Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240546 Renewal 03/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(a)Individual #1 Isp does not state financial independence. The agency is not tracking her spending.There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. The Program Specialist immediately updated individual #1s assessment to address her financial independence and needs/wants and then sent track changes to the SC on 3/14/2024 to update individual #1s ISP to specifically state the individual is able to manage their weekly spending money they receive from their rep payee and that they do not wish to have Bethel store or track their money. 03/15/2024 Implemented
6400.141(c)(3)Individual #1 did not have a current TDAP last one dated 1/25/2012 on her physical dated 3/14/23.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The Medical Coordinator immediately contacted individual #1s PCP to schedule a TDAP vaccine appointment. The PCP stated they do not have the ability to give this vaccine, but this vaccine is available in their connecting office and the soonest she could be seen was when she was already scheduled for her physical on 3/20/24. Individual #1 received an order for the vaccine on 3/20/24 and received the vaccine on 3/22/24. 03/22/2024 Implemented
6400.143(a)Individual #1 refused dental appointments on 9/27/22 and 11/29/23 and no refusal plan was created to address the issueIf an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual #1 is already scheduled for a dental appointment and has agreed to attend the appointment. A refusal plan is currently being developed by the Program Specialist and Medical Coordinator. The plan will be completed by 3/27/2024 for individual #1 to address any type of routine medical or dental or treatment refusals. 03/27/2024 Implemented
SIN-00201232 Renewal 03/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The 10/21/21 fire drill documentation lists evacuation time as 3.22. This exceeds the 2/12 minute 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. All Bethel Care direct support staff will be retrained on fire drill forms and this regulation by April 15, 2022. It will now be the Program Assistants role to audit the fire drill forms monthly to ensure they are filled out entirely and that the information is correct. In the event that the evacuation time does not meet state requirements, the dsps will conduct a new fire drill. 04/15/2022 Implemented
6400.113(a)The designated meeting location for fire drills was changed in July 2021, however there is no documentation that Individuals #1 and #2 were retrained on the new specific meeting location. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The location for the fire drills was changed in July 2021. It is the responsibility of the Program Specialist to retrain all staff and individuals of the meeting place prior to the change and training records shall be kept. All individuals and Bethel Care staff will be re-trained on this regulation and the meeting places by April 15, 2022. 04/15/2022 Implemented
6400.46(a)The designated meeting location for fire drills was changed in July 2021, however there is no documentation that staff were retrained on the new specific meeting location.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.The location for the fire drills was changed in July 2021. It is the responsibility of the Program Specialist to retrain all staff and individuals of the meeting place prior to the change and training records shall be kept. All individuals and Bethel Care staff will be re-trained on this regulation and the meeting places by April 15, 2022. 04/15/2022 Implemented
SIN-00185558 Renewal 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)During the virtual inspection on 3/31/21, the following poisons where found unlocked: Tide laundry detergent, a large bottle of pot cleaning detergent, and glade air freshener. Individual #1, who comes to this house each day, is not safe around poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. It is important for the health and safety of the individual to have poisons locked and inaccessible if their plan requires it. Although the house was vacant, the individual does visit the house during the day. The laundry soap was not locked. It is the responsibility of the house manager to ensure the individuals plan is followed and that poisonous materials are locked. The house manager and all direct support will be retrained on this regulation by 5/15/2021. 05/15/2021 Implemented
6400.66The light outside the door of the side exit was not operable. There was a light bulb in the light, but it did not work. The provider did put a new light bulb in while the inspector was still conducting the inspection, and the light still did not work.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. It is important for the health and safety of the individual to ensure there is adequate lighting. Although the house was vacant, the individual does visit the house during the day. All rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes need to be operable and lit to avoid accidents. It is the responsibility of the compliance manager to ensure that any new site follows this regulation. The house manager and all direct support will be retrained on this regulation by 5/15/2021. 05/15/2021 Implemented
6400.77(a)There was no first aid kit at the home during the inspection. A home shall have a first aid kit. It is important to the health and safety of the individual that there be a first aid kit in the house. Although the house is vacant, the kit must be readily available at all times. It is the responsibility of the house manager to ensure that the kits are in the homes and all required items are in them. All house managers will be retrained on this regulation by 5/15/21 05/15/2021 Implemented
SIN-00220354 Renewal 03/07/2023 Compliant - Finalized