Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228028 Renewal 07/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 had blood work ordered 8/30/2022 and 12/14/2022 and there is no documentation of the appointment or the results ("Repeated Violation-5/10/2023, et al").Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. On 8/4/23 - Staff were retrained on the importance of ensuring that Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. on 7/14/23 -a review of her current and upcoming appointments was also completed with staff. 08/04/2023 Implemented
6400.151(a)Program Specialist #1 had a physical examination completed 5/21/2021 and not again since ("Repeated Violation- 3/17/2022, 12/15/2022 et al"). 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. On 8/3/23 the program specialist was retrained on the importance of having an up-to-date physical which pertains to any staff person that 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. the program specialist had a physical completed on 7/14/23 . 07/14/2023 Implemented
6400.151(c)(2)Program Specialist #1 had a Tuberculin skin test completed 5/23/2021 and not again since. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. On 8/3/23 the program specialist was retrained on the importance of having an up-to-date physical and TB The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. the program specialist had a physical completed on 7/14/23 which documented his prior TB completed on 1/3/23 and read on 1/5/23. 07/14/2023 Implemented
6400.165(c)Individual #1 is prescribed Mupirocin 2% Topical Ointment with instructions to apply topically two times per day. Individual #1's July 2023 medication administration record documents a single administration on 7/01/2023, 7/04/2023, and 7/05/2023, and no administrations for 7/03/2023 and any date after 7/05/2023.A prescription medication shall be administered as prescribed.A medication error was entered since the medication was not given as prescribed. Staff on 8/4/23 were trained on the importance of following/ensuing that all prescription medication be administered as prescribed. 08/14/2023 Implemented
6400.165(g)Individual #1's psychiatric medication review completed 12/27/2022 did not include the reason for prescribing the medication, the need to continue the medication, and the necessary dosage ("Repeated Violation- 3/17/2022, 12/15/2022 et al").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.Staff on 8/4/23 were retrained on the importance of ensuring that 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. staff were also retrained on the proper form to use for psyche appointments as well as the areas that need to be filled out in completion. 08/04/2023 Implemented
6400.182(c)Individual #1's physical examination completed 1/12/2023 has a recommendation for a DASH diet and Individual #1's individual support plan, last updated 4/11/2023, states the individual is not required to follow any specialized diet. Individual #1's individual support plan, last updated 4/11/2023, states the individual can self-medicate and the assessment completed 7/04/2023 documents she is unable to self-administer medications ("Repeated Violation- 9/20/2022 et al").The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 7/14/23 via email - The supports coordinator was notified of the updated on the DASH diet and staff retrained on its components on 8/4/23. the DASH diet was also reviewed with the individual on 8/4/23 and healthy food choices discussed that are in line with the dash diet. 08/04/2023 Implemented
6400.194(b)Individual #1 currently has a restrictive procedure plan. There is no documentation of Individual #1's human rights team including a professional who has a recognized degree, certification or license relating to behavioral support.The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan.on 8/4/23 and 8/2/23- staff were retrained on the importance of checking the program book of the client to ensure that information on the human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. the behavior support representative and director of the western region for PDCS was contacted to request the information and the director of PDCS western region information sent on 8/8/23 certification/license, related to behavior support. 08/14/2023 Implemented
6400.195(b)Individual #1's restrictive procedure plan was reviewed by the human rights team 8/10/2022, and not again since.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.Staff was trained on the importance of ensuring that 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 behavior support representative and director of the western region for PDCS was contacted and - BW next human rights team will actually occur on 8/9/23 and the prior HRT February meeting notes were sent for February 2023. 08/09/2023 Implemented
SIN-00216576 Renewal 12/15/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)Individual #1 is diagnosed with hearing loss in both ears and is prescribed hearing aids. During the inspection the smoke detector in the living room in front of the main entrance was not interconnected with Individual #1's bed shaker and bedroom strobes at 3:11pm "Repeated Violation- 11/01/2022, 8/15/2022, and 3/17/2022, et al". If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. on 12/19/22 all staff were retrained on the fact that If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. on 1/6/2023 all staff had a fire safety refresher where smoke detectors/strobes, fire safety with hearing-impaired adults were all reviewed and the importance and staff role during a drill. the contractor will assess current smoke detectors with strobes at the home on 1/10/22 and coming up with a plan for a hard-wired system and install for January 2023. the smoke detectors and strobes were reset, and any nonfunctioning equipment removed, and mock fire drill conducted on 1/4/2023. 01/16/2023 Implemented
6400.141(a)Individual #1 had a physical examination completed 4/19/2021 and then again 10/28/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis- the components and importance of the annual physical were reviewed during the training as well 12/19/2022 Implemented
6400.151(a)Direct service Worker #7, date of hire 5/06/2021, had an initial physical examination completed 12/13/2022 "Repeated Violation- 3/17/2022, et al". 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. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for staff which should be completed physical examination within 12 months prior to employment and every 2 years thereafter. The components and importance of the annual physical were reviewed during the training as well 12/19/2022 Implemented
6400.46(b)Direct Service Worker #5's training in fire safety completed 3/01/2022, does not document a fire safety expert conducted the trainings.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).on 1/6/2023 all staff partipated in a fire safety refresher training. 12.19.2022 all staff were retrained on the importance of fires safety training and its components including trainer/student roles and sign off . 01/06/2023 Implemented
