Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228519 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment did not have a completion date(s); therefore, compliance could not be measured as to whether it had been conducted either within 3-6 months of the current license's expiration date or within 6-9 months following the last annual inspection by the Department.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 provider shall complete a self assessment with the completion date. 08/21/2023 Implemented
6400.22(e)(1)On 7/19/23, Individual #1's financial record was not up-to-date, as the ledger was found to be missing transactions, including funds received by and disbursements made to them for purchases. The agency provides assistance in maintaining Individual #1's finances, as their 5/9/23 assessment indicates the need for help in this skill domain. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. The home financial records shall have the dates and amounts of deposits and withdrawls 08/21/2023 Implemented
6400.68(b)On 7/19/23, the hot water temperature of the bathtub in the bathroom located in the bedroom hallway measured 124.35°F at 12:19 PM. [Repeated Violation---11/9/21, 10/4/22, et al] Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water shall not exceed 120 degrees 08/21/2023 Implemented
6400.141(c)(7)Individual #1's date-of-birth is 10/3/95. They had a gynecological examination on 3/28/22, and then again on 6/2/23.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The physical exam shall include: gyne exam including a breast exam and pap test for women 18 years of age or older. 08/21/2023 Implemented
6400.142(a)Individual #1 had a dental examination completed on 4/28/22, and then again on 6/18/23.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual shall have a dental exam completed annually. 08/21/2023 Implemented
6400.151(c)(2)Direct Support Worker #1 had a tuberculin skin test via Mantoux method placed on 2/3/23 but then was read on 2/15/23. 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. Physical exam shall have a tb SKIN test with neg results every 2 years or if positive an initial chest xray. 08/21/2023 Implemented
6400.151(c)(3)Direct Support Worker #1's most recent physical examination completed on 3/4/22 did not include a signed statement that they are free of communicable diseases or that they have a communicable disease but is able to work in the home provided specific precautions are taken to prevent the spread of disease to individuals. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Physcial exam shall include a signed statement that staff is free from communicable diseases or has a communicable disease but is able to work 08/21/2023 Implemented
6400.15(b)The agency used the Self-Inspection and Declaration Tool to measure and record compliance at the home instead of the Department's Licensing Inspection Instrument.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency shall use the dept of licensing inspection instrument for the community homes for individuals with IDD. 08/21/2023 Implemented
6400.165(f)Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. A written protocol to address their social, emotional, and environmental needs related to the symptoms of the psychiatric illness was not found as part of their individual plan or anywhere else in their record.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Med is prescribed to treatment of diagnosed psych illness, there shall be a written protocol as part of the individual plan to address SEEP. 08/21/2023 Implemented
6400.166(a)(11)On 7/19/23, Individual #1's prescribed Tretinoin Cream 0.025%--Mix pea-size amount with gentle moisturizer and apply topically to face every other night---was missing a diagnosis or purpose on their July 2023 Medication Administration Record.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.A MAR shall be kept including the purpose for the medication including PRN 08/21/2023 Implemented
6400.181(f)Individual #1's most recent assessment was completed on 5/9/23 for an individual plan annual review meeting held on 5/10/23.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.THe program specialist shall provide assessment to the individual plan team at least 30 days prior to ISP meeting 08/21/2023 Implemented
SIN-00225067 Unannounced Monitoring 05/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)On 5/24/23, at 10:59 AM the dining room chair had a leg that was loose and unstable from the base and the framing comprising the seating base was broken and apart. Furniture and equipment shall be nonhazardous, clean and sturdy. Furniture shall be sturdy, Provider threw away broken chair. 05/27/2023 Implemented
6400.77(b)On 5/24/23, the first aid kit did not contain a thermometer at 11:10 AM. 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. New first aid kit was purchased to ensure all necessary equipment is inside the first aid kit. 05/27/2023 Implemented
SIN-00223562 Unannounced Monitoring 04/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)On 4/28/23, Individual #1's most recent individual plan was not in the home at 11:41 AM. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The provider has placed the plan in the individuals home. 05/04/2023 Implemented
6400.163(d)On 4/28/23, the following expired PRN medications for Individual #2 were found unlocked in the entryway closet: Gavilax Pow.; Phenyleprine HCI 10 mg tabs; and Milk of Magn. Sus 400/5M. Individual #2 passed away in September of 2021.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The provider has thrown away expired meds for deceased individual. 05/04/2023 Implemented
