Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229781 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: December 2022, March 2023, and April 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 conducted during sleeping hours on 10/28/22, and then again on 05/21/23. 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
6400.46(b)Direct Service Worker #1 had fire safety training on 02/11/22, and no documentation of an additional training was provided to measure compliance with this regulation. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Direct Service Worker #1 completed the fire safety training on 8/24/23. 09/29/2023 Implemented
6400.52(c)(1)Direct Service Worker #1's training for the annual training year, dated 07/01/22 to 06/30/23, did not include the following topics: 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.Direct Service Worker #1 completed the required training on 8/22/2023. 09/29/2023 Implemented
6400.52(c)(4)Direct Service Worker #1's training for the annual training year, dated 07/01/22 to 06/30/23, did not include the following topics: recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Direct Service worker #1 completed the required training on 8/30/23. 09/29/2023 Implemented
SIN-00192949 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
6400.165(g)Individual #1 had a psychiatric medication review on 4/6/2021 and then again on 7/13/2021.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.This individual's psychiatric medication review was on 7/13/21 and he just had his next appointment on 10/6/21 which is 85 days. The next appointment will be made at the end of his 10/6/21 appointment and was schedule for 12/29/21 which is 84 days between appointments. 10/06/2021 Implemented
SIN-00157691 Renewal 06/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 3:00PM, the hot water measured 134.8 degrees Fahrenheit at the bathtub in the bathroom off the hallway on the first floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. Overnight staff will check water temperatures nightly in all bathrooms. The sink and bathtub/shower temperatures will be checked and documented on a Shower/Bathtub/Sink Temperature Log. Temperatures are not to exceed 120 degrees. If any issues, staff will notify the supervisor and maintenance via email immediately. [On 6/24/19, the site supervisor adjusted the water heater and recheck the temperature later that evening, the hot water temperature measured 118°F. On 6/30/19 the water temperature measured 116°F. Water temperature measured on July 9, 10, 11 measured 116°F, 119°F, 118°F, respectively, at the bath/shower according to the temperature log submitted to the Department on 7/15/19 by Compliance Officer & Director of Quality Improvement. Prior to measuring and adjusting hot water temperature, the CEO or designee shall educate all staff persons responsible for measuring, reporting and adjusting hot water temperatures of the procedures to measure, report, document and adjust water temperatures. Documentation of the trainings shall be kept. At least monthly for 1 year, a designated management staff person shall audit the aforementioned temperature log to ensure completion and hot water temperature at all bathtubs and showers does not exceed 120°F and procedures are followed if the water temperature exceeds 120°F. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/11/2019 07/31/2019 Implemented
6400.105At 2:45PM, a large cardboard box, a small cardboard box and 3 pieces of unstained wood were being stored within ten inches of the furnace in the basement of the home.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. All residential supervisors and senior habilitation specialist will be retrained on state regulations 6400.105 relating to flammable and combustibles being stored within 36 inches of the heating sources. TCV's maintenance department will section off 36 inches on all heating sources by using bright reflective tape. If the heating source is enclosed, a sign will be posted on the door to indicate no storage. [Items were moved away from the furnace at the time of discovery during the inspection. Within 30 days of receipt of the plan of correction, all staff persons shall be notified that flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources and to monitor during the course of their daily duties. Immediately and at least monthly, a designated staff person shall complete a walk through of all community living homes to ensure flammable and combustible supplies and equipment are utilized safely and stored away from heat sources. (DPOC by AES,HSLS on 7/11/19)] 07/15/2019 Implemented
6400.112(c)The fire drill record for the fire drill conducted on 5/17/19 did not address problems encountered. The section of the form was left blank.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 Report will be updated to include a question on whether there were any issues experienced. If so, a comment box must be filled out explaining the situation. All completed fire drill reports will be sent to residential manager for review. The updated Fire Drill Report will be reviewed with residential supervisors and senior habilitation specialists and will include all requirements of completing the form. The form will be updated by July 11th and training will be provided on July 11th. [Within 30 days of receipt of plan of correction and upon hire, all staff persons responsible for conducting fire drills shall be educated in the procedure for conducting and documenting fire drill including addressing "problems encountered" Documentation of all of the trainings and aforementioned audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/11/2019 Implemented
SIN-00137358 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, department director, 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
