worker #1 actual working start date was not until 11/27/18. Effective immediately CEO will do a review of background checks prior to staff having direct contact to ensure compliance. A hiring / orientation checklist will continue to be used to maintain compliance. [Documentation of the audits of required criminal history record check by the CEO shall be kept. (DPOC by AES,HSLS on 7/5/2019)] 03/26/2019 Implemented
6400.103The agency's "Emergency Disaster Plan" policy does not include emergency evacuation procedures which include a means of transportation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Emergency disaster plan was updated by provider to include emergency evacuation procedures that include means of transportation. Going forward to maintain compliance an annual review process has been put into place for policy and procedure updates. [The written emergency evacuation procedure was updated on 3/25/19 to include the means of transportation. Documentation of the aforementioned annual review of policy and procedure updates shall be kept. (DPOC by AES,HSLS on 7/5/19)] 03/26/2019 Implemented
6400.112(c)The fire drill held on 10/24/18 does not include the amount of time it took for evacuation. The fire drills held on 1/11/19, 1/28/19, and 2/10/19 do not include the amount of time it took for evacuation documented in minutes and seconds.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. To avoid non-compliance going forward the current fire drill form has been updated to reflect minutes and seconds. Regulations does not specify time to be documented in minutes and seconds it only mentions that the time and amount of time is to be kept. A review of regulations with staff has been given to ensure that evacuation time is documented according o regulations. [Upon completion of fire drills, the CEO or designee shall audit the fire drill records to ensure fire drills are conducted and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/5/19)] 03/27/2019 Implemented
6400.112(d)The fire drill held on 1/11/19 had an evacuation time of 3 minutes. The fire drill held on 2/10/19 had an evacuation time of 3 1/2 minutes. The home does not have an extended evacuation time in writing by a fire safety expert. 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. To maintain compliance upon initial fire drill training a verbal instruction will be given to ensure that individuals are aware of the importance of evacuating within 2 1/2 minutes. If evacuation does not occur within 2 1/2 min time frame an fire safety expert will be contacted to do a drill and specify the extended evacuation time in writing or give recommendations to help meet regulatory time frame . A review with staff has been given on fire drill evacuation time based on regulations. [Upon completion, the CEO or designee shall audit the fire drill records to ensure fire drills are conducted and documented as required. Immediately, the CEO or designee shall develop and implement procedures if fire drills are not conducted as required and train staff persons of the procedure to ensure the health and safety of the individuals. (DPOC by AES,HSLS on 7/5/19)] 03/26/2019 Implemented
6400.113(a)Individual #1, date of admission 1/25/19, was instructed in general fire safety on 1/28/19. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. To avoid future non-compliance general fire safety training will be instructed upon arrival. The program specialist and CEO have been given an overview of regulations and instruction as to when the fire safety training shall occur. Program Specialist and CEO will check for compliance. [Upon admission, the CEO or designee shall audit the training records for the individual's fire safety training to ensure timely completion with required information instructed in the individual's primary language or mode of communications. (DPOC by AED,HSLS on 7/5/19)] 04/29/2019 Implemented
6400.141(c)(3)Individual #1's physical examination, dated 3/7/19, does not include immunizations. Individual #2's physical examination, dated 1/15/19, does not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. To avoid non-compliance an annual review calendar has been created for record reviews. Training has been given to direct care staff and program specialist to look over the information on physical form and make sure that immunizations have been included. A review of physical form will be done by the program specialist to ensure immunizations has been included. A follow up with doctor will occur if information needed is not listed. Individual #1 immunizations have been included on form during physical appt 5/3/19 . Individual #2 immunizations have been included on form during physical on 6/6/19. 05/22/2019 Implemented
6400.141(c)(6)Individual #1's physical examination, dated 3/7/19, does not include Tuberculin skin testing. Individual #2's physical examination, dated 1/15/19, does not include Tuberculin skin testing.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. To avoid non-compliance an annual review calendar has been created for record reviews. TB skin test have been scheduled for individual #1 and individual #2 the results will be included with physical examination records. Program specialist has been given a review of 6400 regulations concerning tuberculin skin testing. 05/22/2019 Implemented
6400.141(c)(11)Individual #1's physical examination, dated 3/7/19, does not include an assessment of the individual's health maintenance needs and medication regimen. Individual #2's physical examination, dated 1/15/19, does not include an assessment of the individual's health maintenance needs and medication regimen.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Additional training has been given to direct care staff and program specialist to look over the information on physical form and make sure that the entire form has been filled out during appts, if it is not staff will explain to the doctor that the form needs completed. A review of physical form will be done by the program specialist to ensure information needed has been included. A follow up with doctor will occur if information needed is not listed. Individual #1 assessment of health maintenance needs and medication regimen have been included on form during physical appt 5/3/19 . Individual #2 assessment of health maintenance needs and medication regimen have been included on form during physical on 6/6/19. An annual review calendar has been created for record reviews to avoid non-compliance. 05/22/2019 Implemented