6400.163(h)On 4/28/23, the following expired PRN for medications Individual #2 were found unlocked in the closet near the front door of the home: Gavilax Pow.; Phenyleprine HCI 10 mg tabs; and Milk of Magn. Sus 400/5M. Individual #2 passed away in September 2021.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The provider has discarded the expired medications. 05/04/2023 Implemented
SIN-00212928 Renewal 10/04/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 10/5/22 at 10:40 AM, the sliding glass doors leading to the outside patio was observed to not have any light source.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The Provider has purchased motion sensor lighting for the outside patio for all apartments. 10/25/2022 Implemented
6400.68(b)On 10/5/22, the hot water temperature in the bathtub of the bathroom located in the hallway on the main level measured 140.5°F at 10:30 AM. [Repeat violation 11/9/21 et al.] Hot water temperatures in bathtubs and showers may not exceed 120°F. The Provider has purchased new thermostatic faucets and shower heads for the bathroom to regulate water temp for all apartments. 10/25/2022 Not Implemented
6400.141(c)(1)Individual #1's physical examination completed on 8/3/22 did not include a physician's review of their previous medical history.The physical examination shall include: A review of previous medical history. As a result of violation 141c The Provider has implemented a new form for physical examinations for all clients. The new form includes previous medical history. 10/25/2022 Implemented
6400.141(c)(13)Under the "Allergies" field on Individual #1's physical exam completed on 8/3/22, it indicates "NKA." However, Individual #1's 10/22/21 physical exam under the "Allergies" field, it lists "Amoxicillin, Penicillin, and Erthromycin." Additionally, Individual #1's 9/28/22 individual plan states "allergies to bee stings, Adderall, and Seroquel."The physical examination shall include: Allergies or contraindicated medications.As a result of violation 141c The Provider has implemented a new form for physical examinations for all clients. 10/25/2022 Implemented
6400.212(b)The medical interpreter's identity, credentials, and reading results for Individual #1's tuberculin skin test via Mantoux method planted on 8/3/22 were not provided. Entries in an individual's record shall be legible, dated and signed by the person making the entry. The Provider has implemented a new form for physical examinations for all clients. The new form includes a review of the individuals previous medical history, health maintenance needs, TB/Mantoux test will include the name and title of person reading results. 10/25/2022 Implemented
6400.214(b)On 10/5/22 at 10:22 AM, it was found that the following records for individual #1 were not located on site: their most recent physical exams, dental exams, and dental hygiene plans. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The provider has placed records including but not limited to physical and dental exams for all individuals in the residential home. 10/25/2022 Not Implemented
6400.34(a)Individual #1 was informed and explained their rights on 1/8/22. The rights document did not include the following: 6400.32c...the right to be free from exploitation and abandonment; 6400.32n...the right to unrestricted and private access to telecommunications; 6400.32r2... the right to limiting access to their bedroom except in a life-safety emergency or with their expressed permission; and 6400.32s... the right to having a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.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 Provider has updated the individual rights form and reviewed with all clients. 10/25/2022 Implemented
6400.165(g)Individual #1's psychiatric medication reviews completed on 12/30/21, 2/4/22, 4/11/22, 6/16/22, and 9/8/22 are missing the necessary medication dosages, the reasons for prescribing the medications as well as the need to continue those medications.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.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. 10/25/2022 Implemented
SIN-00196387 Renewal 11/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 11/10/2021 at 10:52AM, the hot water temperature at the bathtub in the hallway bathroom of the home measured 130.6°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Program Specialist notified maintenance of the apt complex to turn down the water heater to 120 degrees or lower. House managers will keep a monthly log on the water temp in bathtub. House manger will notify maintenance if the water temp is greater than 120 degrees. Water temp log sent to ODP. 12/05/2021 Implemented
6400.112(c)The written fire drill records for the fire drills held on 9/13/2021 and 10/16/2021 did not include the exit route used.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. Program specialist has revised the fire drill log to include exit route used. Program specialist trained staff on the new fire drill form. Fire drill was conducted 12/1 at the identified location, and ensuring that all areas of the Fire Drill Record was properly documented; as well as indicating the exit route was include. The training and updated fire drill log was sent to ODP. 12/05/2021 Implemented
