Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228030 Renewal 07/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace inspection completed 1/06/2022 and then again 6/16/2023.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. Staff (lead staff) were trained on 8/7/23 regarding the importance of ensuring that the 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. 08/07/2023 Implemented
6400.171On 7/13/2023, there was a 20oz bottle of Hellmann's Mayonnaise in the refrigerator, with a best if used by date of 4/10/2023 ("Repeated Violation-11/01/2022, et al").Food shall be protected from contamination while being stored, prepared, transported and served. On 7/14/23 and 8/7/23 staff were trained on the importance of ensuring that Food shall be protected from contamination while being stored, prepared, transported and served. an inventory of current food and expirations within all homes were completed and checked for compliance. 08/14/2023 Implemented
6400.181(f)Individual #1's assessment, completed 4/23/2022, was not sent to the plan team prior to the individual support plan meeting 5/30/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.on 8/3/23 - The program specialist was retrained on the importance of providing the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. He was also trained on who needs to be included on the email and the assessment due dates were also reviewed and calendar appointments made as reminders to send. 08/03/2023 Implemented
SIN-00223822 Unannounced Monitoring 04/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)On 4/27/2023 the wall behind the first-floor bathroom sink, had a large horizontal crack approximately 1/2 inch wide and 2 feet long above where the paneling ends (Repeated Violation 9/20/2022 and 12/15/2022, et al). Floors, walls, ceilings and other surfaces shall be free of hazards.On 5/2/23 all direct care staff were retained on the importance of floors, walls and ceilings being in good repair and how to report when follow up repair is needed. The contractor was contacted to assess all floors walls and ceiling and visited the home to assess the repair to the wall on 5/5/23, per his availability he will be fixing the items that are not in good repair on 5/20/23 and finish on 5/27/23. On 5/1/23 the Residential director was retrained on what is needed to complete compliance checks of the homes and why its important that floors walls and ceiling should be in good repair within the homes. 05/02/2023 Implemented
6400.72(b)On 4/27/2023 the frame around the window screen in the first-floor bathroom was cracked and broken causing a whole that could allow bugs to enter and the screen in the window in the bedroom on the first floor had several small holes in it that could allow buts to enter (Repeated Violation 8/15/2022 and 12/15/2022, et al). Screens, windows and doors shall be in good repair. On 5/2/23 all direct care staff were retained on the importance of screens, windows and doors shall be in good repair . On 5/5/23 the contractor visited the home to assess the screens and will place an order for more appropriate screens to fit the window , per his availability he will be fixing the items that are not in good repair on 5/20/23 and finish on 5/27/23. On 5/1/23 the Residential director was retrained on what is needed to complete compliance checks of the homes and why it's important that screens windows and doors should be in good repair within the homes. 05/02/2023 Implemented
6400.73(a)On 4/27/2023 the handrail from the back yard to the garage door and driveway was wobbly and not secure (Repeated Violation 8/15/2022, et al). Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 5/2/23 all direct care staff were retained on the importance of having each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 5/5/23 the contractor visited the home to assess the exterior handrail and will order supplies to repair the rail. Per his availability he will be fixing the items that are not in good repair on 5/20/23 and finish on 5/27/23. On 5/1/23 the Residential director was retrained on what is needed to complete compliance checks of the homes and why its important that the handrail/ramps is in good repair within and outside of the homes. 05/09/2023 Implemented
6400.76(a)On 4/27/2023 the blinds on Individual #1's bedroom window were bent, had broken panels, and had two tacks sticking out of the blinds (Repeated Violation 9/20/2022, et al). Furniture and equipment shall be nonhazardous, clean and sturdy. On 5/2/23 all direct care staff were retained on the importance of having furniture and equipment shall be nonhazardous, clean and sturdy. New rods and drapery were purchased and will be installed by 5/17/23. On 5/1/23 the Residential director was retrained on what is needed to complete compliance checks of the homes and why its important that furniture and equipment shall be nonhazardous, clean and sturdy. . 05/17/2023 Implemented
6400.101On 4/27/2023 the exit door from the living room to the side of the home had a dead bolt lock which stuck in place and was difficult to open, taking multiple people several attempts to open (Repeated Violation 9/20/2022, et al).Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 5/2/23 all direct care staff were retained on the importance of having each Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 5/1/23 the contractor visited the home to assess the door and replaced the lock by 5/1/23. On 5/1/23 the Residential director was retrained on what is needed to complete compliance checks of the homes and why it is important that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 05/01/2023 Implemented
