Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227434 Unannounced Monitoring 07/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Floors, walls, ceilings and other surfaces are not free of hazards. The kitchen countertop on the front right side of the sink is broken and presents a hazard. (Repeat Violation 8/25/22, 1/31/23 and 2/27/23) Floors, walls, ceilings and other surfaces shall be free of hazards.The kitchen countertop was replaced. 07/21/2023 Implemented
SIN-00225937 Unannounced Monitoring 06/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)The water temperature in the bathroom sink and the bathroom tub did not exceed 89 degrees. The home shall have hot and cold water.A home shall have hot and cold running water under pressure. Provider adjusted the hot water heater. 06/07/2023 Implemented
SIN-00223253 Unannounced Monitoring 04/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not maintained in the home. The kitchen cabinets, specifically the cabinets under the sink and to the right of the sink were covered in a grease like substance. (Repeat Violation 5/12/22, 6/21/22, 7/25/22, 8/25/22, 2/27/22, 3/21/22)Clean and sanitary conditions shall be maintained in the home. Provider wiped down and cleaned the kitchen cabinets. 04/22/2023 Implemented
6400.101The sliding glass doors in the dining area were not unobstructed. There was a piece of wood placed in the base of the sliding doors that prevented the door from opening more than approximately 4 inches, creating a blocked egress. (Repeat Violation 6/21/22)Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Provider removed and discarded the stick blocking the sliding glass door. 04/20/2023 Implemented
6400.141(c)(4)Individual #2's annual physical exam dated 1/19/23 did not include a hearing examination. (Repeat Violation 7/25/22, 2/27/23)The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Provider has contacted an ear doctor to provide the ear exam for 06/09/23 04/21/2023 Implemented
SIN-00221522 Unannounced Monitoring 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom attached to the bedroom had clean and sanitary issues. This bedroom is vacant, and it was said that the bathroom has not been used as the individual uses the main bathroom. However, the sink in this bathroom has what appeared to be soap scum around the bottom of the sink. The shower walls also appeared to have soap scum on it.Clean and sanitary conditions shall be maintained in the home. Provider cleaned the sink and stand-in shower. 03/21/2023 Implemented
6400.76(a)At the time of inspection there was lint the size of a golf ball inside the dryer. This is hazardous as it increases the risk of fire occurring in the home. Furniture and equipment shall be nonhazardous, clean and sturdy. Provider removed the lint from the dryer. 03/21/2023 Implemented
6400.82(f)The bathroom in the main area of the home did not have paper or cloth towels.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Cloth towel was being laundered. Provider placed a paper towel while licensor still on site. 03/21/2023 Implemented
SIN-00220083 Unannounced Monitoring 02/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Water temperature in the bathtub of the home measured at 131.9 degrees, exceeding the maximum of 120 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Provider requested for a temperature adjustment for the Individual's home. 02/27/2023 Implemented
SIN-00218413 Unannounced Monitoring 01/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The home's kitchen window lacked a secure screen, and no other screen was present in the home that could be fit into the window should it be opened.Windows, including windows in doors, shall be securely screened when windows or doors are open. Provider placed a work order to replace the window screen. 02/03/2023 Implemented
6400.72(c)The interior handle and locking mechanism of the rear sliding door, which is an outside door, was visibly broken at the time of inspection. The locking mechanism on the door could not be engaged despite repeated attempts---it was inoperable, leaving the rear entrance unsecured from intrusion. Outside doors shall have operable locks.Provider placed a work order to replace the faulty door lock. 02/03/2023 Implemented
6400.77(b)At the time of inspection, there was no thermometer present in the home's first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Provider located thermostat and placed it in the first aid kit. 01/31/2023 Implemented
SIN-00216600 Unannounced Monitoring 12/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At the time of inspection, the hot water temperature in the bathroom sink and tub registered at 128 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Provider contacted maintenance for water temperature readjustment. 12/23/2022 Implemented