6400.141(a)Individual #1, date of admission 9/13/2021 had a physical examination completed prior to admission on 1/4/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Program Specialist and supervisor has determined that upon the admission of Individual # 1 on 9/13/21 the annual physical received was completed more than a year prior to admission. In order to prevent this citation from reoccurring the supervisor will ensure that during the proper transitioning of an individual, that their entire admissions checklist including a complete annual physical be secured by the house manager and or program specialist prior to the individual moving into the residential home. The Supervisor will update the Resident Admissions check list to specify the required areas to be complete on an individual's physical assessment documentation. 12/05/2021 Implemented
6400.141(c)(14)Individual #1's most recent physical examination, dated 10/22/2021, does 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. It has been determined that individual #1 annual physical was not completely filled out by the physician. In order to prevent this citation from reoccurring the house/lead supervisor and program specialist will ensure that during the individuals appt all medical forms will be filled out in it's entirety prior to the individual leaving the doctors office. The supervisor will update the check list to specify the required areas to be completed on an individuals physical documentation. 12/05/2021 Implemented
6400.181(d)Individual 1's assessment, dated 11/1/2021, was not dated by the program specialist.The program specialist shall sign and date the assessment. Program specialist didn't sign annual assessment Program Specialist signed annual assessment on 11/1/21. 12/05/2021 Implemented
6400.181(e)(1)Individual #1's assessment, completed 11/1/2021, does not include functional strengths, needs and preferences of the individual. [Repeat Violation, 12/15/2020] The assessment must include the following information: Functional strengths, needs and preferences of the individual. The CEO has created a new assessment to address the strengths, needs and preference of the individual. The CEO will train the program specialist and/or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment forms. The new form will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.181(e)(10)Individual 1's assessment, completed 11/1/2021, does not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The CEO has created a new assessment to address the lifetime medical history of the individual. The CEO will train the program specialist and/or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment forms. The new form will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.181(e)(12)Individual 1's assessment, completed 11/1/2021, does not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The CEO has created a new assessment to address the recommendations for specific areas of training, programming and services of the individual. The CEO will train the program specialist and/or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment forms. The new form will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.182(c)Individual #1's most recent Individual Plan, dated 9/2/2021, states, "[Individual #1] can independently evacuate during a fire" and "[Individual #1] recognizes poisonous substances and has no concerns that she would ingest these substances." Individual #1's assessment, dated 11/1/2021, assesses Individual #1 at a Level 1, needing total guidance including physical manipulation and being assisted through the entire process for both of these areas.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Individual #1 had moved to the home, the assessor did not request the SC update the plan to reflect the residential supervision levels. The CEO has made revisions to the initial and annual assessments so necessary information is clearly defined. All adjustments to the assessment template will be made by the program specialist on or before 12/10/2021. All assessments will be reviewed by the CEO to ensure quality and compliance in 2021 and forward. 12/05/2021 Implemented
SIN-00180330 Renewal 12/15/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's physical examination, completed 4/2/20 did not include immunization records.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 Director has notified Individual #1 previous PCP to obtain immunization record. The PCP is mailing the copy of immunization record to Individual #1 residence and staff will place in Individual #1 file. Going forward Director will create an admission packet checklist to make sure that all necessary documents including immunization record is on file at time of admission. [A copy of the immunization record for Individual #1 was provided to the Department on 1/11/21. Upon completion, the CEO or designee educated in the requirements of Individual's physical examinations shall audit individuals' physical examinations to ensure all required information is completed and all health services are arranged and provided as ordered. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.141(c)(11)Individual #1's physical examination, completed 4/2/20 indicated to see medication list. The medication list was not attached.