Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235697 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not maintained in the home. In the storage area of the basement, there was an TV stand and carpeting that were dirty and damaged by some form of moisture.Clean and sanitary conditions shall be maintained in the home. On 12/17/2023, the owner of BroMack removed all items stored in this area of the basement of the home and disposed of them. Additionally, the area was cleaned. No household items will be stored in this area in the future. This has been communicated to the Residential Supervisor and she communicated it to her staff on 12/26/23. 12/26/2023 Implemented
6400.112(c)Written fire drill records for fire drills conducted on 1/30/23, 4/10/23, 5/30/23 and 10/25/23 did not include whether the fire alarm or smoke detector were operative.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 staff member responsible for not completing all aspects of the fire drill correctly was retrained by our Fire Safety Trainer on 12/18/2023. Additionally, all staff were retrained 12/26/2023 on the importance of completing fire drills with fidelity and trained on the new Fire Drill Form. 12/26/2023 Implemented
SIN-00216039 Renewal 12/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)Asleep fire drills were documented as occurring on 12/15/21 and 7/15/22. Fire drills are to be held during sleeping hours at least every six months. The timeframe between documented asleep drills conducted exceeds regulation.A fire drill shall be held during sleeping hours at least every 6 months. Our Residential Supervisors at each of our Residences completes a weekly checklist with reminders about mandatory responsibilities. We have added an item to reflect the need for an overnight fire drill every 4 months, March, August and November. Program Specialist, Cristina Osorio, will meet with the supervisors to review the regulation, introduce the new item on the checklist and the new mandate to hold a fire drill during sleeping hours every 4 months. 12/22/2022 Implemented
SIN-00201081 Renewal 03/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)The fire extinguisher located in the kitchen had a rating of 1A-10BC which did not meet the minimum 2A-10BC rating required by regulation. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). This violation of BroMack's misunderstanding of the Regulation. Upon this inspection, the Inspector made of aware of the Regulation as it relates to extinguisher capacity. As a result, the fire extinguisher was replaced with another that has a rating of 3A-40BC. Photographic evidence was sent to the Inspector on 3/17/2022. 03/17/2022 Implemented
6400.141(c)(6)Individual #1 had a late Tuberculin skin testing by Mantoux method. Individual #1 had a Mantoux test on 5/31/2019, then not again until 12/20/2021, which exceeds the requirement of testing every two years.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. This violation occurred as a result BroMack's assumption that the TB test was given at the time of the annual physical. This individual came to us in February of 2021 from at State Hospital setting and just had his annual physical there in December of 2020. When we scheduled his annual physical for December 2021. At that appointment, it was noticed that the TB test was overdue and we requested the test be administered. The TB test was administered on 12/20/2021 at his annual physical appointment. 04/07/2022 Implemented
6400.165(b)A tube of antibiotic ointment with a prescription label stating that it was prescribed for Individual #1 and should be applied topically on a pro re nata basis, was found in Individual#1's medication box but was not listed on the Individual's current Medication Administration Record.A prescription order shall be kept current.The ointment in question was prescribed in August 2021 as a result of a brush burn. We contacted the doctor and were instructed to apply antibiotic ointment that we could purchase OTC. We informed the doctor that we could not apply this medication without a prescription. The pharmacy that this individual typically uses was closed, so the prescription was called in to another pharmacy. We retrieved the medication and added it to the August MAR. However, the Residential Supervisor failed to inform his regular pharmacy of the addition of this medication, which is why this medication was not listed on the subsequent MARs. On the day of inspection, the Program Specialist added this medication to the MAR while the inspector observed. On Wednesday, April 6, 2022, the Residential Supervisor called the individual's regular pharmacy and had the ointment in question added to the MAR. 03/11/2022 Implemented