SIN-00214998 Unannounced Monitoring 11/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons are not locked in the home. Individual #2's Individual Service Plan indicates that the individual is not safe with poisons and chemicals are locked. There was an Airwick plug in Air Freshener in Individual #2' bedroom. Warnings on the package indicate to seek medical attention and contact poison control.Poisonous materials shall be kept locked or made inaccessible to individuals. The air freshener was removed and locked. 11/14/2022 Implemented
6400.104Notification to the local fire department is not current. There was a change in the individual who resides in the home and what bedroom the individual is located in on 10/7/22. The notification to the fire department is dated 5/2021.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The notification letter was reviewed, updated, and a copy sent to the local fire department. 11/15/2022 Implemented
6400.213(6)Individual #2's individual Record maintained in the home did not contain a current annual assessment.Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment). A current copy of the annual assessment was printed and placed in the resident book. 11/15/2022 Implemented
6400.34(a)Individual #2 was not annually informed of the individual's rights. Individual #2 was informed of the individual's rights on 6/5/2021 and was not informed of the individual's rights again until 8/13/22.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 leadership team debriefed on this violation in order to identify areas of improvement. Areas identified were worked upon. 11/18/2022 Implemented
6400.213(7)Individual #2's individual record maintained in the home did not contain Individual plan documents as required by this chapter.Each individual's record must include the following information: Individual plan documents as required by this chapter.A current copy of the plan was printed and placed in the resident book. 11/14/2022 Implemented
SIN-00210757 Unannounced Monitoring 08/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The screen to the bedroom window of Individual #1 was out of the window and laying on the ground to the right of the window. The screen for the rear sliding door was broken and laying on the ground outside in front of the sliding glass door. Windows and screens shall be in good repair. Screens, windows and doors shall be in good repair. Maintenance crew was working on a previously placed work order for the sliding door. As maintenance arrived, they replaced both screens, i..e for the door and the window. 08/18/2022 Implemented
SIN-00209274 Unannounced Monitoring 07/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not being maintained in the home. The shower/bathtub had a layer of soap scum on the walls and in the tub. (Repeat Violation 6/21/22, 5/12/22, 3/11/22)Clean and sanitary conditions shall be maintained in the home. Bathtub/ shower was cleaned immediately. 09/07/2022 Implemented
SIN-00208684 Unannounced Monitoring 06/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)There was a closet in which cleaning supplies, hand sanitizer, Glade air freshener and fabric softener sheets. A 30-pack of assorted flavor snack chips was also stored on a shelf in the closet.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Food items were separated from the chemicals. 08/16/2022 Implemented
6400.64(a)The Individual's personal bathroom was not clean at the time of the inspection. The mirror had a film over it that it made it difficult to see one's reflection. The bathtub had a significant amount of soap scum around the bottom of the tub.Clean and sanitary conditions shall be maintained in the home. The bathroom was cleaned and staff instructed to check the bathroom before the end of their shift to ensure it is clean and take any appropriate steps if any cleaning is needed. 08/16/2022 Implemented
6400.77(b)There was no tape or gauze in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit has been replenished with items including tape and gauze. 08/16/2022 Implemented
6400.144The Individual is prescribed Tessalon 20mg. to be taken as needed for cough. This medication was listed on the medication administration record (MAR) but was not available in the home at time of inspection,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. A new script for Tessalon was sent to the pharmacy and the medication was picked up. 08/16/2022 Implemented
6400.32(r)(5)The staff did not have a key to the door to access the second bedroom (currently vacant) at the time of the inspection.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.A key to the second room in the home is available for staff at this time. 08/16/2022 Implemented