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. Program specialist has made an appointment via tele-medicine for Feb 4, 2020 for Individual #1 physician to review medication regimen. Going forward Program Specialist will create a tracking sheet to remind staff during appointments to review the need of medications and if there is a need for blood work to obtain prescription for lab work. [Individual #1 had a Health maintenance medication list with PCP office on 1/11/21. A copy of the report had medications listed for Individual #1. A copy was provided to the Department on 1/11/21. Upon completion, the CEO or designee educated in the requirements of Individual's physical examinations shall audit individuals' physical examinations to ensure all required information is completed and all health services are arranged and provided as ordered. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.181(e)(1)Individual #1's assessment completed 1/8/2020 did not include strengths, needs, preferences of the individual. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Functional strengths needs and preference was added to Individual #1 assessment. The program specialist will review Chapter 6400 regulations again regarding assessments to ensure that all required information is included in the assessment. The Director/CEO will aid the program specialist in producing the proper documentation for the previous and future months, along with obtaining the necessary tools and knowledge to be more effective program specialist overall. [Individual #1's assessment was updated to include the functional strengths and needs, a copy was provided to the Department on 1/11/21. Immediately, the program specialist and CEO shall audit the current assessment documentation to ensure all required information is included so completion of all individual's assessment are completed with all required information. Immediately and at least quarterly for 1 year and continuing at least annually, the Program Specialist shall audit all Individual's current assessments to ensure all the required information is included, accurate and up to date. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 01/04/2021 Implemented
6400.181(e)(2)Individual #1's assessment, completed 1/8/2020 did not include dislikes and interests of the individual.The assessment must include the following information: The likes, dislikes and interest of the individual. Dislikes and interest was added to Individual #1 assessment. The program specialist will review Chapter 6400 regulations again regarding assessments to ensure that all required information is included in the assessment. The Director/CEO will aid the program specialist in producing the proper documentation for the previous and future months, along with obtaining the necessary tools and knowledge to be more effective program specialist overall [Individual #1's assessment was updated to include dislikes and interests of the individual, a copy was provided to the Department on 1/11/21. Immediately, the program specialist and CEO shall audit the current assessment documentation to ensure all required information is included so completion of all individual's assessment are completed with all required information. Immediately and at least quarterly for 1 year and continuing at least annually, the Program Specialist shall audit all Individual's current assessments to ensure all the required information is included, accurate and up to date. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 01/04/2021 Implemented
6400.181(e)(14)Individual #1's assessment, completed 1/8/2020 did not include 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. The ability to swim was added to Individual #1 assessment. The program specialist will review Chapter 6400 regulations again regarding assessments to ensure that all required information is included in the assessment. The Director/CEO will aid the program specialist in producing the proper documentation for the previous and future months, along with obtaining the necessary tools and knowledge to be more effective program specialist overall. [Individual #1's assessment was updated to include that s/he is unable to swim, a copy was provided to the Department on 1/11/21. Immediately, the program specialist and CEO shall audit the current assessment documentation to ensure all required information is included so completion of all individual's assessment are completed with all required information. Immediately and at least quarterly for 1 year and continuing at least annually, the Program Specialist shall audit all Individual's current assessments to ensure all the required information is included, accurate and up to date. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 01/04/2021 Implemented
6400.15(b)The agency did not complete a self-assessment on the Department licensing inspection instrument for community homes. The agency used a programmatic self-assessment document.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The Director has completed the self assessment of the home on Dec 30, 2020. Annually thereafter the Director or an appointed representative will complete the assessment 3-6 months prior to expiration of the Certificate of Compliance. [Self-assessment, dated 12/15-17/21, completed on the Department licensing instrument was submitted to the Department on 1/11/21. Upon completion, the CEO or designee shall audit the self-assessment to ensure full and accurate completion on the most recent Department licensing inspection instrument. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 1/14/2021)] 12/31/2020 Implemented