6400.46(d)Direct Service Worker #6, date of hire 6/29/2021, was trained in in first aid, Heimlich techniques and cardio-pulmonary resuscitation 9/10/2019 and then again 10/12/2021 [Repeated Violation- 3/17/2022, et al].Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.12/19/22 all staff were retrained on the importance on keeping in compliance with trainings including CPR and adhering to due dates. 12/19/2022 Implemented
6400.50(a)Residential Director #3's, date of hire 9/14/2022, orientation training completed 9/15/2022, does not document the actual length of time the trainings. Direct Service Worker #4's, date of hire 10/14/2022, orientation training completed 10/14/2022, does not document the actual length of time the trainings. Direct Service Worker #5, date of hire 2/28/2022, does not document the length of time the orientation trainings. Direct Service Worker #6, date of hire 6/18/2021, orientation training completed 6/18/2021 does not document the actual length of the time. Direct Service Worker #7's, date of hire 5/09/2021, orientation training completed 5/09/2021 does not document the actual length of time.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.on 12/19/22 all staff were trained on the importance of utilizing the new form which has a start and end time which is mandatory to be filled out. 12/19/2022 Implemented
6400.52(c)(1)Chief Executive Officer #1's 2021 annual training does not include training on application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.the annual training hours form was updated to reflect all sub sections needed. the CEO completed a new annual training refresher on 1/4/2022 01/04/2023 Implemented
6400.52(c)(3)Chief Executive Officer #1's 2021 annual training does not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.the annual training hours form was updated to reflect all sub sections needed including individual rights. the CEO completed a new annual training refresher on 1/4/2022 01/04/2023 Implemented
6400.162(a)Direct Service Worker #6's current medication annual practicum training documented 10/18/2022 was not complete and only includes one medication administration record review. Direct Service Worker #6 administered 8:00pm medications to Individual #1 12/02/2022. Direct Service Worker #7's annual practicum training documented as 6/23/2022, is not complete and only includes one medication administration record review. Direct Service Worker #7 administered all 8:00am medications to Individual #1 12/01/2022,12/02/202212/06/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/12/2022, 12/13/2022, 12/14/2022, and 12/15/2022.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Staff (med admin trainer/director of residential) was retrained on the importance of ensuring that a home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. The MAR reviews and observations that were not included prior due to an oversight were updated for each staff person. 01/10/2023 Not Implemented
6400.165(g)Individual #1's psychiatric medication review completed 10/19/2022 did not include a review of the following medications: Sertraline 100mg, Aripiprazole 5mg, and Perphenazine 4mg "Repeated Violation- 3/17/2022, et al".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.On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the psyche appointments and 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. 12/19/2022 Not Implemented
6400.166(a)(5)Individual #1's December 2022 medication administration record did not include the dosage for the prescribed Aviane "Repeated Violation- 8/15/2022 and 3/17/2022, et al".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.All staff were retrained on the importance of documentation on the MAR and their roles. the December mar was updated to reflect the current dosage and the January mar was reviewed to reflect the correct dosage as well. 01/16/2023 Implemented
6400.166(a)(9)Individual #1 is prescribed Nyamyc powder 100,000 with instructions to apply topically to affected areas 3 times a day as needed for rash. Individual #1's December 2022 medication administration record documents the frequency as apply topically to affected areas 3 times daily for skin irritation "Repeated Violation- 8/15/2022 and 3/17/2022, et al".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.on 12/19/2022 - all staff were retrained on the importance of ensuring that a A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. the record was updated to reflect appropriate frequency 01/16/2023 Implemented
SIN-00214184 Unannounced Monitoring 11/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)During the inspection conducted 11/01/2022 the water temperature measured 122.3°F at the kitchen sink at 12:54PM.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. On11/1/2022 the temperature was tested at the kitchen sink, and it reflected a temp of 122.3 degrees. the hot water temperature was turned down manually at hot water tank in the basement that same day and tested during the fire drill on 11/1/22. As a precaution, the maintenance follow up was initiated. The maintenance man was scheduled for 11/10/22 but had to be pushed back to 11/18/22, due to a conflict. Until the maintenance man clears all issues, the residential director is testing the temperature at all water sources within the Anthon home at least once a week (last completed on 11/11/22). Lead Staff (11/10/22) and residential director ( 11/9/22) were retrained on importance of completing hot water temperature checks and the compliance standard for hot water within a residential group home and how to report issues if they present themselves. 11/18/2022 Implemented
6400.110(f)Individual #1 had an audiologist appointment completed 10/17/2022 where the medical provider documents the individual having sensory neural and conductive hearing loss. During the inspection conducted 11/01/2022 the smoke detectors were not equipped so that the individual can be alerted in the event of a fire. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. The safe awake fire alarm was installed, and fire drill completed on 11/1/2022, which was able to detect/interconnect to the audible signal of the smoke alarm and it alerts the individual of the smoke alarm going off by providing a very strong vibration via bed shaker. the bed shaker was installed under her mattress and the second alert mechanism includes flashing strobe light located at the top of the device. Lead staff (11/10/22) and director (11/9/22) retrained on the importance of completing fire drills and also how to support an individual with hearing deficits during a fire drill and supportive devices in place. 11/14/2022 Implemented
6400.171During the inspection conducted 11/01/2022 there were two chicken patties identified in the refrigerator, on a disposable plate uncovered.Food shall be protected from contamination while being stored, prepared, transported and served. Lead staff (11/10/22) and residential director (11/9/22) were retrained on the importance of food safety and making sure that continued compliance occurs as it pertains to food safety handling, packaging and storing of food. On the day (11/1/22) of the incident the staff onsite and also the individual who is high functioning were retrained on proper food packaging/handling process. 11/21/2022 Implemented