SIN-00216578 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom on the first floor, across from the staircase descending to the basement, had an exhaust fan covered in dust and debris "Repeated Violation- 8/15/2022, et al".Clean and sanitary conditions shall be maintained in the home. on 12/19/2023 (direct care/program specialist /director of residential) were retrained on the importance of keeping a clean and sanitary residential home. On 1/9/2023 the exhaust fan was re-cleaned once the construction work was competed in the bathroom. 01/16/2023 Implemented
6400.72(a)The bathroom on the first floor, across from the staircase descending to the basement, had a window with a removable screen covering only half of the window and was not secure "Repeated Violation- 9/20/2022, et al".Windows, including windows in doors, shall be securely screened when windows or doors are open. on 12/19/2023 (direct care/program specialist /director of residential) were retrained on the importance of keeping Windows, including windows in doors, securely screened when windows or doors are open. maintenance man is scheduled to come to the site on 1/10/23 to complete the work. 01/10/2023 Implemented
6400.72(b)The doorknob on the door leading from the basement to the garage was not secured [Repeated Violation- 3/17/2022, et al]. Screens, windows and doors shall be in good repair. on 12/19/2023 (direct care/program specialist /director of residential) were retrained on the importance of keeping screens, windows and doors shall be in good repair. maintenance man is scheduled to come to the site on 1/10/23 to complete the work on the doorknob replacement 01/16/2023 Implemented
6400.112(a)There was no fire drill conducted in August 2022. An unannounced fire drill shall be held at least once a month. all staff (direct care/program specialist/director of residential) on 1.6.2023 had refresher fire drill training which reviewed the importance of completing an unannounced drill monthly basis 01/06/2023 Implemented
6400.181(e)(12)Individual #1's assessment completed 4/23/2022 did not include recommendations for specific areas of training, programming and services. It states not applicable.The assessment must include the following information: Recommendations for specific areas of training, programming and services. on 12/19/22- Staff (program specialist and director of residential) were retrained on the due dates, importance of assessments, sign off on assessments and per the assessment recommendations for specific areas of training, programming and services for the individual. the 4.23.22 assessment was updated to include Recommendations for specific areas of training, programming and services and this reviewed for compliance by the director of residential and director of operations 1/9/2023 01/09/2023 Implemented
6400.34(a)Individual #1 was informed of their individual rights and the document did not contain a date that the rights were reviewed. Therefore, compliance could not be measured.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.on 12/19/2023 (direct care/program specialist /director of residential) were retrained on the importance of ensuring that 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. the individual rights were updated to reflect the correct date completed 12/19/2022 Implemented
6400.165(g)Individual #1's psychiatric medication reviews completed 4/06/2022, 7/27/2022, and 11/22/2022 were not signed by a licensed physician. Individual #1's psychiatric medication reviews completed 7/27/2022 and 11/22/2022 did not include the current medications or need to continue the medications "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 completing a psyche medication review, documentation involved, frequency and the importance of a licensed physical completing the psyche review and components to be filled out. 12/19/2022 Implemented
SIN-00210425 Unannounced Monitoring 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 11:51 AM on 8/15/22, baked on grease and chards on food particles were found on the bottom inside the oven as well as the interior glass of the oven door. Additionally, a pot of frying oil was resting on top of several baking sheets inside the oven.Clean and sanitary conditions shall be maintained in the home. Oven was deep cleaned the day of the unannounced inspection on 8/15/22. On 8/15/22 - Staff were retrained on the acceptable level of clean and sanitary conditions that should be maintained in the home. Director was retrained on 8/15/22 and 8/31/22 on the concern referenced. 08/31/2022 Implemented
6400.64(f)At 11:35 AM on 8/15/22, a large, black outdoor trashcan was found at the end of the driveway with an unclosed lid and garbage bags protruding from the top. Additionally, a garbage bag was found on the ground leaning against the garbage can.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Additional 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
6400.66On 8/15/22 at 12:05 PM, the rear exit door off the living room was observed without an outside light source in the area. The laundry area next furnace and hot water tank in the basement did not have sufficient lighting. The only ceiling light fixture in the area was found inoperable at 12:25 PM on 8/15/22. The basement's only outside exit was found with an inoperable light at 12:25 PM on 8/15/22. [Repeat violation from 3/17/22.]Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 8/15/22, Light bulbs were installed in the basement light fixture and currently operates, and sufficient lighting is available. outdoor solar lights were purchased and additional lights for ground will be purchase on 9/15/22 in order to provide a lights source outside the living door area. 09/15/2022 Implemented