6400.112(a)An unannounced fire drill was not held in August 2017. [Repeat violation 7/20/17 et. al.] An unannounced fire drill shall be held at least once a month. The site supervisors and program managers will be re-trained on fire safety requirements by 8/1/2018. Specifically, we will review the following areas: 1. You must have a drill every month 2. The drill must be documented on the updated current form 3. If it takes more than 2 ½ minutes to evacuate you must repeat the drill within 24 hours 4. You must vary the location of the fire 5. You must vary the evacuation route (you can¿t always use the same exit) 6. You must vary the day of week and time of day 7. You must list the time of the drill both minutes and seconds ¿ if it is 2 minutes even put 0 seconds 8. Overnight drills (October & April) must take place between 12:00 midnight and 6 am. 9. If staff do not receive the fire safety training by their annual due date they will be removed from the schedule. All fire drill forms are to be submitted to the department administrative assistant by the 15th of the month. The administrative assistant is responsible for reviewing the drills to make sure they are compliant. If they are not compliant they will be returned to the site supervisor and the drill will be re-done. The department training curriculum is revised annually (in July) so that all employees will receive the fire safety training every 11 months. All supervisors and program managers were re-trained on this policy in July, 2018. 07/27/2018 Implemented
6400.142(a)Individual #1's most recent dental examination was 8/30/16.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 #1 had a dental appointment on 6/29/18, documentation scanned to Nancy Armstrong. A standard operating procedure has been developed for tracking and monitoring all medical appointments. The current medical appointments have been loaded into a chart which the program manager will sort by ¿next due¿ and review with each site supervisor at the beginning of each month. The supervisors will be responsible to provide copies of appointment documentation of each required appointment to the program manager. Once the documentation is received the program manager will review the appointment summary to make sure it is appropriately filled out. If the form is complete the program manager will update the medical appointment chart to maintain current information and send the copy of the appointment summary to the program specialist. The program manager was trained on this process on 7/18/18. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 10% sample of individuals' dental appointment documentation to ensure timely completion. (AS 7/20/18)] 07/18/2018 Implemented
6400.186(a)Individual #1's ISP review end-dated 9/10/17 was signed and dated by Individual #1 on 12/22/17. [Repeat violation 7/20/17 et.al.]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. 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-00118137 Renewal 07/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment (using a Self-Inspection and Declaration tool) between 4/3/17 and 4/18/17. The expiration of the agency's certificate of compliance was 6/9/17.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. A self-inspection policy was developed to ensure the correct form is completed within 3-6 months prior to the expiration date of TCV¿s Certificate of Compliance. The policy is below. It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance, TCV will conduct a self-assessment of programs 3-6 months before expiration of the current license. PROCEDURE The department director or delegate is responsible for ensuring a self-inspection of the program is completed within 3-6 months before the expiration of the current license. The department director will notify the program manager when the LII is due. The program manager will work with site supervisors and program specialists to ensure thorough review of all regulatory requirements and accurate documentation of compliance on the licensing inspection instrument scoresheet. If an area of non-compliance is identified during the self-inspection the program manager and site supervisor are responsible to resolve the issue. If the issue is unable to be resolved, the program manager will notify the department director and a plan of action will be developed to prevent future occurrences of the same violation. The LII can be found at dhs.state.pa or by searching licensing inspection instrument and selecting the program regulations (either 6400 or 2380) The program manager will submit the LII to the department director no later than April 1 of each year. The department director will maintain the LII for the upcoming audit which typically occur in July.[At least 3 months prior to the expiration of the certificate of compliance the Director of IDD Services shall review all self-inspections to ensure timely completion on the Department's licensing inspection instrument. Documentation of the audit of the self inspections shall be kept. (AS 8/11/17)] 08/04/2017 Implemented
6400.15(b)The agency completed a self-assessment of the home using the Department's Self-Inspection and Declaration Tool used for self-inspection of a new home.The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance. The correct form was identified on 7/21/2017. Supervisors have been provided the correct LII tool and are working with the program manager and department director to complete self- inspections by 8/31/2017. A self-inspection policy was developed which is included below. It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance, TCV will conduct a self-assessment of programs 3-6 months before expiration of the current license. PROCEDURE The department director or delegate is responsible for ensuring a self-inspection of the program is completed within 3-6 months before the expiration of the current license. The department director will notify the program manager when the LII is due. The program manager will work with site supervisors and program specialists to ensure thorough review of all regulatory requirements and accurate documentation of compliance on the licensing inspection instrument scoresheet. If an area of non-compliance is identified during the self-inspection the program manager and site supervisor are responsible to resolve the issue. If the issue is unable to be resolved, the program manager will notify the department director and a plan of action will be developed to prevent future occurrences of the same violation. The LII can be found at dhs.state.pa or by searching licensing inspection instrument and selecting the program regulations (either 6400 or 2380) The program manager will submit the LII to the department director no later than April 1 of each year. The department director will maintain the LII for the upcoming audit which typically occur in July. [At least 3 months prior to the expiration of the certificate of compliance the Director of IDD Services shall review all self-inspections to ensure timely completion on the Department's licensing inspection instrument. Documentation of the audit of the self inspections shall be kept. (AS 8/11/17)] 08/04/2017 Implemented