6400.163(h)There was a white bag filled with old medication on the floor in the staff office. Inside the bag were discontinued medications including trazadone, fluticas-salmete (advair), tussin dm syrup, and mupiricin ointment, These medications were not disposed of properly.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Medications were disposed of as per regulations and staff were reminded to use the established protocol for medication disposal. 08/16/2022 Implemented
6400.166(c)Individual #1 is prescribed Trileptal 300mg. tablet, 1 tablet to be taken by mouth 3 times per day. The Individual refused to take this medication on 6/08/2022 at 2PM. There was no record if the prescriber was notified of the refusal. When asked, the staff replied that they do not notify the doctor when the Individual refuses medication.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Staff were retrained on proper documentation and reporting of medication refusals. They were reminded that in addition to documenting refusals, the prescribing doctor must be informed. 08/16/2022 Implemented
6400.186Individual #1's supervision care needs are 1:1 at all times. While in the community, the Individual shall be within arm's length of staff, unless in the bathroom. In the home, the Individual is able to be left unattended in their bedroom with periodic checks. When this inspector arrived at the home at the time of the inspection, Individual #1 was outside alone smoking a cigarette. The Individual allowed the licensing inspector into the home and let the staff know that the inspector was present. Inside the home, a behavior specialist was at the dining room table and the Direct Support Professional (DSP) was in the kitchen washing dishes. Once the licensing representative entered the kitchen, the individual went back outside to finish smoking, without 1:1 supervision. During the inspection, the licensing staff asked the DSP to contact Director Linda Muldrew. The DSP went to the staff office to make the phone call. The licensing inspector walked outside and found the Individual talking to a male neighbor approximately two doors down from her apartment. At the time the licensing inspector arrived, and continuing after the licensing inspector's arrival, the DSP was not providing arm-length supervision to the individual while in the community setting, as required by the current Individual Support Plan (ISP) for Individual #1.The home shall implement the individual plan, including revisions.The above incident was reviewed, Leadership met with staff involved and before returning scheduled shift staff was retrained on the individual's ISP and BSP. Leadership continue to monitor staff. 08/16/2022 Implemented
SIN-00205237 Unannounced Monitoring 05/12/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen floor was not clean and sanitary as it was very sticky. (Repeat Violation 3/11/22)Clean and sanitary conditions shall be maintained in the home. Staff cleaned the kitchen floors shortly after this inspections. Staff were reminded to use the provided cleaning supplies in the right amounts in order to achieve acceptable outcome. 08/16/2022 Not Implemented
6400.68(a)Water temperature was too low, 86.7 degrees. (Repeat 3/11/22)A home shall have hot and cold running water under pressure. The water temperature was adjusted and the last reading before submission of this response was 114 degrees. 08/16/2022 Implemented
6400.71There were no emergency numbers on or near the telephone. (Repeat Violation 3/11/22)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. A list of emergency phone numbers was printed and posted in the home. 08/16/2022 Implemented
6400.141(a)Individual #5 had an annual physical completed on 3/3/21. Individual #5's next annual physical was completed on 4/12/22. Individual #5's annual physical was 40 days late, exceeding the 12-month/annual requirement. (Repeat 1/25/22)An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Provider called the PCP to schedule the next appointment (2023). 08/16/2022 Implemented
6400.144The provider is not arranging medical care for the individual. Individual #5 is followed by a gastroenterologist. The individual had an appointment on 2/7/22 and was to return in three months on 5/9/22 for a 3 month follow up. The induvial did not attend the 5/9/22 appointment. Information provided indicated that the individual did not attend the appointment due to a street being closed. The agency is not providing for Individual #5's dental needs. Individual #5 was referred to an oral surgeon for extractions on 12/21/21. There is not documentation that Individual #5 saw the oral surgeon to have this dental work completed. Individual #5 is followed by a Nutritionist. Induvial #5 was to have an appointment on 12/13/21. There was no documentation of this appointment occurring. The individual is scheduled for an appointment on 6/28/22. (Repeat Violation 3/11/22)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. Individual #5 saw her gastroenterologist on 6/14 and Nutritionist on 7/15. Individual #5 has continued to cancel or reschedule her dental appointments. 08/16/2022 Implemented