6400.141(c)(12)Individual #1's physical examination, dated 3/7/19, does not include physical limitations of the individual. Individual #2's physical examination, dated 1/15/19, does not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. Additional training has been given to direct care staff and program specialist on looking over the information on physical form and make sure that the entire form has been filled out during appts, if it is not staff will explain to the doctor that the form needs completed. A review of physical form will be done by the program specialist to ensure information needed has been included. A follow up with doctor will occur if information needed is not listed. Individual #1 physical limitations have been included on form during physical appt 5/3/19 . Individual #2 physical limitations have been included on form during physical on 6/6/19. To avoid non-compliance an annual review calendar has been created for record reviews 05/22/2019 Implemented
6400.141(c)(13)Individual #1's physical examination, dated 3/7/19, does not include the individual's allergies. Individual #2's physical examination, dated 1/15/19, does not include the individual's allergies.The physical examination shall include: Allergies or contraindicated medications.To avoid non-compliance an annual review calendar has been created for record reviews. Additional training has been given to direct care staff and program specialist to look over the information on physical form and make sure that the entire form has been filled out during appts, if it is not staff will explain to the doctor that the form needs completed. A review of physical form will be done by the program specialist to ensure information needed has been included. A follow up with doctor will occur if information needed is not listed. Individual #1 allergies have been included on form during physical appt 5/3/19 . Individual #2 allergies have been included on form during physical on 6/6/19. Individual #1 & 2 both have no known allergies 05/22/2019 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 3/7/19, does not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination, dated 1/15/19, does not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. To avoid non-compliance an annual review calendar has been created for record reviews. Training has been given to direct care staff and program specialist to look over the information on physical form and make sure that the entire form has been filled out during appts, if it is not staff will explain to the doctor that the form needs completed. A review of physical form will be done by the program specialist to ensure information needed has been included. A follow up with doctor will occur if information needed is not listed. Individual #1 medical information pertinent to diagnosis and treatment in case of emergency have been included on form during physical appt 5/3/19 . Individual #2 medical information pertinent to diagnosis and treatment in case of emergency have been included on form during physical on 6/6/19. 05/22/2019 Implemented
6400.141(c)(15)Individual #1's physical examination, dated 3/7/19, does not include special instructions for the individual's diet. Individual #2's physical examination, dated 1/15/19, does not include special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. The Program specialist and staff have been trained to look over the information on physical form and make sure that the entire form has been filled out during appts, if it is not staff will explain to the doctor that the form needs completed. A review of physical form will be done by the program specialist to ensure information needed has been included. If not, a follow up with doctor will occur. Individual #1 special diet instructions have been included on form during physical appt 5/3/19 . Individual #2 special diet instructions have been included on form during physical on 6/6/19. To avoid future non-compliance an annual review calendar has been created for record reviews. 05/22/2019 Implemented
6400.165Individual #1 is prescribed Aripirazole 30 mg with the instructions "take a half tablet at bedtime;" however, the medication was not administered on 3/1/19, 3/2/19, and 3/3/19. These medication errors were not documented and no follow-up action was documented.Documentation of medication errors and follow-up action taken shall be kept. The program specialist and staff have been re-trained on incident management and reporting medication errors within 72 hrs. To avoid non-compliance in the future the program specialist shall be made aware by staff ,documentation and a follow up will be made. No longer using pharmacy associated with this violation. The previous pharmacy did not have the mediation available the day is was prescribed. The doctor was informed and gave direction to give as soon as possible. The new pharmacy selected will deliver medications in numbered blister packs and auto-refill. 05/22/2019 Implemented
6400.167(b)Aripirazole 30 mg., take a half tablet at bedtime prescribed to Individual #1 was not administered on 3/1/19, 3/2/19, and 3/3/19. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The program specialist has obtained instructions from individuals doctor 4/1/19 stating what action are to be taken if meds are not available or dose is missed. Staff have been re-trained on what actions to take if this occurs and to immediately contact the program specialist. Staff have been directed to pay close attention to how many days are left before prescription needs refilled, staff will inform the program specialist at least 8 days prior to needing refilled. The pharmacy used in this particular situation did not have the medication available and was not very helpful. A new pharmacy is being used and medications come numbered in blister packs and delivered, automatically refilled by the pharmacy. 05/22/2019 Implemented