6400.67(a)On 8/15/22 at 11:59 AM, the tub drain in the full bathroom on the main level off of the kitchen was discovered obstructed with hair and other debris causing water to back up in the tub. [Repeat violation from 3/17/22.]Floors, walls, ceilings and other surfaces shall be in good repair. The tub and the slow drain were fixed by the handyman on site on 8/20/22. The direct care staff and director of operations (MS) were trained on 8/15/22 on the importance of checking floors, walls and ceiling and tubs and if not in good repair, reporting the issue to management so that follow up and occur. 09/16/2022 Implemented
6400.73(a)The outdoor railing on the main walkway leading to the front door that includes 3 steps was discovered loose, wobbly, and unsecured at 11:37 AM 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 was installed on 9/13/22. 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. 09/13/1922 Implemented
6400.80(b)At 11:37 AM on 8/15/22, weeds and vegetation, measuring 3-4 ft. in height were found along the driveway's edge meeting the front yard's retaining wall. 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 18,2022. 08/18/2022 Implemented
6400.111(f)On 8/15/22 at 12:30 PM, the basement was observed lacking a fire extinguisher. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguisher was installed on 8/17/22 in the basement by ABC fire extinguisher. a fire drill was conducted for the month of august for the day of the install and no issues or concerns reported. On 8/15/2022 - all direct care staff and director of residential (MS) were trained on the importance of having a fire extinguisher inspected yearly by a fire expert and making sure one is on every level of the home. 08/17/2022 Implemented
6400.214(a)The following records for Individual #1 were not located onsite at 1:11 PM on 8/15/22: personal, demographic information, including their name, sex, admission date, birthdate and Social Security number. [Repeat 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 books are onsite, and readily available with personal info, demographic info, etc. on 8/15/22 - Staff and director of residential were trained on the importance of keeping an UpToDate program book onsite at the homes and what components should be onsite within it. 09/13/2022 Implemented
6400.214(b)The following most recent records for Individual #1 were not located onsite at 1:11 PM on 8/15/22: incident reports and functional assessments. 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 books are onsite, and readily available with incident reports/functional assessments, etc on 8/15/22 - Staff and director of residential were trained on the importance of keeping an UpToDate program book onsite at the homes and what components should be onsite within it. 09/13/2022 Implemented
6400.166(a)(11)On 8/15/22, Individual #2's August 2022 Medication Administration Record was missing the diagnosis or purpose for the prescribed Lisinopril (5 mg tab), Aripiprazole (10 mg tab), Carbamazepine ER (300 mg cap), Cholecalciferol (50 mcg; 2000IU), and Citalopram (20 mg tab). [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 diagnosis or purpose for the prescribed medication. on 8/15/22- staff were retrained om the importance of having the purpose 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 om 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. 09/18/2022 Implemented
SIN-00202068 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
6400.73(a)During the onsite inspection on 3/18/2022 the black handrail to the right of the steps outside of the home leading to the front entrance, was loose and not secure. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The hand rail was secured by a handy man/maintenance guy on 4/29/2022, he added additional screws/bolts to stabilize the railing. staff were retrained on ensuring that all ramps, handrails connected to interior/exterior stairways exceeding two steps should be secured properly 04/28/2022 Not Implemented
6400.101During the onsite inspection on 3/18/2022 a door leading to the garage was identified with a turn lock on the outside of the door which when engaged would allow someone to be locked inside of the garage. There is no man door leading to the outside from in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. direct care staff were retrained on the importance of checking, reporting and correcting any possible obstructions in located Stairways, halls, doorways, passageways and exits from rooms and from the building, all of which should clear and accessible . The garage door lock was fixed . 04/28/2022 Not Implemented
6400.141(c)(1)Individual #1's physical examination completed 5/25/2021 did not include: A review of previous medical history.The physical examination shall include: A review of previous medical history. Staff were retrained on medical appointments process and all documentation required for annual physical and and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his previous medical history was documented. 04/28/2022 Implemented
