Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235022 Unannounced Monitoring 11/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)On 11/16/2023 at 11:38 AM, the automatic smoke detector in the basement of the home was inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Immediately upon its discovery, maintenance reinstalled batteries to the device. Once the installation was complete a test was performed to ensure all detectors in the home were in sync and operable. 11/29/2023 Implemented
SIN-00215111 Unannounced Monitoring 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The three concrete outside steps, to the right of the porch in the back of the home, do not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. While participating in an unannounced inspection held by licensing reps on 11/21/2022, it appeared that the outside steps located on the right side of the residence exceeded two steps and required a handrail, this was due to the walkway cutting off after the second step. As a result of this, the agency's maintenance team was instructed to correct the 2 steps with cement and create a new walkway by extending it to allow an additional walk space in the event of an unexpected evacuation. 11/29/2022 Implemented
6400.80(b)There is a flexible downspout drainpipe across the top of the outside steps to the right of the porch in the rear of the home. There are two broken pieces of what appears to be broken concrete or rock approximately 6 to 9 inches in diameter at either end of the middle step of the three outside steps. In addition, there is broken and cracked concrete and various sizes of broken concrete bricks and rocks along the route to the front of the home. These conditions outside of the home pose serious risks of tripping and falling. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.While participating in an unannounced inspection held by licensing reps on 11/21/2022, it was discovered that items located in the backyard of the Lincoln Avenue Ext residence could pose a possible fall risk. After the discovery of these items, the agency's maintenance team was notified and instructed to remove and correct all items that would pose a safety hazard. The agency's maintenance team reported to the residence to begin repairs after licensing reps departed from residence on 11/21/22 12/09/2022 Implemented
SIN-00213952 Unannounced Monitoring 10/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)On 8/20/2022, the provider purchased items, reportedly, for Individual #1's birthday party to be later reimbursed for by Individual #1's representative payee. The items purchases includes, but are not limited to: a four pound pack of sugar, Ground Cinnamon, three foil pans, plastic plates, plastic cups, three gift bags, plastic cutlery, a tablecover, a pack of napkins, paper towels, shopping bags, Kingsford Match Light Briquets, aluminum foil and various food items including bananas.Individual funds and property shall be used for the individual's benefit. Upon discovery of the violation, The agency's Operations Manager notified the rep payee of the error and informed the rep payee that the agency will not require reimbursement for the listed purchases. The rep payee was also informed to provide personal funds in advance, on a monthly or as needed basis. On 11/07/2022 personal funds were provided by the individual's rep payee and dispersed to the residence. A personal expense sheet for the current month was also provided for staff members to track and document the individual¿s personal expenses. 12/12/2022 Implemented
6400.22(d)(1)On 10/24/2022, Operations Manager #1 reported that the provider purchases items for Individual #1 and then sends a reimbursement request to his Representative Payee. Operations Manager #1 had a "cash on hand report" with a list of business and amount spent at each location on her cellular telephone and showed the document to the Licensing Representatives. The provider does not keep an up-to-date financial record of funds for Individual #1 to included funds received by Individual #1's Representative Payee.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Upon discovery of violation 6400.22.(d)(1), The agency's Operations Manager informed the individual's rep payee that all personal funds must be sent on a monthly or as needed basis. Personal funds were collected and provided to the residence for personal usage on 11/7/2022. Staff Members were informed that all personal expenses must be documented appropriately and spent in accordance with the needs of the individual. 12/12/2022 Implemented
SIN-00211005 Unannounced Monitoring 08/26/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101There is a turn lock on the door in the kitchen of the home leading to the basement that would prevent egress from the basement when engaged. [Repeat Violation, 3/10/2022, 5/26/2022, 10/29/2021]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 08/26/22, It was discovered that the turn lock of the basement door was installed on the unintended side of the door. The turn lock to the basement door was reversed by The AHH Maintenance Team on the afternoon of 08/26/22. 08/26/2022 Not Implemented