6400.181(e)(4)Individual #1's assessment completed 7/04/2022 does not include the individual's need for supervision in the home. The assessment must include the following information: The individual's need for supervision. Individual #1 assessment did not include the need for supervision within the home and a team meeting was scheduled for 11/14/22 to discuss supervision within the home, community etc. On 11/9/22 the program specialist and residential director were retrained on the importance of having up to date supervision levels that give detailed explanation of the level of supervision (example - arm's length) in all scenarios (home /communities, etc) 12/15/2022 Implemented
6400.166(a)(4)Individual #1 is prescribed Aviane 28 tablet, take 1 tablet by mouth daily, and on the November 2022 medication administration record it documents the name of the medication as Vienva ("Repeated Violation-3/17/2022, et al").A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The label for the birth control has been updated to reflect the current birth control being used. Lead staff and residential director were trained on (11/2/22) the new PDC process (mar delivery, how to order meds, etc.). Lead staff (11/10/22) and Director of Residential (11/9/22) were trained on the MAR and its requirements and checks needed. 11/21/2022 Implemented
6400.166(a)(5)Individual #1 is prescribed Prazosin 2mg capsule, take 1 capsule by mouth daily for anxiety, and on the November 2022 medication administration record it documents the strength as Prazosin 1mg capsule ("Repeated Violation-3/17/2022, et al").A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The medication strength on the MAR was updated to reflect the appropriate amount once confirmed. All lead staff and residential director were trained on (11/2/22) the new PDC process (mar delivery, how to order meds, etc.). Lead staff (11/10/22) and Director of Residential (11/9/22) were trained on the MAR and its requirements and cross-checks needed. 11/21/2022 Implemented
SIN-00210411 Unannounced Monitoring 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 3:20 PM on 8/15/22, several cleaners, including 2.53 quarts of liquid bleach were found unlocked underneath the kitchen sink cabinet. Additionally, underneath the sink in the unlocked vanity cabinet of the full bathroom located on the main level, a 23 fl. oz. bottle of Windex, a 1 lb., 5 oz. can of Comet cleaner, and a 24 fl. oz. bottle of Clorox toilet bowl cleaner were discovered. Individual #1's 7/4/22 assessment states "[they] [do] not know how to safely use cleaning products. [They] [do] not know what warning labels mean.Poisonous materials shall be kept locked or made inaccessible to individuals. individual had a recent ISP where it was discussed if she were safe around poisons and her usage of poisons such as bathroom cleaners. per the team discussion (includes behavior support) which included the individual it was determined that she was safe around poisons and has been helping clean the bathroom, and they (poisons/cleaners) could be kept unlocked within the home. staff and management were retrained on this on 8/23/22 08/23/2022 Implemented
6400.64(f)At 3:43 PM on 8/15/22, a large, outdoor black trash can was discovered in the garage without its lid completely closed, and garbage bags protruding outward. Another garbage bag was noted on the floor leaning against the trash can.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.dditional trash cans were purchased and placed at the homes to use outside to hold the overflow of trash. ON 8/15/22 -Staff were retrained on how to break down boxes, reminders for the current trash days and what is the importance of keeping trash can outside the home closed at all times in order to reduce the likely of insects or rodents getting into the trash. Director was trained on 8/15/22 and refresher on 8/31/22 on the same topic. the client who is higher functioning was trained as well since he sometimes takes out the trash as part of his chores. 08/31/2022 Implemented
6400.67(a)At 2:40 PM on 8/15/22, the gutter running along the entire front façade of the home was observed to be sagging, collapsing, and detaching from the fascia. [Repeat violation from 3/17/22.]Floors, walls, ceilings and other surfaces shall be in good repair. On 8.15.22 staff and director were retrained on the importance of having floors walls and ceiling in good repair including the gutters of the homes. the gutters at collins were fixed /updated and cleaned by a gutter repair company on 9/7/2022 09/07/2022 Implemented
6400.73(a)The outdoor railing on the main walkway leading to the front door that includes 7 steps was discovered loose, wobbly, and unsecured at 2:42 PM on 8/15/22. [Repeat violation from 3/17/22.] Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The outdoor railing at the Collins site was found to be wobbly although the bolts were tightened prior. Due to the bolts continuing to get loose , it was decided that the railing would be replaced by a wood railing that is secured in concrete foundation. This new railing will be installed on 9/14/22. On 8/15/22 - all staff including the Director of residential (MS)were retrained on the importance of ensuring that a railing is available for any outdoor stairway that exceeds two steps. 09/14/2022 Implemented
6400.80(b)On 8/15/22 at 2:40 PM, weeds, vines, and vegetation, measuring 3-6 ft. and greater in height were found along the driveway's edge meeting the front yard's retaining wall and up the front of the house. Vines and vegetation were also noted, wrapped around the backside of the house. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The staff and director of residential (MS ) retrained on the importance of maintaining and keep the outside of the home in good repair. the vegetation and weeds were removed, and the lawn cut on august 26,2022. 08/26/2022 Implemented
6400.214(a)The following records for Individual #1 were not located onsite at 2:57 PM on 8/15/22: personal, demographic information, including their name, sex, admission date, birthdate and Social Security number. [Repeat violation from 3/17/22.]Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.as of 9/13/2022 - the program and medical books are onsite, and readily available with incident reports/functional assessments, dental exams, personal info, demographic info, etc. on 8/15/22 - Staff and director of residential were trained on the importance of keeping an UpToDate program and medical book onsite at the homes and what components should be onsite within it. 09/13/2022 Implemented