6400.34(a)Individual # 1 was informed and explained individual rights on 9/1/20. The rights document did not include: 6400.32(a) An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 6400.32(b) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion; 6400.32(c) An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment; 6400.32(d) An individual shall be treated with dignity and respect, 6400.32(e) An individual has the right to make choices and accept risks; 6400.32(f) An individual has the right to refuse to participate in activities and services; 6400.32(g) An individual has the right to control the individual's own schedule and activities; 6400.32(h) An individual has the right to privacy of person and possessions; 6400.32(i) An individual has the right of access to and security of the individual's possessions; 6400.32(j) An individual has the right to voice concerns about the services the individual receives; 6400.32(k) An individual has the right to participate in the development and implementation of the individual plan; 6400.32(l) an individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses; 6400.32(m) an individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses; 6400.32(n) unrestricted and private access to telecommunications; 6400.32(o) An individual has the right to manage and access the individual's finances; 6400.32(p) choose with whom to share a bedroom; 6400.32(q) to furnish and decorate the individuals bedroom and common areas of the home; 6400.32(r) to lock the individuals bedroom door; 6400.32(s) to an entry mechanism to lock and unlock the entrance to the home, and 6400.32(t) access to food at any time; 6400.32(u) An individual has the right to make health care decisions; 6400.32(v) An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual Rights was updated and signed by Individual #1 on 12/31/2020. Going forward each individual admitted will have the individual rights in his/her admission packet to review and sign upon admission and annually thereafter. [Individual Rights document was updated to include all individual rights per 6400 regulations and was signed by Individual #1 on 1/21/21, copy provided to the Department on 1/21/21 Upon admission and annually, the CEO or designee shall review all individual rights documentation to ensure the full individual rights and the process to report rights violations are informed and explained to all individuals. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/21/21)] 12/31/2020 Implemented
6400.46(d)Direct Service Worker #1 did not have current training in first aid.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Direct Care Worker #1 scheduled First Aid training for 1/16/2020. The Supervisor will ensure that all staff has required training upon initial hire as well as within the time frames required by the 6400 regulations. The program specialist will develop an audit tool to track staff training including first aid required within 30 days of receipt of this plan of correction. [Direct Service Worker #1 completed first aid training completed on 1/20/21, documentation of the training certificate was provided to the Department on 1/21/21. Immediately, the CEO or designee shall develop and implement a staff training tracking system to include a notification, scheduling, review and tracking document to ensure all staff persons are trained as required and documentation is maintained as required. At least quarterly, the CEO or designee shall audit the training tracking document to ensure it is up-to-date and staff are trained as required. (DPOC by AES,HSLS)] 12/31/2020 Implemented
6400.50(a)The fire safety training records for Program Specialist #1, Direct Service Worker #2 and Chief Executive Officer #3 did not include the training source, content, dates, and length of the training.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.A fire safety inspection conducted by a fire safety expert has been scheduled with ABC Fire Solutions. The Director or designee will be responsible for maintaining documentation of these actions. Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. [CEO #3 completed Plan to Get out Alive fire safety on 1/5/21 for 2 hours, certificate submitted to the Department on 1/11/2021. Program Specialist #3 completed Plan to Get out Alive fire safety on 1/5/21 for 2 hours, certificate submitted to the Department on 1/20/2021 . Direct Service worker #2 completed Plan to Get out Alive fire safety on 1/5/21 for 2 hours, certificate submitted to the Department on 1/20/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/20/21)] 12/31/2020 Implemented
6400.52(c)(1)Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships and kept in program specialist and CEO file. [CEO #3 completed Person Centered Practice training on 1/10/2021. Program Specialist #1 completed Person Centered Practice training on 1/8/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.52(c)(2)Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations. Chief Executive Officer #3, date of hire 9/15/2018, annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The Director has created a tool for annual trainings specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction The annual training hours will be specified of prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act and the child protective services law. The training will be kept in the CEO and Program Specialist employee file. [CEO #3 completed Abuse Detection, reporting and prevention of abuse suspected abuse and alleged abuse on 1/10/2021. Program Specialist #1 completed Abuse Detection, reporting and prevention of abuse suspected abuse and alleged abuse on 1/7/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.52(c)(3)Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass individual rights. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of Individual Rights. The training will be kept in CEO and Program Specialist employee file. [CEO #3 completed Individual rights training on 1/7/2021. Program Specialist #1 completed Individual rights training on 1/7/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.52(c)(4)Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass recognizing and reporting incidents. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of Reporting Incidents all trainings will be kept in employee file[CEO #3 completed Individual rights training on 1/7/2021. Program Specialist #1 completed Individual rights training on 1/7/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.52(c)(5)Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of safe and appropriate use of behavior supports if the person works directly with an individual. All training will be kept in employee file. [CEO #3 completed DDx: Functional Behavioral Assessment and Behavior Support Planning training on 1/10/2021. Program Specialist #1 completed DDx: Functional Behavioral Assessment and Behavior Support Planning training on 1/8/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
6400.166(a)(13)Individual #1's December 2020 medication administration record did not include the signature and initials for Direct Service Worker #2 who administered medications to Individual #1 on 12/2/2020, 12/5/2020, and 12/6/2020 at 8:00AM.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 Director who is a DPW certified medication administration train the trainer and observer has retrained staff on medication administration. Direct care worker #2 passed the medication administration training on 12/31/2020. The Director will ensure that all future medication administration trainings are performed by a certified DPW medication administration trainer whose certifications are current. [The January 2021 medication record for Individual #1 recorded all medication administrations form January 1 to January 11, 20212. (copy submitted to the Department on 1/11/21). At least monthly and immediately following any medication changes, a designated staff person who is qualified to administer medications shall audit the current medication administration record the medications and physicians' orders for the individual(s) to ensure individual(s) are administered medication as prescribed and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/20) 12/31/2020 Implemented
6400.166(b)Calcium 500mg, Carbamazepine SUS 100/5ml, Ferrous Sulfate 325mg prescribed to Individual #1 were not documented as administered at 8:00AM on 12/16/2020.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Director who is a DPW certified medication administration train the trainer and observer has retrained staff on medication administration. Direct care worker #2 passed the medication administration training on 1/4/2021. The Director will ensure that all future medication administration training are performed by a certified DPW medication administration trainer whose certifications are current.[The January 2021 medication record for Individual #1 recorded all medication administrations form January 1 to January 11, 20212. (copy submitted to the Department on 1/11/21). At least monthly and immediately following any medication changes, a designated staff person who is qualified to administer medications shall audit the current medication administration record the medications and physicians' orders for the individual(s) to ensure individual(s) are administered medication as prescribed and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/20) 01/04/2021 Implemented
6400.213(1)(i)Individual #1's record did not include eye color, hair color, primary language, and religious affiliation.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Updated face sheet was placed in Individual #1 file with all pertinent information including eye and hair color, religion and primary language. Going forward a face sheet will be placed in each admission packet to be filled out in it's entirety and placed in individuals medical record. [A copy of the updated "face sheet" for Individual #1 to include eye color, hair color, primary language, and religious affiliation was provided to the Department on 1/11/21. At least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure all required information is included as per 6400.213(1)-(8). Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] 12/31/2020 Implemented
SIN-00161158 Renewal 08/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(c)The agency did not have documentation of the Chief Executive Officer #1, date of hire 5/1/19 qualifications; therefore, compliance could not be measured. A chief executive officer shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years work experience in administration or the human services field. CEO has a Master's Degree in Business Administration with 5 years experience in working with individuals with intellectual disabilities. Copies will be kept in the CEO file that was created by the Director of Operations and will be available upon request. [Copies of the CEO's qualifications were provided to the Department and shall be kept by the agency and available upon request by the Department. (DPOC by AES,HSLS on 9/11/19)] 08/05/2019 Implemented
