Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229782 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no unannounced fire drill was held in the following months: November 2022, December of 2022, May 2023, and June 2023. An unannounced fire drill shall be held at least once a month. A fire drill schedule for Sept 2022 to Sept 2023 was created for all of the residential sites. This was shared with the site supervisors. A Microsoft form was created for the staff to complete after the drill. Once they submit the form, the Compliance officer, IDD Director and IDD Residential Manager will get an alert in their email. In addition, reminder alerts have been set in the manager and supervisor¿s outlook calendars. 08/29/2023 Implemented
6400.112(e)A fire drill was held during sleeping hours in the home on 10/21/22, and then again on 07/15/23. This exceeds the at least every 6-month requirement.A fire drill shall be held during sleeping hours at least every 6 months. A fire drill schedule for Sept 2022 to Sept 2023 was created for all of the residential sites. This was shared with the site supervisors. A Microsoft form was created for the staff to complete after the drill. Once they submit the form, the Compliance officer, IDD Director and IDD Residential Manager will get an alert in their email. In addition, reminder alerts have been set in the manager and supervisor¿s outlook calendars. 08/29/2023 Implemented
6400.165(g)Individual #1 has been prescribed medication to treat symptoms of a diagnosed psychiatric illness. A psychiatric medication review by a licensed physician on 02/10/23, and then again on 07/14/23. This exceeds the every 3-month requirement.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.It has been confirmed that Individual #1 next psychiatric appointment is scheduled for 10/12 (within 90 days of previous appointment) Our plan of correction for this is the same as our "Plan to Maintain Compliance." 09/29/2023 Implemented
SIN-00213828 Renewal 08/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home did not complete a self-assessment.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 agency will develop a schedule for all agency self-assessments be completed in the month of February which is 4 months prior to the end of the agency's certificate of compliance. All site supervisors will be trained on completion of self assessments to include not leaving any blanks on assessments. 11/16/2022 Implemented
6400.106The furnace inspection and cleaning was completed on 6/3/2021, and then again on 6/30/2022. This exceeds the annual requirement.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Agency to schedule with Caruso Heating and Cooling annual furnace inspections prior to 6/29/23 and on an automatic reoccurring annual schedule there after. 08/25/2022 Implemented
6400.141(a)Individual #1 did not have a physical examination completed in 2021, therefore, compliance could not be measured with the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had his 2022 physical on 2/14/22. 08/25/2022 Implemented
6400.141(c)(6)Individual #1 had a tuberculin evaluation completed on 10/30/2019, and then again on 2/14/2022. This exceeds the 2-year requirement.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 #1 had a TB test on 2/14/22. Next one due is 2/14/24. 08/25/2022 Implemented
6400.166(a)(11)Individual #2's August 2022 Medication Administration Record did not include the diagnosis or purpose for the following medications: Alfuzosin HCL ER 10 Mg, Buspirone HCL 15 Mg, Clonazepam 1 Mg TabletA 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.Verified with pharmacy the diagnosis/purpose for all medications listed on MAR for each individual to be in compliance with this code. 08/25/2022 Implemented
SIN-00192950 Renewal 09/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of this home.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. All new site supervisors and residential program manager will be trained on Self-Assessments and completion of Self-Assessment tool as it relates to regulation 6400.15a,b,and c. This training will be completed by October 12, 2021. The training record will be maintained in the employee personnel file. As per regulation 6400.15a a Self-Assessment tool will be completed for this service location 3-6 months following this licensing review and 3 to 6 months prior to the end of the current licensing agreement date. These are to be completed by December 15, 2021 and the second to be completed by April 15, 2022. and annually there after. 10/15/2021 Implemented
6400.141(c)(6)Individual #1's most recent Tuberculin skin testing by Mantoux method, completed on 10/24/2019, was read and signed by a Certified Nursing Assistant.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 #1's annual physical and TB skin test is scheduled for 11/4/21. The residents physical form has been revised to indicate that the TB Skin Test must be given and read by an LPN, RN, NP, PA or the physician. 10/12/2021 Implemented
SIN-00137360 Renewal 06/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 3/27/18. The agency's certificate of compliance has an expiration date of 6/9/18. [Repeat violation 7/20/17 et. al.]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 self-assessment of programs policy was updated on 7/10/2018 to align with the correct expiration date of the license instead of the licensing visit date. The policy was also updated to include that the program manager will review the documents and work with the site supervisors and administrative assistant to ensure all areas are reviewed. The management team will be trained on the new policy by 8/19/2018.[Documentation of trainings and reviews shall be kept. (AS 7/20/18)] 08/19/2018 Implemented