6400.214(b)The following records for Individual #1 were not located onsite at 2:57 PM on 8/15/22: dental exams, functional assessments, and individual plan. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. as of 9/13/2022 - the program and medical books are onsite, and readily available with incident reports/functional assessments, dental exams, etc. on 8/15/22 - Staff and director of residential were trained on the importance of keeping an UpToDate program and medical book onsite at the homes and what components should be onsite within it. 09/13/2022 Implemented
6400.166(a)(4)On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing: name of medication. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.the medication administration record was updated for august and also September and now currently reflects the PRN fluticasone name of the medication on the MAR. on 8/15/22- staff and director of residential (MS) were retrained on the importance of having the name of the medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(5)On 8/15/22, Individual #1's August 2022 Medication Administration Record was missing the strength of medication for the prescribed Larissia. The strength of this medication, (0.1 mg/ 0.02 mg), was found only on its packaging box. On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing: strength of medication. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.the medication administration record was updated for august and also September and now currently reflects the strength of the medications on the MAR. on 8/15/22- staff and director of residential (MS) were retrained on the importance of having the strength of a medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(6)On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing: dosage form. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.the medication administration record was updated for august and also September and now currently reflects the PRN fluticasone dosage form on the MAR. on 8/15/22- staff and director of residential (MS) were retrained on the importance of having the dosage form of a medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(7)On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing: dose of medication. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.the medication administration record was updated for august and also September and now currently reflects the PRN fluticasone dose on the MAR. on 8/15/22- staff and director of residential (MS) were retrained on the importance of having the dose of a medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(8)On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing; route of administration. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.the medication administration record was updated for august and also September and now currently reflects the PRN fluticasone route of administration on the MAR. on 8/15/22- staff and director of residential (MS) were retrained om the importance of having the route of administration of a medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(9)On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing: frequency of administration. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.the medication administration record was updated for august and also September and now currently reflects the PRN fluticasone frequency of administration on the MAR. on 8/15/22- staff and director of residential (MS) were retrained on the importance of having the frequency of administration of a medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(11)On 8/15/22, the following pro re nata medication was discovered onsite and being used by Individual #1: Fluticasone Propionate (50 mcg spray). However, the aforementioned pro re nata medication was not recorded on Individual #1's August 2022 Medication Administration Record, as the following element was missing: diagnosis or purpose, including pro re nata. [Repeat violation from 3/17/22.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.the medication administration record was updated for august and also September and now currently reflects the PRN fluticasone diagnosis or purpose on the MAR. on 8/15/22- staff and director of residential (MS) were retrained on the importance of having the diagnosis and or purpose of a medication listed on the MAR and the importance of doing all the checks when doing med administration and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
6400.166(a)(13)On 8/15/22, Individual #1's and Individual #2's August 2022 Medication Administration Records were observed missing a staff signature key identifying the initials of the medication administrators. [Repeat violation from 3/17/22.]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 medication administration record was updated for august and also September and now currently reflects all staff signatures an initials on the MAR. on 8/15/22- staff were retrained on the importance of having the staff signatures and initials listed on the MAR and the importance of doing all the checks when doing med administration as well as signing off at the start of the month on the back of the MAR with signatures and initials and if an error is noticed who to contact immediately so that it can be rectified. 09/19/2022 Implemented
SIN-00202066 Renewal 03/17/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency certificate of compliance expired 1/12/2022 and the self-assessment of the home was completed 2/09/2022. The self-assessment form used was last updated in 2018.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. The agency (CSL) conducted a retraining with the Director of residential and program specialist regarding the due dates of the self-assessment as well as the importance of completing Lii, which are due 3 to 6 months prior to the certificate of compliance expiration. During the training a new self-assessment was completed for each home to utilize as a sample moving forward. 04/29/2022 Not Implemented
6400.64(c)During the onsite inspection on 3/18/2022 in the garage attached to the home there was a large black outside trash can that was full of bags of garbage that were building out of the top of the can. There were also four tall kitchen size bags of garbage stacked against the wall of the garage. There was a pungent odor and the garbage bags had flies on them.Trash shall be removed from the premises at least once per week. Direct care staff were cross- retrained on 3/28/22 importance of ensuring that the trash for all homes weekly on the assigned trash days and the importance of health and safety. staff were also trained on the follow up corrective plan, in situations which the trash was not picked up. Trash department for the municipality was contacted by the director of residential and trash was picked up, since it was overlooked during the time of the licensing. 03/28/2022 Implemented