6400.46(e)Program Specialist #2, date of hire 5/1/19, did not have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation.Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Program Specialist #2 was trained on principles of normalization, rights and program planning and implementation. Documentation was not readily available upon request, documentation is now available. Documentation is in the programs specialist file located in the office. The Director of Operations will ensure staff have training and documentation to be kept in file. [Copies of the documentation of orientation were provided to the Department on 9/11/19. Immediately, the CEO or designee shall develop and implement a record keeping system to ensure all staff persons records including training are kept and available upon request by the Department. (DPOC by AES,HSLS on 9/11/2019)] 09/05/2019 Implemented
6400.68(b)At 10:37AM, the hot water measured at 134.7 degrees Fahrenheit in the bathtub in the bathroom of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water temperature was reset by the apartment complex maintenance department on 8/23/19 a work order was received and placed in the maintenance file located in the office and available upon request. Director of Operations rechecked the water temperature with a thermometer that is kept in the kitchen drawer on 8/29/19 water temperature was 118 degree Fahrenheit. Director of Operations will train all staff on how to measure and document water temperature on a weekly basis. Staff will be trained to immediately notify the Director of Operations if the water temperature goes above 120 degrees, the Director of Operations will notify apartment maintenance to reset water temperature and provide a work order showing the water temperature was reset. 09/05/2019 Implemented
6400.44(c)(2)The agency could not provide documentation of Program Specialist #2, date of hire 5/1/19, work experience; therefore, compliance could not be measured.A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism.Program specialist is a Licensed practical nurse with 60 plus credit hours and 5 years experience working with individuals with intellectual disabilities. The Director of Operations has created a file with the qualifications and will be kept in the program specialist file located in the office available upon request. [Program specialist #2 has a Bachelor Degree in Nursing, copy of diploma and resume provided to the Department on 9/11/2019. Prior to hire, the CEO or designee shall verify the required qualification of staff persons including the program specialist position and ensure qualifications are kept and available upon request by the department. (DPOC by AES,HSLS on 9/11/19)] 09/05/2019 Implemented
6400.51(a)(1)Chief Executive Officer #1, date of hire 5/1/19 and Program Specialist #2, date of hire 5/1/19, did not complete orientation.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.CEO#1 completed a 4 day orientation on 7/15/19-7/18/19 and Program Specialist #2 completed a 4 day orientation on 8/26/19-8/29/19 copies were not readily available, copies are now available and is kept in the CEO and program specialist file that is kept in the office available upon request. [Copies of the documentation of orientation were provided to the Department on 9/11/19. Immediately, the CEO or designee shall develop and implement a record keeping system to ensure all staff persons records including training are kept and available upon request by the Department. (DPOC by AES,HSLS on 9/11/2019)] 09/05/2019 Implemented
SIN-00141032 Renewal 09/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(a)The home did not have a first aid kit A home shall have a first aid kit. Purchasing a first aid that contains all the required items according to the 6400 regulations. Will educate staff on the importance of of the home having a first aid kit so this will not happen again. [Immediately, and continuing at least monthly, the CEO or designee shall audit all first aid kits to ensure all required items are included and there are supplies on hand for restocking as needed. Documentation of audits shall be kept. Immediately and upon hire and as needed, the CEO or designee shall educate all staff persons of the locations and the supplies included in first aid kits and the location of extra supplies for restocking as needed and the procedures to obtain items as needed. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/3/18)] 09/12/2018 Implemented
6400.111(a)The fire extinguisher located in the kitchen of the home had a rating of 1-A 10BCThere shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Purchasing a new fire extinguisher with a 2-A rating and have it tagged/inspected by a fire safety expert. Will educate staff on the importance of having the correct 2-A fire extinguisher so that this will not happen again. [Immediately, upon opening new homes and continuing at least monthly, the CEO or designee shall complete an onsite check of all community homes including all fire extinguisher to ensure there is at least one operable fire extinguisher with a minimum 2-A rating on each floor of the home(s). Documentation of on site checks shall be kept. (DPOC by AES,HSLS on 10/3/18)] 09/12/2018 Implemented
SIN-00226587 Unannounced Monitoring 06/23/2023 Compliant - Finalized
SIN-00221237 Unannounced Monitoring 03/17/2023 Compliant - Finalized