6400.165(g)Individual #5 is prescribed psychotropic medications to treat psychiatric illness. Individual #5 had a review of psychotropic medications on 3/7/22 There is no documentation completed by a licensed physician of these medication reviews. (Repeat 1/25/22 and 4/8/22)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 #5 has received medication reviews for her psychotropic medications since this inspection. 08/16/2022 Not Implemented
6400.166(b)Individual #5 is prescribed Topiramate (Topamax 100mg) Take one tablet by mouth 2 times daily at 8AM and 8PM. The medication was removed from the blister pack; however, the medication was not documented as administered on May 12, 2022 on the Medication Administration Record (Repeat 1/25/22 and 4/8/22)The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff involved was addressed and reeducated on proper documentation of medication administration. 08/16/2022 Implemented
6400.166(c)Individual #5 is prescribed Triple Antibiotic Ointment, apply topically to affected area 4 times daily at 8AM, 12N, 4PM and 8PM. This is medication is prescribed for an open wound. Individual #5 refused this medication on 5/11/22. There is no documentation of the refusal on the Medication Administration Record and there is no documentation that this refusal was reported to the prescribing physician. Individual #5 is prescribed Mupirocin 2%, apply topically to affected area three times daily at 8AM, 2PM and 8PM for 14 days. This mediation is prescribed for an open wound. Individual #5 refused this medication on 5/11/22 and 5/12/22 at 8AM and 8PM. There is no documentation of the refusal on the Medication Administration Record and there is no documentation that this refusal was reported to the prescribing physician. (Repeat 3/11/22)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.The provider continued to inform Individual #5's doctor about her refusals and the individual was offered education on the importance of taking her medications as prescribed. Individual #5 spoke to her doctors and the creams were discontinued. The individual's team was retrained on documentation. 08/16/2022 Implemented
SIN-00202010 Unannounced Monitoring 03/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Under the bathroom, sink was an unlabeled spray bottle with white polka dots filled ¼ of the way with a brown liquid. Staff and Individual #2 stated that the bottle contained clove and water for her hair.Poisonous materials shall be stored in their original, labeled containers. Individual #2 and her staff were educated on policy 6400.62. Individual #2 was encouraged not to use substances that are not prescribed by her doctor. 03/12/2022 Implemented
6400.64(a)Clean and sanitary conditions shall be maintained in the home. During the monitoring on 3/11/21, the living room wall where the television is mounted was dirty with splatters of red and brown spots all over it which resembled food residue.Clean and sanitary conditions shall be maintained in the home. The living room wall was cleaned. 03/11/2022 Implemented
6400.64(e)During the monitoring on 3/11/21,the kitchen garbage can approximately 20 inches high did not have a lid on it.Trash receptacles over 18 inches high shall have lids. A new garbage can was purchased for the kitchen. 03/14/2022 Implemented
6400.67(a)The front window had 9 blinds that were bent. The hallway closet door was missing a door knob. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds were replaced and the hallway closet door knob installed. 03/14/2022 Implemented
6400.144Individual #2 is prescribed Voltaren 1% gel, apply 2 gm top. To aff. area(s) 4x daily @ 8am-12pm-4pm-8pm. The medication was not available in the home. Individual #2 is prescribed Albuterol Sol 2.5 Mg/ 3 ML, use 1 vial via neb every 4 hrs as needed. This medication was not available in the home. Individual #2 is prescribed Melatonin 5 mg tablet, take ½ tablet (2.5 mg) by mouth nightly as needed for insomnia and the medication was not listed on their March 2022 Medication Administration Record. Pharmaceutical services are not being provided for the individual by the agency. (Repeat Violation 9/22/21, 12/14/21, 1/25/22)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. Provider received Voltaren 1% gel from the pharmacy on 3/11/22. Albuterol sol 2.5 Mg/3Ml available in the home at the time of inspection, however staff on shift, was unable to locate the medication upon request. Medication was in a different drawer in the medication cabinet. Melatonin 5mg, was previously discontinued. Medication removed from the home immediately. 03/11/2022 Implemented