6400.66During the inspection on 3/18/2020, there were multiple lights not operable in the basement. The entire right side of the basement floor was unlit and the lighting above the washer and dryer was very dim. The far right corner of the basement had a place for a bulb, but no bulb was present in the socket.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The basement lights at Anthon were replaced on 3/22/22 and home checklist was completed by Director of residential Retraining on regulation 6400.66- was conducted by the Director of Operations and the importance of making sure that all lights within the homes is working was discussed. Training of the lead staff of the home was also conducted by the Director of Residential as well and a specific closet in the basement was dedicated to house any extra lights. 03/22/2022 Not Implemented
6400.82(e)During the inspection on 3/18/2022, the full bathroom on the first floor of the home did not have a non-slip surface or mat in the bathtub. Bathtubs and showers shall have a nonslip surface or mat. Staff (Director and lead staff) were retrained (3/22/22) on the importance of the non-slip mat in the tub and the potential safety hazard that it would cause if not in place. A non-slip mat was put in the bathroom which was already onsite at the home but had not been opened. 04/28/2022 Implemented
6400.110(c)During the inspection on 3/18/2022 the smoke detector on the ceiling of the hallway between the staff bedroom and the individual's bedroom was inoperable when tested. There was no other smoke detector located in the hallway.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. On the day of the inspection the smoke detector assigned to the hallway was onsite but did not have batteries and it was not hanging in the assigned location. While the inspector was onsite, the director replaced the batteries and are hung the smoke detector in the appropriate place in the hallway. The director and staff were retraining on the home checklist and the importance of checking in safety concerns such as the proper functioning and placement of all smoke detectors. a fire drill was also completed on 3/18/2022. 04/28/2022 Implemented
6400.142(f)Individual #1, date of admission 5/04/2021, does not have a plan written for dental hygiene or documentation in writing that the individual has achieved dental hygiene independence.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Individual # 1 dental hygiene plan was updated on 3/22/22. Re-training was completed with the Program specialist and also the director to reaffirm the need for a dental hygiene plan for each of our individuals. 03/22/2022 Not Implemented
6400.151(a)Direct Service Worker #1 had a physical examination completed 8/29/2019 and then again 12/12/2021. Program Specialist #2, date of hire 6/03/2019, had an initial physical examination completed 5/21/2021. 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. The director of residential was retrained on the importance of physicals and TB compliance for all Staff. Online tracking system was reinstated - which the director of operations reviewed and trained the director of residential Pittsburgh 03/23/2022 Not Implemented
6400.151(c)(2)Direct Service Worker #1 had a tuberculin skin test completed 8/29/2019 and then again 12/12/2021. Program Specialist #2, date of hire 6/03/2019, had a tuberculin skin test read on 5/23/2021 but does not include the name and title of the person that read the results. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The director of residential was retrained on the importance of physicals and TB compliance for all Staff. Online tracking system was reinstated - which the director of operations reviewed and trained the director of residential Pittsburgh 03/23/2022 Not Implemented
6400.181(a)Individual #1, date of admission 5/04/2021, had an initial assessment completed 7/04/2021. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The program specialist and the director of residential were retrained on the due dates for assessments and the importance of following the 60 calendar days. 03/23/2022 Not Implemented
6400.46(d)Direct Service Worker #1 had training in first aid, Heimlich techniques and cardio-pulmonary resuscitation completed 8/25/2019 and then again 1/12/2022. Program Specialist #2, date of hire 6/03/2019, had child and infant first aid, Heimlich techniques and cardio-pulmonary resuscitation training completed 3/05/2020 and 3/01/2022, but has not been trained on adults.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.The director of residential Pittsburgh was retrained on the importance of all staff having up to date CPR and first aid for adults, as well as the due date parameters for completing CPR/first aid in order to be in compliance. Program specialist was trained/completed on adults CPR. 03/23/2022 Not Implemented
6400.52(a)(1)Direct Service Professional #1, date of hire 8/29/2018, had 12 hours of training from 1/01/2021 through 12/31/2021.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.the director of residential was re-trained by the Director of operations on the requirement of the 24hrs training and came up with a plan to implement it monthly trainings for staff via staff meetings, ODP and or PCHC site.These training updates will be submitted monthly to the director of operations and updated in Box online system. 04/29/2022 Not Implemented
6400.162(b)(2)(i)Direct Service Worker #1, date of hire 8/29/2018, had initial medication administration training completed 9/25/2021 and nothing prior. Director of Operations #3 stated that Direct Service Worker #1 has been administering medications since date of hire.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Oral medications.Direct care staff was retrained on Med Admin refresher on May 2, 2022. Compliance checks regarding medication administration will be completed by the leadership team and information regarding medication administration compliance of staff will be updated by the current med trainers 05/09/2022 Not Implemented
6400.165(c)Individual #1 is prescribed Naproxen 500mg tablet, take one tablet by mouth two times a day. The March 2022 medication administration record states to take 1 tablet by mouth every 12 hours as needed. The medication is being administered as a pro re nata medication.A prescription medication shall be administered as prescribed.Staff were retrained on completing med checks on a regular basis in order to compare the medications to the MAR. Any discrepancy will be reported to management to follow up. The director will conduct random home checks during which he will inspect MARS within the home and send updates to the operations director. 03/22/2022 Not Implemented
6400.165(g)Individual #1 is prescribed Sertraline Hydrochloride 100mg tablet for depression. Individual #1, date of admission 5/04/2022, has no record of having any psychiatric medication reviews completed by a licensed physician.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.staff were retrained on what to do during a med appointment and what documentation needs to be filled out for a psyche appointment. Since the current psyche doctor at mercy hospital has given the agency a hard time with filling out documentation. The Care sense has been in contact with family links , and they are giving us a referral on 5/2/22 for psyche doctor within their agency ( family links )in order to remain in compliance. 05/02/2022 Not Implemented