6400.46(g)Direct Service Worker #1 had fire safety training on 3/15/16 and then again on 4/13/17.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). [Immediately, the Director of IDD Services shall develop and implement a tracking system to ensure all program specialist and direct service workers are trained annually in required areas of fire safety. At least quarterly, for 1 year a designated management staff person shall audit the tracking system to ensure fire safety training is completed, timely. Documentation of audits shall be kept. (AS 8/11/17)] 08/04/2017 Implemented
6400.141(c)(9)The most recent prostate examination completed for Individual #1, date of birth 7/3/69, was 3/29/16.The physical examination shall include: A prostate examination for men 40 years of age or older. A prostate exam has been scheduled for November 8, 2017. The documentation timeframes worksheet includes the requirement for a prostate exam and will be completed for all current individuals by 8/31/17. The monthly documentation checklist that will be submitted by the fifth of each month also includes confirmation that all medical appointments and screenings are completed. The program specialist monthly documentation policy is listed below. It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance TCV will monitor completion of all regulatory documents. PROCEDURE Upon admission and at each annual ISP review meeting the program specialist will complete the Individual documentation timeframes worksheet. When an ISP is scheduled the Program specialist will email the program manager to notify of the meeting. Within 5 days following the meeting the program specialist will update the individual documentation timeframes worksheet and submit a copy to the program manager. Each month the program specialist will complete the monthly documentation checklist for the previous month. The checklist will be submitted to the program manager by the fifth of the month. The program manager will audit 10% of the monthly summaries, 10% of the service plan three month reviews, 100% of incidents, 100% of medication logs, and 10% of financial documentation. The program manager will also follow up on any issues and make sure all documentation is filed appropriately. The program specialist and program manager will meet monthly to review the monthly documentation form. 08/04/2017 Implemented
6400.164(b)The medication Chlorhexidne 0.12% rinse prescribed for Individual #1 was not initialed as administered on 7/3/17 at 7:30AM. (Repeated Violation-7/21/16, et al) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The direct care worker who was to administer the Chlorhexidine believed she had administered the medication and since this is a liquid medication it is difficult to determine if this is a medication error or a documentation error. The staff person was retrained by a medication trainer and received a counseling documentation for this error. All staff will be trained on the medication check policy that is included in this POC. It is the policy of TCV to assure that medications are administered to individuals as prescribed. The following procedure has been developed in an effort to prevent medication errors. At designated times of each day/evening staff are to verify that the staff working the shift before them administered each medication that was scheduled to be given. The designated times will vary per site. The supervisor is responsible to ensure that all staff is aware of the times Medication Checks are to be completed. ¿ Every residential site will have a check list for each individual¿s medications. ¿ There will be a separate med check sheet/list for the designated medication administration times at each site. ¿ This checklist will be saved in the PHI folder for that site. It is updated as needed by the site Supervisor, SRA or designee. ¿ Hard copies of the checklists are kept in a location easily accessible to all staff (i.e., staff desk, filing cabinet, etc.). ¿ At the designated times, staff are to pull out a checklist and all current medication packs for the corresponding individual. ¿ Staff will look at each medication pack and ensure that the bubble for the corresponding day has been popped and is empty. ¿ Staff will place a check mark next to each medication on the list indicating that they have checked each medication pack. ¿ Completion of the medication check should then be documented in the Communication Log by the staff member. The checklist will either be taped into the communication log or placed in a location specified by the site supervisor. ¿ If a blister pack is empty staff should replace it with one from the stock medications. If a replacement is not available the staff member should contact the pharmacy for a refill. ¿ If during the medication check, it is found that a medication was not given (i.e., the bubble pack was not popped, etc.), staff should follow the Incident Management Policy and report it to the Supervisor/SRA via the sites on-call phone. 08/04/2017 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 5/10/17, to the plan team members on 6/8/17 for an annual ISP meeting on 6/15/17.