6400.112(c)The written fire drill record for the fire drill held on 7/29/2022 does not include exact time of the fire drill, AM or PM is missing. [Repeat Violation, 3/10/2022]A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Immediately upon its discovery on 8/26/22, the missed documentation was verified and corrected by the AHH House Manager who was able to verify that exact time that the drill had been conducted. 08/26/2022 Implemented
6400.214(b)Individual #1's most current assessment and physical examination were not at the home.The most current copies of record information required in § 6400.213(2)¿(8) shall be kept at the residential home.On 08/25/22, staff members were advised to bring in all current medical records to the AHH Office for Management to review for Compliance. As a result of this, most recent records were not present at the residential home during the time of the unannounced inspection conducted by DHS Licensing reps on 08/26/22. On 8/29/22-9/2/22, all current medical records were reviewed for compliance and returned to the residential homes by the AHH Management Team on 9/2/22. 09/02/2022 Implemented
SIN-00205818 Unannounced Monitoring 05/26/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 5/26/2022, Licensing Representatives arrived at the home at 1:06PM and were told that the Direct Service Worker left to pick the individual up from school and he is the only one with a key to the staff office and Medication Administration Record and medications. They were told that the Direct Service Worker would return shortly. The Licensing Representatives departed from the home at 1:27PM and returned at 2:39PM. The Direct Service Worker still had not returned to the home with the individual and the Operations Manager could not reach him. The Licensing Representatives departed the home at 3:00PM without access to the individual's Medication Administration Record and medications preventing.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.During an unannounced inspection on 05/26/2022, it was discovered that keys to the individual¿s records, and medications were not present in the home. In the absence of the staff member The Operations Manager was able to provide access to the individual¿s medication record electronically. Once the staff member returned to the home, the keys were collected by The House Manager and provided to The Maintenance Manager to produce additional copies and allow 24/7 access to Management. Additional keys were provided to the House Manager on 05/26/2022. A medication audit was conducted by the House Manager as a weekly requirement of the agency. 07/27/2022 Implemented
6400.62(a)A bottle of Hydrogen Peroxide with warning instructions to contact poison control if ingested was unlocked and accessible in the cabinet above the sink in the bathroom of the home. Individual #1 is not assessed safe with poisons. [Repeat Violation, 7/1/2021, 10/29/2021, 12/3/2021]Poisonous materials shall be kept locked or made inaccessible to individuals. Immediately upon discovery of the Hydrogen Peroxide , the chemical was removed and discarded by the House Manager on 05/26/2022. A lock was placed on the cabinet for staff members to properly store poisonous materials by The Maintenance manager on 05/27/2022. 07/22/2022 Not Implemented
6400.64(a)The top of the inside of the microwave was splattered with food particles. [Repeat Violation, 7/1/2021, 10/29/2021, 12/3/2021]Clean and sanitary conditions shall be maintained in the home. During an unannounced inspection on 05/26/2022 it was discovered that the top of the inside of the residence microwave was splattered with food particles. Upon notification of the discovery, a microwave safe cover was purchased by The House Manager on 05/26/2022 and all staff members were instructed to cover all food items and to clean the microwave after each use. 07/08/2022 Implemented
6400.67(a)The toilet seat in the bathroom on the first floor of the home was secured to the toilet by only one of two bolts thus allowing the toilet seat to move approximately one to two inches from side to side from the toilet. [Repeat Violation, 7/1/2021, 10/29/2021, 12/3/2021]Floors, walls, ceilings and other surfaces shall be in good repair. During an unannounced inspection on 05/26/2022, it was reported that the seat to the commode of the main restroom was secured by one of two bults. After the missing bolt was discovered, the maintenance manager was notified to correct the issue. The toilet seat was safely secured with two bolts by the maintenance manager on 05/27/2022. 07/08/2022 Not Implemented
6400.71Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. During an unannounced inspection on 05/26/2022, it was discovered that the resident¿s home phone did not list emergency phone numbers. Immediately after its discovery on 05/26/2022, The House Manager reported to the residence and placed 911 on the back of the living room phone. The House Manager also provided the residence with additional labels of emergency contacts for in the future. 07/27/2022 Implemented