6400.166(a)(11)The March 2022 medication administration record for Individual #1 did not include diagnosis or purpose for the following medications: Loratadine 10mg, Aripiprazole 5mg, Prazosin HCL 1mg, Stool Softener 100mg, Docusate Sodium 100mg, Naproxen 500mg, Spironolactone 25mg, Sertraline Hydrochloride 100mg, Vienva 0.1-20mg/mcg, and Polyethylene Glycol 1oz.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Staff (director and direct care) were retrained on what items should be listed on the MAR for all clients. The director will conduct random home checks during which he will inspect MARS within the home and send updates to the operations director 03/22/2022 Implemented
6400.166(a)(13)Individual #1 is prescribed Aripiprazole 5mg tablet, take 1 tablet by mouth daily. There is no record of administration on 3/04/2022, 3/11/2022, and 3/12/2022 for the 9pm dose. On 3/02/22 the 9pm does was administered at 10:58pm. On 3/03/2022 the 9pm dose was administered at 11:23pm. On 3/13/2022 the 9pm dose was administered at 7:01pm. Individual #1 is prescribed Docusate Sodium 100mg capsule, take 2 capsules by mouth at bedtime. There is no record of administration on 3/04/2022 or 3/11/2022 for the 9pm administration.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.Staff ( Director and lead staff )were retrained on the process of documentation on the medication administration . reviewed documentation errors and reporting and the MAR per the medicine Shoppe. 03/18/2022 Not Implemented
6400.181(f)Individual #1's assessment completed 7/04/2021 was never sent to the plan team and the individual had a plan team meeting on 7/19/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program Specialist was retrained on the requirement of completing the assessments and the process of submitting the assessment 30 days prior to the calendar meeting. 04/28/2022 Implemented
6400.213(1)(i)Individual #1's record did not include religion.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Individual #1 record was updated to reflect religion. Staff Program specialist and Director was retrained on all items needed for an individual's record. 03/23/2022 Implemented
SIN-00183645 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. Individual #1 had a mirror purchased and placed in her room on 3/10/2021. To avoid this error in the future, CSL monthly home checklist was updated to reflect, checks for mirrors in each individual¿s room. On 2/26/2021 - The new Program Director (MS) was trained on the requirement of having a mirror in each individual bedroom as well as the usage of the checklist 03/10/2021 Implemented
6400.106The furnace of the home was inspected and cleaned 11/27/19 and then again 2/17/21. [Repeat Violation-11/13/19; et al]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. The furnace of the home was delayed in inspection, due to COVID-19 exposure/quarantine within the home during the time of the regular inspection in December 2020. To avoid the error in the future, the furnace inspection will be scheduled more than a month in advance. The furnace inspection company, Restano was already contacted by the program director (MS) and the next available time to schedule inspection for yearly inspection/cleaning is September 2021 for February 2022. The furnace inspection reminder has been created in outlook as an appointment reminder to scheduled annual furnace inspection for all homes. 03/11/2021 Implemented
6400.113(a)Individual #1, date of admission 8/25/17, was most recently instructed in general fire safety training on 1/2/21. There was not a record of previous fire safety training for Individual #1; therefore, compliance could not be measured. 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. Individual #1 training document regarding fire safety for 2020 was not presented at the time of the licensing. Individual #1 had a completed fire safety training for 2020 but due to not having the centralized system being utilized by the prior management staff, CSL was unable to locate the document at the time of the licensing. Since licensing occurred, new management staff is in place and he was trained on the regulation (2/26/021) and the centralized filing system. The CSL centralized filing system has been updated and reflects the firesaftey folder per year for each individual. On a monthly basis the PC checklist will be updated to reflect expiration month and reminder for all individuals fire safety training. 02/26/2021 Implemented
6400.141(a)Individual #1 had physical examinations completed on 7/26/19 and then again on 8/19/20. [Repeat Violation-11/13/19; et al]An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had a physical examination completed on 7/26/2019 and was scheduled for a follow up on doctor¿s office to 8/19/2020, which was outside the allotted yearly regulated timeframe. The Program director (MS) and Assistant operations director (JJ) were trained on the annual physical regulation requirement on 2/26/2021. The PC checklist that reflects appointments (annual physical), fires safety, etc. and is updated to reflect the current physical date and the next due date. The PC checklist is reviewed and submitted monthly. 02/26/2021 Implemented
6400.181(e)(14)Individual #1's assessment completed 10/10/20 does not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim.Since the Individual #1 assessment did not reflect her knowledge of water safety and ability to swim, her assessment has been updated to reflect her knowledge of tempering water / water safety and or ability to swim. The Program specialist has been retrained on the regulation requirement. 03/10/2021 Implemented
6400.34(a)Individual #1 was most recently informed and explained individual rights on 1/19/19.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual #1 training document regarding Individual/consumer rights for 2020 was not presented at the time of the licensing. Individual #1 had a completed consumer rights training for 2020 but due to not having the centralized system being utilized by the prior management staff, CSL was unable to locate the document at the time of the licensing. Since licensing occurred, new management staff is in place and he was trained on the regulation (2/26/021) and the centralized filing system. The CSL centralized system has been updated and reflects the consumer rights folder per year for each individual. On a monthly basis the PC checklist will be updated to reflect expiration month and reminder due date for all consumer rights training. 03/10/2021 Implemented