6400.241(a)A pot of spaghetti noodles were left on the back burner of the stove uncovered at the time of the monitoring. Individual #2 confirmed that it was left over spaghetti noodles from her dinner from the night before. Food shall be stored in covered containers. Food shall be stored in covered containers. Staff involved was retrained on her shift responsibilities including food handling and storage. Staff was reminded that even though individual #2 prepares most of her meals, staff must ensure that proper food handling and storage is maintained. Leftovers will be stored in covered containers and labeled. Food that is more than 3 days old will be disposed of. 03/14/2022 Implemented
6400.163(h)Individual #2 is prescribed Amonium Lactate 12% Loti, apply to both feet once daily at 8am. The bottle located in the home expired on 3/4/22. The medication remained with the individual's medications and was not disposed of properly. Individual #2 is prescribed Albuterol HFA 90 MC INHA, inhale 2 puffs every 6 hours a needed. The medication expired 1/30/22. The medication remained with the individual's medications and was not disposed of properly. Individual #2 is prescribed Mupirocin 2% ointment, apply topically to affected area(s) 3x daily as needed. The medication expired 3/3/22. The medication remained with the individual's medications and was not disposed of properly. (Repeat Violation 1/25/22)Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Provider removed the expired medication from the home. 03/11/2022 Implemented
6400.165(c)Individual #2 is prescribed Amonium Lactate 12% Loti, apply to both feet once daily at 8am. There were no initials on the Medication Administration Record (MAR) for the current month (3/1/22-3/11/22) to indicate that the medication was administered as prescribed. Individual #2 Triamcinolone 0.1% cream, apply a thin layer to affected area(s) 2x daily @8a-8p. The corresponding entry on the (MAR) documents the same instructions as on the pharmacy label, except someone had added PRN to the MAR record. There were no initials on the MAR for the current month to indicate that the medication was administered twice per day as ordered. Individual #1 is prescribed Clotrimazole-Betamethasone cream to be applied twice daily at 8am and 8pm. The corresponding entry on the MAR documents the same instructions as on the pharmacy label, except someone had added PRN to the MAR record. There were no initials on the MAR for the current month to indicate that the medication was administered twice per day as ordered. (Repeat violation 12/14/21, 1/25/22)A prescription medication shall be administered as prescribed.Individual #2 repeatedly refused, Ammonium lactate 12%, Triamcinolone 0.1% cream, and Clotrimazole-Betamethasone. An appointment was scheduled for individual #2 to discuss the above medications. The medications were discontinued. 04/12/2022 Implemented
6400.166(a)(13)Individual #2 is prescribed a pro re nata (PRN) Acetaminophen 500mg take 1 tablet by mouth every 6 hrs as needed for mild-moderate pain. The medication appears to have been administered twice on 3/7/22 as they were removed from the blister pack but are not initialed on the Mediation Administration Record (MAR) as being administered at 8am on 3/7/22 and 8pm on 3/7/22.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.Provider met with the staff and reviewed medication documentation records. 03/11/2022 Implemented
6400.166(c)Individual #2 is prescribed Chlorhexidine 0.12 rinse, swish & spit 1 tablespoonful (1 capful) 2x daily @ 8AM-8PM. Individual #2 has refused the medication at 8am and 8pm for the current month (3/1-3/11) and there is no documentation on if the refusals have been reported to the prescriber, or the individual being educated on the benefits of taking her medications as prescribed.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Individual #2 continually refused Chlorhexidine 0.12%. Provider reviewed medication documentation with staff. Individual #2, had an appointment with the doctor regarding Chlorhexidine 0.12%. Medication changed to PRN. 03/11/2022 Implemented
SIN-00199342 Unannounced Monitoring 01/25/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drills conducted in January, February, March, April, November and December of 2021 did not document on the fire drill record whether the fire alarms or smoke detectors were operable at the time the drill were conducted.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. The fire drill process was reviewed with all staff involved with focus on documentation. 02/09/2022 Implemented