6400.168(a)Direct Service Worker #1 administered medications to Individual #2 on 3/1/19, 3/2/19, 3/4/19 and 3/5/19. Direct Service Worker #1, date of hire 10/19/18, did not fully complete the initial medication administration course; two of the four medication administration observations were not completed and the training documents were not signed by the medication administration trainer. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Direct Service Worker #1 has been scheduled to retake the medication administration course upon completion the program specialist will check the training documents to ensure all four observations have been completed and trainer has signed. To avoid non-compliance in the future a thorough review of med training documentation will done on new hires prior to administering meds. A review of training documentation will occur semi-annually. 05/22/2019 Implemented
6400.168(e)Documentation of the Medication administration training course for the medication admistratrion trainer was not available. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.Additional training was provided to the program specialist on the requirements of medication administration trainer documentation. The medication administration trainer at AIMED Services was contacted by the program specialist 3/26/19 . Documentation of the medication administration trainer was obtained and is on file at the provider office. To avoid non-compliance in the future the program specialist will obtain a current copy of trainers certificate currently using and if a new agency is used the program specialist will obtain the trainers documentation and have on file. A review of trainers documentation will be done annually. 03/26/2019 Implemented
SIN-00131437 Initial review 02/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 10:55AM, the hot water temperature measured 125.6 °F in the shower in the bathroom attached to the bedroom on the left side of the hallway on the second floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water tank was turned down and will not exceed 120 degrees. [On 3/28/18, the owners adjusted the hot water temperature and tested the hot water temperature which measured 120°F. Immediately and at least weekly until the home is occupied, the CEO or designee shall measure the hot water temperature to ensure the hot water temperature does not exceed 120°F in bathtubs and showers. Upon admission of individual(s) to the home, at least daily until the hot water does not exceed 120°F for 1 week and then continuing at least weekly for 1 month and then continuing at least monthly, the CEO or designee shall measure the hot water temperature to ensure the hot water temperature does not exceed 120°F in bathtubs and showers. Documentation of who, where, when and the person taking the temperature shall be kept. (AS 4/4/18)] 03/28/2018 Implemented
6400.101The front door, back door and the door leading into the garage were equipped with slide chains and door knob key locks that prevented egress out of the home and the garage when engaged. There is not a standard door in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Slide chains and door knob key locks were removed from front door, back door and door leading to garage. Purchased and replaced door knob key locks with turn locks that will not prevent egress out of the home. [New locking mechanisms were purchased on 3/26/18 and installed on 3/28/18 by the owners of the home. Upon hire, the CEO or designee shall train all staff persons working in the home(s) that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor for obstructed egresses and to immediately clear or to contact the CEO or designee as needed. Documentation of trainings shall be kept. (AS 4/4/18)] 03/28/2018 Implemented
6400.110(e)The home, which had three stories including the basement, first and second floors, did not have interconnected smoke detectors.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Purchased three interconnected smoke detectors. Replaced previous smoke detectors on all three stories with interconnected detectors. (tested and operable) [New smoke detectors were purchased on 3/26/18 and installed on 3/28/18 by the owners of the home and tested and operable. Immediately and continuing at least monthly, the CEO or designated staff person who is educated in the smoke detectors and the inoperable smoke detector policy (documentation of the training shall be kept) shall test the smoke detectors to ensure the smoke detectors on each floor are interconnected and audible throughout the home(s) as required. Documentation of the testing shall be kept. (AS 4/4/18)] 03/28/2018 Implemented
6400.111(a)The fire extinguishers located in the kitchen on the first floor and in the basement were had a 1-A rating. There was not a fire extinguisher on the second floor of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Purchased three new extinguishers with 2-A rating. Replaced fire extinguishers in the kitchen on first floor and basement with 2-A. Additional 2-A extinguisher was put into place on the second floor. [New fire extinguishers were purchased on 3/26/18 and installed on 3/28/18 by the owners of the home. Immediately and continuing at least monthly, the CEO or designated staff person trained in 6400.111(a)-(f) shall check all fire extinguishers in the home to ensure there is at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic and requirements of 6400.111(a)-(f) are met. Documentation of the checks shall be kept. (AS 4/4/18)] 03/28/2018 Implemented
SIN-00232601 Renewal 10/11/2023 Compliant - Finalized
SIN-00214222 Renewal 11/01/2022 Compliant - Finalized