6400.165(c)Individual #1 was prescribed MiraLAX Powder, mix 1 packet in 8 ounces of fluid and take by mouth once a day for 7 days. Individual #1 was administered the MiraLAX Powder from 2/1/21 through 2/23/21 at 8:00 PM. Individual #1 is prescribed Naproxen, 250 mg, take 1 tablet by mouth with food or milk twice a day as needed for menstrual pains for 14 days. Individual #1 was administered the Naproxen on 2/3/21, 2/4/21, 2/5/21, 2/6/21, 2/7/21, 2/8/21, 2/10/21, 2/11/21, 2/12/21, 2/13/21, 2/14/21, 2/15/21, 2/17/21, 2/18/21, 2/19/21, 2/20/21, 2/21/21, 2/22/21 and 2/24/21.A prescription medication shall be administered as prescribed.Individual #1 medication administration record was updated to reflect only the specified days allowed. Signage was posted as reminder within the home regarding prn medications. Staff had a refresher on individual#1 meds, their diagnosis, time given, med errors, what to do if there is an error. The director (new hire) was also signed up for med administration class and the goal is to have him do the med trainer class, to have additional med trainers and observers onsite. Staff were also trained on the revised overnight checks of medication and medication administration. 02/25/2021 Implemented
6400.165(g)Individual #1 is prescribed Olanzapine (Zyprexa), 5 mg, take one tablet by mouth nightly (bedtime) and Prozac (Fluoxetine), 40 mg, take 1 capsule by mouth every morning to treat symptoms of a psychiatric illness. Individual #1 has not had a review of the medication prescribed to treat symptoms of the psychiatric illness. [Repeat Violation-11/13/19; et al]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.Individual # 1 did not complete her scheduled medication review within the 3-month period as specified by regulations. The program director and PC were trained on the regulation. The program Director reached out to the doctor¿s office and the next scheduled appointment for individual #1 Psyche is scheduled for 3/16/2021. The director and PC will utilize the PC checklist, which will be updated monthly with current and upcoming appointments 02/26/2021 Implemented
6400.166(a)(11)Individual #1's February 2021 medication administration record did not include a diagnosis or purpose for the following medications: Miralax Powder; Multivitamin; Olanzapine, 5 mg, and Prozac, 40 mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1 medication administration record was updated, per the doctor¿s feedback, to reflect the diagnosis or purpose for all medications. The Program Director and Assistant operations director were retrained on the regulations pertaining to diagnosis on medication administration record. 02/26/2021 Implemented
6400.213(7)The most recent invitation to an annual ISP meeting on 7/10/19 was included in Individual #1's record.Each individual's record must include the following information: Individual plan documents as required by this chapter.Individual #1 most recent annual ISP invitation was not included and or available for licensing and due to this the Program Specialist was retrained on the regulations. The PS reached out to the Supports coordinator to introduce the new management staff and to request nay prior copies for ISP invite letters and, ensure that he is on the contact list moving forward for all ISP invites 03/10/2021 Implemented
SIN-00166898 Renewal 11/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Program Specialist #1, date of hire 6/3/19, does not have a physical examination. 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. New Hire Staffing checklist will be completed prior to staff hire and all documents needed (ie.- physical/tb) and checked off- staff was retrained on the new hire checklist process. JS has on file physical with updated TB [Program Specialist #1 had a physical examination including tuberculin skin testing completed on 5/23/19. All staff persons' files were reviewed on 11/20/19 for annual physical examinations and tuberculin testing by the administrative team in each region. At least quarterly, 5 to 10 % of staff files will be randomly selected and checked by the administrative team per region to ensure all staff persons have physical examinations completed timely and are available for review upon request by the Department. (DPOC by AES,HSLS on 1/2/20)] 12/30/2019 Implemented
6400.151(c)(2)Program Specialist #1, date of hire 6/3/19 does not have a Tuberculin testing. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. New Hire Staffing checklist will be completed prior to staff hire and all documents needed (ie.- physical/tb) and checked- staff was retrained on the new hire checklist process. JS has on file physical with updated TB [Program Specialist #1 had a physical examination including tuberculin skin testing completed on 5/23/19. All staff persons' files were reviewed on 11/20/19 for annual physical examinations and tuberculin testing by the administrative team in each region. At least quarterly, 5 to 10 % of staff files will be randomly selected and checked by the administrative team per region to ensure all staff persons have physical examinations completed timely and are available for review upon request by the Department. (DPOC by AES,HSLS on 1/2/20)] 12/30/2019 Implemented
SIN-00146718 Renewal 11/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)There was not a smoke detector in 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. During the licensing visit, smoke detector was at the top of the basement steps and was relocated to the basement area on 12/3/18 by the washer and dryer on the wall by the bathroom. The house will have 1 to 2 house safety checks conducted by the lead staff and or manager and the fire extinguishers will be checked for placement and functionality. This check will also occur during the monthly fire drills . The location of the smoke detectors was noted on the firedrill 12/28/18 and the safety check 12/17/18 of the site. and will be ongoing. [At least quarterly for 1 year, the CEO or designee shall audit monthly fire drill and safety check documentation to ensure completion and that all homes have operable smoke detectors on each floor of the home. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/4/19)] 12/03/2018 Implemented
6400.181(a)Individual #1, date of admission 2/26/18 had an initial assessment completed on 04/30/18. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. All program specialist will be retrained on the time frame for completion of initial assessment of all new individuals and the schedule of all consumer assessments on going . The Program specialist will also maintain a tracking calendar which will be reviewed by the director monthly. [Documentation of the aforementioned trainings shall be kept. Documentation of aforementioned monthly reviews shall be kept. (DPOC by AES,HSLS 2/4/19)] 12/05/2018 Implemented
SIN-00126572 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination completed on 7/22/17 did not include medical information pertinent to diagnoses and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. As of 1/4/18 the Regional Manager was made aware that any future new admissions must have a CareSense Living individual physical form completed and reviewed by the Program Specialist prior to admission so as to avoid having sections not documented or completed that are necessary. [Individual #1's physical examination was updated on 2/2/18 to address medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and upon completion of individuals' physical examinations, the program specialist and the regional manager shall audit individuals' current physical examinations to ensure all required information as per 6400.141(c)(1)-(15) is included and there are not any areas of required information left blank. Missing information shall be immediately obtained. Documentation of audits shall be kept. (AS 2/20/18)] 01/04/2018 Implemented