6400.165(c)Individual #1 is prescribed Chlorhexidine 0.12% oral rinse. The pharmacy label on the bottle states that the rinse shall be used twice daily at 8am and 8pm. The corresponding entry on the Medication Administration Record (MAR) documents the same instructions as on the pharmacy label, except someone had added "PRN" (pro re nata) on the MAR record. There were no initials on the MAR for the current month to indicate that the medication was administered twice per day as ordered. Individual #1 is prescribed Triamcinolone 0.1% cream to be applied twice daily at 8am and 8pm. The corresponding entry on the MAR documents the same instructions as on the pharmacy label, except someone had added PRN to the MAR record. There were no initials on the MAR for the current month to indicate that the medication was administered twice per day as ordered. Individual #1 is prescribed Clotrimazole-Betamethasone cream to be applied twice daily at 8am and 8pm. The corresponding entry on the MAR documents the same instructions as on the pharmacy label, except someone had added PRN to the MAR record. There were no initials on the MAR for the current month to indicate that the medication was administered twice per day as ordered.A prescription medication shall be administered as prescribed.The pharmacy has updated the MAR to reflect Clotrimazole-Betamethsone Cream as a PRN. Individual #1 requested her doctor to discontinue Chlorhexidine oral rinse and triamcinolone because she was not using them. The doctor declined the request stating that individual #1 has repeatedly changed her mind after changes are made to these prescriptions. Individual #1 was educated on the benefits of taking her medications as prescribed. 02/01/2022 Not Implemented
SIN-00166740 Renewal 11/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #2 (DOB: 9/19/1997) was admitted on 11/20/2018. She didn't have a physical exam until 12/3/2018.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual 2's Insurance needed to be transferred, a new card ordered, and an appointment made for the physical. Physical was completed on 12/03/2018. Staff have been trained in the regulatory requirement. Support Coordination and families are notified of the regulatory requirements during the admission process. 12/03/2018 Implemented
6400.141(c)(6)Individual #2's (DOB: 9/19/1997) most current TB test is dated 10/2/2017.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual 2 cancelled the previous TB test appointment. TB test completed on 11/11/2019. Staff have been trained in the regulatory requirement. Support Coordination and families are notified of the regulatory requirements during the admission process. 11/11/2019 Implemented
6400.181(e)(9)This area wasn't evaluated on Individual #2's assessment dated 6/6/2019.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. Individual 2's functional ability will be added in the assessment as requested. Individual 2 will be assessed by the program specialist and the correct data will be entered into the assessment. 11/20/2019 Implemented
6400.181(e)(13)(i)This area wasn't evaluated on Individual #2's assessment dated 6/6/2019.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Individual 2's assessment, will include health and progress over the last year as requested. 11/20/2019 Implemented
6400.181(e)(13)(viii)This area wasn't evaluated on Individual #2's assessment dated 6/6/2019.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Individual 2's assessment will be completed in its entirety, and managing personal property shall be included. 11/20/2019 Implemented
6400.165(g)Individual #2 was admitted on 11/20/2018. She hasn't had any psychiatric medication reviews since her admission.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 2 mental health benefits took a while to transfer. Once benefits transferred, an appointment was made for individual 2 to see a psychiatrist. The practice that individual 2 is seen, requires therapy first before meeting with a psychiatrist. An appointment to see a psychiatrist, has been scheduled for 01/06/2020. Individual 2's PCP stated that PCP would continue to write scripts for psychotropics, however a psychiatrist is needed for med review. Med review will be requested on the above appointment date. The program specialist will follow up to ensure that all insurance information is transferred and contact is made with psychiatrist before admission. Staff have been retrained. 01/06/2020 Implemented
SIN-00146510 Renewal 11/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 was hired on 5/12/18 and did not have a Pennsylvania State Police criminal history background check completed.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.A PA state criminal background check completed for individual # 1. In future, a new hire checklist that includes PA criminal background check completion, will be completed and reviewed by the president and VP to ensure that compliance is met. 01/09/2019 Implemented