6400.72(b)The screen in the double window in the living room of the home has an hole approximately one and a half inches in diameter. When closed, the front door of the home has an approximately one inch gap between the base of the door and the bottom of the door frame. [Repeat Violation, 7/1/2021, 10/29/2021] Screens, windows and doors shall be in good repair. During an inspection on 05/26/2022, it was discovered that there was a hole located in the living room window screen and a 1.5-centimeter gap at the base of the front door, when closed. Immediately upon notice, the AHH maintenance manager was notified to make corrections. A new window screen was ordered, and a temporary window screen was provided to the residence on 05/26/2022 until the permanent window screen was installed. The permanent window screen has since been installed by the Maintenance Manager on 06/10/22. A weather strip was installed to the base of the front door to close the gap, on 05/27/22. The corrections were made by the Maintenance manager and AHH maintenance team. 07/08/2022 Implemented
6400.171At 1:16PM, a partially used bulk size clear plastic bag of thawed "dinosaur shaped" breaded chicken pieces, with the following instructions "Do not defrost, heat this product from frozen" were in the refrigerator in the kitchen of the home. [Repeat Violation, 12/3/2021]Food shall be protected from contamination while being stored, prepared, transported and served. While inspecting the residence on 05/26/2022, a thawed food item was located in the refrigerator. After identified, the food item was immediately discarded by the House Manager. After the disposal, The House Manager, reposted the AHH food storage policy on the front of the refrigerator for staff members to reference. The House Manager also provided a notice with instructions on food storage and preparation to staff members on 05/26/2022. 07/08/2022 Implemented
SIN-00198073 Renewal 12/16/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(3)The annual training for training year, January 1, 2020 to December 31, 2020, for Program Specialist #1 did not encompass individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 received the Individual Rights training on 1/1/21. The importance of ODP required trainings was reviewed by the agency management team. All trainings have been reviewed for clarity and timely execution. 01/01/2022 Not Implemented
6400.169(d)Direct Service Worker #2's current Medication Administration training did not include the signature page to document successful completion.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Staff #2 received an initial Medication Administration training on 2/18/19 in which the trainer signed off on the training sheet dated for 2/18/19. Staff #2 is also to receive regular medication administration observations. Staff #2 received a most recent observation on 6/17/21, which did not include the trainers signature. Upon discovery of this preliminary violation during the regulatory visit on Decemver 16, 2021, the training form was provided to the trainer to obtain her signature. On December 22, 2021, the Medication Administration training form was signed by the trainer. 12/22/2021 Not Implemented
6400.181(f)The program specialist provided Individual #1's assessment completed 1/6/2021 to the individual plan team on 1/6/2021 for the Individual Plan meeting held on 1/26/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.On December 22, 2021, a training was received by the AD on the purpose, creation, and implementation of the Annual Functional Skills Assessment. The requirement that the assessment is to be provided by an agency representative, to the individual plan team members at least 30 calendar days prior to an individual plan meeting was overemphasized at this training. 12/22/2021 Not Implemented
6400.213(7)Individual #1's record did not include a list of person who participate in the Individual Plan team meeting on 1/26/2021.Each individual's record must include the following information: Individual plan documents as required by this chapter.Upon discovery of this preliminary violation during a regulatory visit on December 16, 2021, on December 16, 2021, the OM emailed Individual #1 Supports Coordinator to request the Signature Sheet that documents the participants who attended Individual #1s ISP meeting on 1/26/21. The OM made a 2nd attempt to request this information on 1/7/22. As of date of the POC, Individual #1s Support Coordinator has not responded back to the OM with this requested documentation. 01/31/2022 Not Implemented
SIN-00235920 Renewal 12/07/2023 Compliant - Finalized
SIN-00232313 Renewal 09/26/2023 Compliant - Finalized
SIN-00223148 Unannounced Monitoring 04/20/2023 Compliant - Finalized
SIN-00219168 Unannounced Monitoring 02/09/2023 Compliant - Finalized
SIN-00209450 Unannounced Monitoring 06/09/2022 Compliant - Finalized
SIN-00189537 Unannounced Monitoring 07/01/2021 Compliant - Finalized
SIN-00186857 Renewal 04/27/2021 Compliant - Finalized