6400.164(b)On 12/24/17, Individual #2 began staying with a family member. Individual #2 is prescribed the following medications: Tegretol 200 mg twice daily, Levothyroxine 125 mcg once daily, Pentasa 500 mg once daily, Pantoprazole 40 mg once daily, Dicyclomine 10 mg four times a day, Omeprazole 20 mg twice daily, Carafate 100 mg/10 ml twice daily, and aspirin 81 mg once daily. From 12/24/17 to 12/28/17, Individual #2's December 2017 Medication Administration Record was not logged as prescribed medications were administered to Individual #2 or if the prescribed medications were taken with him/her. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. CareSense Living utilizes an electronic MAR system. When individual #2 is out of program with her family there has been no way to document on her electronic MAR that her medications were not administered by staff. On 1/4/18 the Program Specialist created a paper MAR form for individual #2 that was sent to the house. When individual #2 is out of program staff will document this on the paper MAR so as to have a tracking system of medication administration during this time period. A new MAR will be generated each month and put in the home. [Four staff persons were trained on 1/11/18, topic of training: ''the paper MAR should be completed for each dosage time when [Individual #2] is out of program.'' At least weekly for 1 month and then continuing at least monthly, a staff person qualified to administer medications or a certified medication trainer shall audit individual #2's medication administration records and all other individuals' medication administration records, prescribed medications and doctors' orders to ensure all individuals are being administered medications as prescribed and administration is documented as required. Documentation of audits shall be kept. (AS 2/20/18)] 01/04/2018 Implemented
6400.186(e)The program specialist did not notify all of Individual #2's plan team members including the adult training facility of the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The Program Specialist has modified the ISP review letter to reflect all team members¿ ability to decline receiving the ISP review. This was completed on 1/4/18 and will be the letter utilized by the Program Specialist from this point forward when sending out the ISP reviews. [Program specialist provided the option to decline notification to the plan team members for Individual #2 with the quarterly review on 11/15/17. Immediately and biannually, the regional manager shall audit all individuals' records to ensure the program specialist notified all individuals' plan team members of the option to decline ISP review documentation and documentation is maintained. (AS 2/20/18)] 01/04/2018 Implemented
SIN-00106396 Initial review 01/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 9:31 AM, the hot water temperature in the bathtub in the bathroom on the main level of the home measured 132.0°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Home manager will ensure that the water temperature is lowered in the water heater below 120 degrees F by 1/18/17. Direct care staff will check water temperature daily to ensure acceptable temperature. Home manager will train staff to ensure compliance. [On 1/17/17, the house manager adjusted the water temperature and measured the water temperature which then the hot water did not exceed 120°F. Immediately, the house manager will develop measurement of hot water procedures and a documentation system to record hot water temperatures. Prior to staff persons being assigned the duty to measure hot water temperatures, they will be trained that the hot water temperatures may not exceed 120°F at the bathtubs or showers in the home, on the procedures to measure hot water temperature to ensure an accurate reading and documentation procedures of measurements. Immediately, and at least weekly for at least 3 months after individuals are admitted and continuing at least monthly thereafter, the house manager or designated trained staff person will measure the hot water temperature in all bathtubs and showers to ensure the hot water temperatures does not exceed 120°F. Documentation of trainings shall be kept. At least quarterly the house manager will review the documentation to ensure measurements are completed and hot water temperatures in bathtubs and showers do not exceed 120°F. (AS 1/17/17)] 01/27/2017 Implemented
6400.81(k)(6)Bedrooms #1, #2, and #3 do not have mirrors. In bedrooms, each individual shall have the following: A mirror. Home manager will ensure that mirrors are placed in all bedrooms by 1/18/17. Home manager will check bedrooms periodically to ensure mirrors are present and will train staff to ensure compliance. [On 1/18/17, the house manager purchase mirrors for each of the bedrooms and delivered to the home. Prior to individuals moving into the home, the house manager shall secure each mirror in each bedroom. Prior to all staff persons working in the home, the staff shall be educated on what each bedroom shall include as per 6400.81(k)(1)-(6) and to check for items throughout the course of their duties. (AS 1/18/17)] 01/18/2017 Implemented
6400.82(e)The bathtub in the bathroom on the main level did not have a nonslip surface or mat.Bathtubs and showers shall have a nonslip surface or mat.Home manager will ensure that a non slip mat is installed in the bathroom by 1/18/17. Home manager will check bathrooms periodically to ensure presence of non slip mat and will train staff to ensure non slip mats are always present.[On 1/18/17, the house manager purchased and placed a nonslip mat in the bathtub of the home. Prior to staff persons working in the home they shall be educated by the house manager as to the required items in bathrooms as per 6400.82(e)-(g) and to check for these items throughout the course of their daily duties. (AS 1/18/17)] 01/18/2017 Implemented
6400.101The door leading from the kitchen to the back yard of the home was equipped with a dead bolt lock requiring a key to unlock from inside the home. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Home manager will ensure that the door lock is replaced with a lock that does not require a key to unlock from the inside by 1/18/17. Home manager will check home doors annually to ensure compliance and will train staff to ensure compliance. [On 1/18/17, the house manager purchased and installed a locking mechanism that can be opened without the use of a key from inside the home. Prior to staff persons working in the homes, staff person shall be trained that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to check for obstructions throughout the course of their duties. (AS 1/18/17)] 01/18/2017 Implemented
SIN-00223829 Unannounced Monitoring 04/27/2023 Compliant - Finalized