6400.141(c)(4)Individual #1's physical examination completed 5/25/2021 did not include: A vision or hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his vison and hearing screening was documented. 04/28/2022 Implemented
6400.141(c)(5)Individual #1's physical examination completed 5/25/2021 did not include: ImmunizationsThe physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his immunizations were documented. 04/28/2022 Implemented
6400.141(c)(11)Individual #1's physical examination completed 5/25/2021 did not include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.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. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his health maintenance needs were documented. 04/28/2022 Implemented
6400.141(c)(12)Individual #1's physical examination completed 5/25/2021 did not include: Physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his physical limitations were documented. 04/28/2022 Implemented
6400.141(c)(14)Individual #1's physical examination completed 5/25/2021 did 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. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his medical information pertinent to diagnosis and treatment in case of an emergency was documented. 04/28/2022 Implemented
6400.141(c)(15)Individual #1's physical examination completed 5/25/2021 did not include: Special instructions for the individual's diet.The physical examination shall include: Special instructions for the individual's diet.Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. Individual #1 completed a new physical on 4/20/22 and his diet was documented. 04/28/2022 Implemented
6400.32(r)Individual #1 was informed of his individual rights and requested lock on his bedroom door on 2/23/2022, and during the on-site inspection conducted 3/18/2022, Individual #1's bedroom did not contain a lock.An individual has the right to lock the individual's bedroom door.Staff ( direct care/program specialist /director of residential ) were retrained on clients' rights including a client right to lock his or her bedroom door. The lock on the bedroom door for individual #1 was updated and he now has a key for his bedroom door. 04/28/2022 Implemented
6400.166(a)(4)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Names of medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.CareSense Living new client admission, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance. admissions coordinator checklist was updates to include a medication intake check off. His Mar was updated 04/28/2022 Implemented
6400.166(a)(5)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Strength of medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight, and the strength of the medications were not listed. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance.His Mar was updated . 04/28/2022 Not Implemented
6400.166(a)(6)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Dosage forms.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight, and the dosage forms of the medications were not listed. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance. His MAR was updated 04/28/2022 Implemented
6400.166(a)(7)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Dose of medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight, and the dose of the medications were not listed. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance. His Mar was updated. 04/28/2022 Not Implemented
6400.166(a)(8)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Routes of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight, and the routes of the medications were not listed. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance. His MAR has been updated . 04/28/2022 Implemented
6400.166(a)(9)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Frequency of administrations.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight, and the frequency of the medications were not listed. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance. 04/28/2022 Implemented
6400.166(a)(11)Individual #1 is prescribed Mapap 325mg tablet, take by mouth 2 tablets every 4-6 hours as needed for pain, not to exceed 3 doses in 24 hours. Individual #1 is prescribed Ibuprofen 800mg tablet, take 1 tab by mouth every 6-8 hours as needed for pain with food. During the inspection on 3/18/2022, Individual #1's March 2022 medication administration record did not include: Diagnosis or purpose for the medications.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.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication added to the MAR which was an oversight, and the diagnosis or purpose of the medications were not listed. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance. his mar has been updated 04/28/2022 Not Implemented
6400.167(a)(1)Individual #1 is prescribed Clozapine 100mg, take by mouth 3 tablets at bedtime, and Clozapine 50mg, take by mouth 1 tablet at bedtime. On 3/17/2022 the 8pm administration of both medications was not administered.Medication errors include the following: Failure to administer a medication.CareSense Living new client, Individual #1, at the time of the inspection did not have all his medication in available to him because his initial medication that he moved in with had a limited supply and had just run out and the previous pharmacy was not able to supply it in a timely manner. The new pharmacy (Medicine shoppe) was able to supply the medication as of 3/18/22 and gave a 30-day supply. Staff (direct care and director) was retrained on reviewing the MAR for accuracy/completion and compliance and reviewed reporting of medication errors and or time frame to report when a dosage is low , in order avoid errors. 04/28/2022 Implemented