6400.31(b)There was not a signed and dated copy of rights/acknowledging receipt of the information on rights in Individual #1's record.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Individual # 1 given a copy of individual rights, and a copy issued to individual # 1's guardian. In future, upon admission, the president and VP will ensure that among all forms, individuals will receive an Individual rights form. 11/22/2018 Implemented
6400.62(a)Gold Bond Lotion (the label states "contact Poison Control if ingested) was found unlocked and accessible in the hall bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals. Gold bond lotion placed in individual # 1 shower caddy which is placed in a locked cabinet. Residential manager will ensure that item stays locked after each use. 11/20/2018 Implemented
6400.151(c)(2)Staff #1 was overdue for Tuberculin skin testing by Mantoux method. Staff #1's most recent Mantoux test was administered on 9/27/16. 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. Reviewed 55 PA code chapter 6400.151(c)(2) with staff # 1. Staff scheduled an appointment to complete the tuberculin testing. An employee new hire checklist developed that will ensure future requirements are met as stated in 55 chapter 6400.151. The VP in charge of hiring, will ensure all documents are up to standard. 11/22/2018 Implemented
6400.163(c)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and there was not documentation in the record of medication reviews conducted at least every 3 months. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.A medical appointment immediately scheduled for individual #1 for a psychiatric medication review for 12/12/2018. In future, the residential manager, will ensure that medication review appointments are scheduled and conducted every 3 months as required in 6400.163 (c) 12/12/2018 Implemented
6400.181(d)The annual assessment for Individual #1 was not signed and dated by the Program Specialist.The program specialist shall sign and date the assessment. Program specialist signed and dated individual # 1's assessment. All future assessments, will be signed and dated timely after completion, by the program specialist. 11/21/2018 Implemented
6400.181(e)(14)The annual assessment for Individual #1 did not document the Individual's 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.Ability to swim added to individual # 1's assessment. In the future, individuals or guardians will complete a form clearly stating an individual's ability to swim. 12/01/2018 Implemented
6400.181(f)The annual assessment for Individual #1 was not provided to the Supports Coordinator and team at least 30 days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Individual # 1 assessment will be submitted to individual #1's team at least 30 days prior to individual # 1 ISP meeting. In the future, assessments will be submitted by the program specialist, in a timely manner to the team 30 days before the ISP meeting. ((Program Specialist will utilize tool to track assessment dates and the dates in which assessments must be distributed -CH 2/7/19)) 11/26/2018 Implemented
6400.186(a)ISP reviews for Individual #1 were not completed timely or were not completed at all. The ISP review covering the period 3/17/18 to 5/16/18 was not completed until at least 10/01/18 (which was the date of hire for the Program Specialist (Staff #2) who signed and dated the quarterly review. A ISP review covering the period 6/17/18 to 8/16/18, also signed and dated by Staff #2, was not completed until at least 10/01/18. There was not a ISP review covering the period 5/17/18 to 6/17/18. There were no ISP reviews from 8/17/18 to the present.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program specialist will complete all quarterly ISP reviews in a timely manner. ISP reviews will be shared with individual #1's team for review. All future reviews will be completed in a timely manner, to meet compliance. ((Program Specialist will utilize a tool to track ISP Review due dates -CH 2/7/19)) 11/28/2018 Implemented
6400.213(1)(i)The record for Individual #1 did not document the Individual's race.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Individual # 1 has Race added to the Ethnicity section of the face sheet. Management reviewed 55 Chapter 6400.213(1)(I) to reinforce compliance. Changes made to the face sheet format for all residents to reflect an individual's Race. Program specialist will ensure that Individuals records reflect their Race. 11/21/2018 Implemented
SIN-00204063 Unannounced Monitoring 04/08/2022 Compliant - Finalized
SIN-00184434 Renewal 02/10/2021 Compliant - Finalized
SIN-00124607 Initial review 11/21/2017 Compliant - Finalized