6400.181(a)Individual #1 had an assessment completed on 10/18/16 and then again 12/7/17. [Repeat violation 7/20/17 et al.] Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. This assessment was completed by a program specialist / site supervisor who is no longer in that position. TCV has hired a dedicated program specialist who has been trained on the regulatory requirements to ensure compliance. The assessment policy was reviewed with the current program specialist to ensure proper understanding of the policy on July 18, 2018. The current policy is for the program specialist to complete the assessment within 50 days of admission, annually, and when there is a change in need. The assessment is to be distributed to all team members at least 120 days before the ISP review date. The assessment is to include the following areas: functional strengths, needs and preferences, likes, dislikes, and interests, current level of performance and progress related to acquisition of functional skills, communication, personal adjustment, and personal needs, need for supervision, ability to self-administer medication, ability to safely use or avoid poisonous materials, knowledge of danger of heat sources, ability to evacuate during a fire, documentation of disability, lifetime medical history, most recent psychological evaluation, recommendations for area of training, progress over the past year, ability to manage personal property, and knowledge of water safety. [Within 15 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system and educate the program specialist on the tracking system to ensure timely completion of assessments. (AS 7/20/18)] 07/18/2018 Implemented
6400.186(b)The ISP reviews for Individual #1 end-dated 6/30/17, 9/30/17, and 12/31/17 were signed by Individual #1 on 6/7/18.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. This review was completed by a program specialist / site supervisor who is no longer in that position. TCV has hired a dedicated program specialist who has been trained on the regulatory requirements to ensure compliance. The ISP three month reviews policy was reviewed with the current program specialist to ensure proper understanding of the policy on July 17, 2018. The current policy is for the program specialist to complete the three month review within 5 days of the end of the review period. The form is to be reviewed with the individual or their guardian within 15 days of the end of the review period and distributed to all appropriate team members within 30 days of the end of the review period. By the fifth of each month the program specialist is to provide the program manager with a checklist of the three month reviews that were completed and the program manager is to review 10% of all completed reviews. If a consumer is unavailable or chooses not to sign the review the program specialist will document the reason and all attempts to obtain the signature on the review form. 07/17/2018 Implemented
SIN-00098389 Renewal 07/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)On 4/29/16, at 6:40 AM, Individual #1 did not evacuate the building during the fire drill. 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. Notification was made to the local fire department in January, 2016 to inform them that this individual may refuse to evacuate and may become aggressive in stressful situations. A goal has been developed and the team is working with this individual to increase his awareness of fire safety and improve his participation in non-preferred activities including fire drills and medical appointments. Behavior support was authorized in Feb, 2016 and will focus on teaching this individual how to manage his stress during non-preferred activities to ensure his health and safety especially during fire drills and medical appointments. [Program specialist shall review monthly fire drill records and/or observe fire drills to ensure all individuals evacuate as required. Program specialist shall complete monthly documentation of Individual #1's participation and progress toward aforementioned outcomes, complete ISP reviews and provide to team members and coordinate training of direct service workers to ensure the health and safety of Individual #1 to include evacuating during fire drills. Documentation shall be kept as required. (AS 9/21/16)] 08/18/2016 Implemented
SIN-00061065 Renewal 07/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Staff Person #1's physical completed on 1/8/14 does not include a signed statement that the staff person is free of communicable diseases or that the specific precautions that are taken that will 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. The staff had a new physical exam completed on 7-9-14 and the corrections were made, the physcial now indicates that the staff is free of communicable diseases. Physical was faxed to BHSL on 7-10-14. To prevent this violation from reoccuring supervisors will review the IDD Sta ff Physical Policy and reinforce the requirements to staff when they are having a physical completed. Supervisors will review all physical forms once completed. 07/26/2014 Implemented
SIN-00177761 Renewal 10/14/2020 Compliant - Finalized
SIN-00077871 Renewal 07/16/2015 Compliant - Finalized