SIN-00183647 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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
6400.110(e)At 1:50 PM 2/24/21, the smoke detector located in the basement of the home was not interconnected and audible throughout the home. This home has three stories including a basement and two residential stories.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. On 2/25/2021- the interconnected smoke detectors we reinstalled and new batteries placed within the smoke detector and a fire drill was conducted by the director of operations . To avoid safety issues, all unoccupied homes for CareSense will have monthly fire drills completed by a management staff fin order to check that all smoke detectors are working appropriately, regardless if clients are occupying the home. Additionally, back up interconnected smoke detectors were purchased and will be kept in the main office if there is ever a faulty detector detected, that needs more than just a battery replacement. 02/25/2021 Implemented
6400.151(a)Direct Service Worker #1 had a physical examination completed on 7/28/17 and then again on 10/23/19. [Repeat Violation-11/13/19; 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. Program director and assistant director were retrained on the regulations ( annual physical frequency for staff) and a tracking system updated in kaliedacare program and ClearCare system that will send reminders out to staff and supervisor, to when their physicals and or tb are about to expire 03/10/2021 Implemented
SIN-00166900 Renewal 11/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was most recently inspected on 9/11/17.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. Furnace was inspected on 11/27/19 by Restano heating and monthly house checks have been updated to reflect furnace inspection check off . Training completed on 11/15/19 with Regional manager and Program supervisor on the importance and regulatory standard for complaint furnace inspections . [Immediately, the CEO or designee shall develop and implement a tracking and scheduling system to ensure timely completion of furnace inspections and cleanings at all community homes and train responsible staff person of the system. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/2/20)] 11/27/2019 Implemented
6400.141(a)Individual #1 had a physical examination completed on 2/12/18 and then again on 4/4/19.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. On 11/15/19 - Regional Manager and Program supervisor were retrained on the requirements that indicate a complete Physical exam for individuals, per regulations (ie ¿ all sections completed in full/free of communicable diseases/ vision and hearing section completed) On 12/18/19 - Direct care staff were retrained on compliance standards that should be met for having a completed physical for CSL indiduals, per regulations. On 1/10/20, Individual #1 PCP will complete the missing sections of the annual physical. [At least monthly, the CEO or designee shall audit the medical calendar tracker to ensure timely completion of all individuals' physical examinations. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/2/20] 01/10/2020 Implemented
6400.141(c)(4)The physical examination, completed 4/4/19 for Individual #1 did not include a hearing screening. This section of the form was blank.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. On 11/15/19 - Regional Manager and Program supervisor were retrained on the requirements that indicate a complete Physical exam for individuals, per regulations (ie ¿ all sections completed in full/free of communicable diseases/ vision and hearing section completed) On 12/18/19 - Direct care staff were retrained on compliance standards that should be met for having a completed annual physical for CSL indiduals, per regulations. On 1/10/20, Individual #1 PCP will complete the missing sections of the annual physical. [At least monthly, the CEO or designee shall audit all individuals' physical examinations completed within the month to ensure all required information is included and referenced documentation is attached and there are not any required areas left blank. Missing information shall be immediately obtained by the assigned program coordinator. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/2/20] 01/10/2020 Implemented
6400.141(c)(10)The physical examination completed on 4/4/19 for Individual #1 does not address communicable disease. This section of the form was blank.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. On 11/15/19 - Regional Manager and Program supervisor were retrained on the requirements that indicate a complete Physical exam for individuals, per regulations (ie ¿ all sections completed in full/free of communicable diseases/ vision and hearing section completed) On 12/18/19 - Direct care staff were retrained on compliance standards that should be met for having a completed annual physical for CSL indiduals, per regulations. On 1/10/20, Individual #1 PCP will complete the missing sections of the annual physical.[At least monthly, the CEO or designee shall audit all individuals' physical examinations completed within the month to ensure all required information is included and referenced documentation is attached and there are not any required areas left blank. Missing information shall be immediately obtained by the assigned program coordinator. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/2/20] 01/10/2020 Implemented