(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). The annual assessment is included in the new "documentation timeframes worksheet" and also in the "monthly documentation checklist" to ensure the document is distributed within the regulatory guidelines. The program specialist monthly documentation policy is included below. It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance TCV will monitor completion of all regulatory documents. PROCEDURE Upon admission and at each annual ISP review meeting the program specialist will complete the Individual documentation timeframes worksheet. When an ISP is scheduled the Program specialist will email the program manager to notify of the meeting. Within 5 days following the meeting the program specialist will update the individual documentation timeframes worksheet and submit a copy to the program manager. Each month the program specialist will complete the monthly documentation checklist for the previous month. The checklist will be submitted to the program manager by the fifth of the month. The program manager will audit 10% of the monthly summaries, 10% of the service plan three month reviews, 100% of incidents, 100% of medication logs, and 10% of financial documentation. The program manager will also follow up on any issues and make sure all documentation is filed appropriately. The program specialist and program manager will meet monthly to review the monthly documentation form. 08/04/2017 Implemented
6400.186(d)The program specialist did not record when Individual #1's ISP review documentation from the review periods 6/4/16 to 9/13/16; 9/14/16 to 12/13/16 and 12/14/16 to 3/13/17 were provided to the plan team members; therefore, compliance could not be measured.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The program specialist confirmed with the SC that the service plans from 6/14 - 9/13 and 9-14 - 12-13 were received. The 12/14 - 3/13 service plan review was provided to the team on 7/20/2017. A three month review policy was created and is included below. It is the policy of TCV Community Services to provide all services as defined by the ISP in compliance with state, county, and federal regulations. Therefore, the program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. PROCEDURE Each program specialist is to document the ISP review date for all assigned individuals on the documentation timeframes worksheet. From the ISP review date the program specialist will determine monthly and three month review due dates and document them on the documentation timeframes worksheet. Based on the ISP review date the program specialist will determine monthly and three month review dates and document all due dates on the ¿Individual Timeframes Worksheet¿ . (PHI/IDD/IDDPolicy & Procedures / forms). The program specialist will notify the program manager of all ISP meetings via email. The form is to be updated at each annual ISP meeting and submitted to the program manager within 5 days of the meeting. The three month review is to include the following information: (1) A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. (2) A review of each section of the ISP specific to the residential home. (3) The program specialist shall document a change in the individual¿s needs, if applicable. (4) The program specialist shall make a recommendation regarding the following, if applicable: (i) The deletion of an outcome or service to support the achievement of an outcome which is no longer appropriate or has been completed. (ii) The addition of an outcome or service to support the achievement of an outcome. (iii) The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. (5) If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment as required under § 6400.181(b) (relating to assessments). (d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Program Specialist is to document that the ISP review was sent to all applicable parties and print supporting documentation to be stored in the consumer¿s chart (ie email confirmation, ect). (e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. (f) If a recommendation for a revision to a service or outcome in the ISP is made, the plan lead as applicable, under § § 2380.182(b) and (c), 2390.152(b) and (c), 6400.182(b) and (c), 6500.152(b) and (c) (relating to development, annual update and revision of the ISP), shall send an invitation for an ISP revision meeting to the plan team members within 30 calendar days of receipt of the recommendation. (g) A revised service or outcome in the ISP shall be implemented by the start date in the ISP as written. At the end of each month the program specialist will review all documentation to ensure it has been completed, signed, dated, sent to all appropriate team members, and filed appropriately. The program specialist will complete a monthly checklist and submit it to the program manager by the fifth of each month confirming completion of the all applicabl 08/04/2017 Implemented
SIN-00061063 Renewal 07/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)The "Rights" statement signed by Individual #1 on 1/1/14 did not include the right per regulation 33(i)regarding the right to unrestricted mailing privileges.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. The Bill of Rights that includes 33(i) was signed by the individual on 7-9-14. This was verified by the BHSL auditor on site. To prevent a reoccurance of this violation the Bill of Rights was updated to include regulation 33(i). Each individual served in TCV's residential facilities have reviewed and signed the updated version. This is kept in each individuals program binder. This will be reviewed annually as per regulation. 07/26/2014 Implemented
6400.46(c)The chief executive officer had 12.5 hours of annual in training year July 1, 2013 to June 30, 2014. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.the correct number of trainings for the cheif executive officer were submitted to BHSL on 7-10-14. To prevent a reoccurance of this violation the CEO will maintain records of 24 hrs of training each fiscal year. the trainings will be secured prior to liscensing. 07/26/2014 Implemented
SIN-00177759 Renewal 10/14/2020 Compliant - Finalized
SIN-00098387 Renewal 07/21/2016 Compliant - Finalized
SIN-00094617 Unannounced Monitoring 07/20/2015 Compliant - Finalized
SIN-00077869 Renewal 07/15/2015 Compliant - Finalized