SIN-00146720 Renewal 11/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Direct Service Worker #1, date of hire 6/22/17, had annual fire safety training on 8/28/17 and then again 9/22/18.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Staff were retrained on the initial and annual trainings due which included fire safety as well as the importance of adhering to compliance deadlines. Staff trainings will be tracked and reviewed monthly by the Manager and Director. [Documentation of the monthly reviews of staff trainings by the manager and the director shall be kept. (DPOC by AES,HSLS on 2/4/19)] 12/15/2018 Implemented
6400.68(b)The hot water temperature measured 141 degrees Fahrenheit at the bath tub in the bathroom on the main level of the home at 1:30PM. (repeated violation et al 12/28/17.) Hot water temperatures in bathtubs and showers may not exceed 120°F. Staff retrained on the fire drill process and documentation of the temperature and reporting procedures if concerns found. Temperature was turned down on the hot water heater .Staff will document water temp during biweekly/monthly house checks and during fire drills. [Immediately and continuing at least weekly for 3 months and then continuing at least monthly as long as the hot water temperature does not exceed 120°F during any of the measurements, a designated staff person trained in measuring, documenting and adjusting hot water temperatures, shall measure hot water temperatures at all community homes. Documentation of measurements shall be kept and reviewed by the CEO or designated management staff person at least quarterly. (DPOC by AES,HSLS on 2/4/19)] 12/27/1918 Implemented
6400.110(c)There was not a smoke detector located in the common area or hallway on the first floor of the home.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. Smoke detectors were moved to the common areas o the hallway. [At least monthly and upon opening a new home, the CEO or designee shall ensure all smoke detectors are located in common areas or hallways as required. Documentation of the monthly checks shall be kept. 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)] 12/05/2018 Implemented
6400.110(e)The smoke detectors (in the basement, first, and second floor) were not interconnected at 1:40PM.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. Interconnected smoke detector was purchased and installed onsite ( 3) [At least monthly and upon opening a new home, the CEO or designee shall ensure all smoke detectors are interconnected as required. Documentation of the monthly checks shall be kept. 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 interconnected smoke detectors as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/4/19)] 12/17/2018 Implemented
6400.112(d)The fire drill held on 03/16/18 at 03:47PM had an evacuation time of 3 minutes 49 seconds. The home does not have an extended evacuation time. 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. Staff were retrained o the fire drill process and the time frame for evacuation. Fire drills will be turned in by the 15th of the month to give time to review( manager/director) , correct any errors and or re-run a drill. [NOT ACCEPTABLE, unannounced fire drills must be completed throughout the each month, and not by the 15th of each month. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure unannounced fire drills are conducted monthly as required including within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. Prior to conducting fire drills, the CEO or designee shall train all staff persons responsible for conducting fire drills of the requirements as per 6400.112(a)-(I) and the aforementioned policies and procedures to ensure fire drills are conducted and documented as required. Upon completion of all fire drills for at least one year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 2/4/19)] 12/31/2018 Implemented
SIN-00126575 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 12/28/17, at 10:54 AM, the hot water temperature in bathtub in the bathroom on the first floor of the home measured at 123.9 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. There is currently no one living in this home. Prior to individuals residing in the home the water temperature will be assured to be below 120 degrees. Once individuals are living in the home the water temperature will be checked weekly by Lead staff and monthly when the house fire drill is conducted. The temperature will be recorded weekly on the community home checklist and monthly on the fire drill form. [Immediately and prior to individual's moving into the home, the CEO or designee shall measure the water temperature and adjust to ensure the water temperature at all bathtubs and showers does not exceed 120°F. Immediately, all staff persons responsible for completing the water temperature checks shall be trained in the aforementioned procedures by the CEO or designated management staff person. Documentation of the training shall be kept. At least monthly for 1 year and then continuing at least quarterly, the CEO or designee shall audits the aforementioned documentation of weekly and monthly checks to ensure completion and that the hot water temperature in all community homes does not exceed 120°F. Documentation of all audits shall be kept. (AS 2/20/18)] 01/04/2018 Implemented
SIN-00214188 Unannounced Monitoring 11/01/2022 Compliant - Finalized