| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00243026
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Renewal
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04/18/2024
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessments were not filled out completely at the time of inspection. | 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.
| Self-assessment will completely be filled by the house managers and program specialist on a quarterly basis to meet the licensing requirements. |
06/03/2024
| Implemented |
| 6400.62(a) | Ajax dish detergent was on the sink in an unlocked environment. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Ajax dish detergent was removed from the sink and locked immediately during the licensing inspection. |
05/08/2024
| Implemented |
| 6400.141(a) | Individual#1's last annual physical exam was completed 2/2/23. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | House Managers will schedule appointments three months in advance of due date or as far in advance as possible to meet the licensing requirements. |
07/12/2024
| Implemented |
| 6400.142(a) | Individual#1's last dental exam was completed on 4/6/22. | 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. | House Managers will schedule appointments three months in advance of due date or as far in advance as possible to meet the licensing requirements. |
06/07/2024
| Implemented |
| 6400.144 | The GI 10/2023 follow up ultrasound to the abdomen due 3/2024, for individual #1 was not completed, arranged or provided for the individual. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| House Managers will schedule appointments three months in advance of due date or as far in advance as possible to meet the licensing requirements. |
06/07/2024
| Implemented |
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SIN-00224039
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Renewal
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04/19/2023
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(9) | Individual 1 does not have a current prostate test or PSA blood test on file. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Because the individual refused the prostate exam, we scheduled a PSA blood test immediately after inspection, results are attached. |
05/01/2023
| Implemented |
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SIN-00203990
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Renewal
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04/21/2022
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | Cleaners were located with various snacks in a closed cabinet in the den addition area. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The materials were immediately separated. Picture attached |
05/04/2022
| Implemented |
| 6400.82(e) | There was no non slip mat or surface in the Master bathroom's Shower stall | Bathtubs and showers shall have a nonslip surface or mat. | a mat was purchased and placed in the shower floor- picture attached |
05/04/2022
| Implemented |
| 6400.82(f) | The Hall bathroom did not have a trash can | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | a trash can was immediately purchased and placed in the restroom. |
05/04/2022
| Implemented |
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SIN-00187194
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Renewal
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04/22/2021
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisons were not kept locked away in the household. A spray bottle of tire shine chemicals was found on a TV stand in individual 1's room. Bottles of hand sanitizer were found in cubbies of the TV stand in the lounge. Method antibacterial spray, Suave shampoo, and All laundry detergent were found in an unlocked cabinet in the lounge as well. Other individuals in the home need supervision when around chemicals and they should be locked. As such, poisons must be locked away in the home when not in use. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous items are kept locked away in a designated closet to ensure consumers are kept safe from them. At no time should poisonous items be placed in an accessible area to consumers in any home where an individual cannot differentiate/identify poisonous or dangerous products. |
04/23/2021
| Implemented |
| 6400.62(d) | Poisonous materials and foods were food stored together. In an unlocked cabinet in the lounge area, the following items were found stored: a bottle of Excedrin, Worcestershire sauce, peanut butter crackers, Method antibacterial spray, and breakfast cereals. Nearby, Suave shampoo, Coca Cola products, and Pop Tarts were stored together on an open shelf. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | All items were removed and placed in their respective areas (attachments below). At no time should poisonous items be placed in an accessible area to consumers or stored with food items. In order to protect the safety of our individuals this item was rectified immediately. |
04/23/2021
| Implemented |
| 6400.64(a) | Clean and sanitary conditions were not maintained throughout the home. Individual 1's bathroom shower had material consistent with dirt or grime observed across its surface. The dish washer had a material consistent with grime or dirt observed around the bottom of the interior of the machine. A line of bright blue toothpaste was also observed caked up on a shelf in the main bathroom's medicine cabinet. | Clean and sanitary conditions shall be maintained in the home. | The shower was clean upon inspection, however due to the age of the bathroom, it appeared on camera as if it were unclean. A work order has been put in to do some cosmetic work to the bathroom, reglazing and improving the overall appearance of the shower. We understand the importance of keeping the home clean and free of dirt and grime. Cleanliness will be maintained throughout the home to ensure the health and safety of our individuals. |
10/30/2021
| Implemented |
| 6400.64(f) | Trash outside the home was not kept in closed receptacles. Trash cans observed outside of the home were overfilled and uncovered. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | This was rectified immediately. The trash receptacles are kept closed and trash will not exceed max capacity. We understand the importance of ensuring the trash bins are closed and not overfilled to prevent trash from being outside of the home which could be a potential hazard to our clients. At no time should our trash bins exceed maximum capacity, and they shall be kept closed when not in use. Overflow of trash contribute to unsightly and unhygienic conditions, to include possible rodent problems. |
04/23/2021
| Implemented |
| 6400.67(a) | Individual 1's room is not free from hazards. Nearly every surface in the bedroom, including large portions of the floor, are covered in general clutter, and the individual also keeps snacks like peppermints near his bed. The individual's room poses both potential fire and pest hazards. A thick build-up of lint was also observed in the dryer lint trap at time of inspection. The amount of lint observed in the trap was significant and poses a fire hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | The individual¿s room was cleaned, and clutter was removed with his approval. The individual will be reminded to keep his room clean and free of clutter. Staff will assist him with cleaning his room to ensure it is hazard free. This topic will be bought up ongoing with our behavior support team as the individual does struggle with keeping conditions tidy, and also prefers staff not be in his bedroom. Frequent encouragement and positive reinforcement will be used in effort to get the individual to work with us to clear up the space little by little. Nothing will be thrown out without the individual¿s approval. |
04/25/2021
| Implemented |
| 6400.71 | Emergency numbers were not kept within line of sight of the house's primary phone line. A list of agency numbers was kept framed near the phone. During inspection, the emergency number list was found inside the frame, behind the agency list. To access the emergency list, the frame had to be opened. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| We are aware of the importance of the emergency phone numbers being in line of sight of phone lines. In order to ensure quick access to the emergency numbers a sign was placed in the dining area, next to our phone, to ensure it is in line of shift per regulations. |
04/23/2021
| Implemented |
| 6400.82(f) | Individual 1's bathroom did not contain a trash can at time of inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The trash can was temporarily moved from the bathroom and was immediately returned to the bathroom after inspection. We understand that every bathroom should have the bare necessities to meet licensing standards as well as be readily available to ensure safe and hygienic conditions for the individuals in the homes. |
04/23/2021
| Implemented |
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SIN-00161363
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Renewal
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08/13/2019
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Behind the washer and dryer in the laundry area, there was a build up of empty detergent bottles, cleaners and dirt.
The interior of the stove was unclean and had food residue throughout the interior. | Clean and sanitary conditions shall be maintained in the home. | The area behind the washer and dryer was cleaned. The empty detergent bottles, cleaner, and dirt were disposed and cleaned. The area behind the washer and dryer will be checked after staff check the lint trap in the dryer. Debris and lint behind the washer and dryer is hazardous and could cause a fire. Lint and detergent bottles are flammable and must be disposed of properly to ensure the safety in the home. The area behind the washer and dryer was cleaned and a picture has been submitted. The interior of the stove had food residue inside. The stove was cleaned thoroughly. In the future, staff will clean and remove food from the interior of the stove. Old food or grease in a stove could cause a fire, so the stove will be cleaned with oven cleaner whenever needed, but at least on a monthly basis. A picture of the cleaned stove/oven was submitted. |
08/15/2019
| Implemented |
| 6400.143(a) | Individual #1's Psychotropic medication was prescribed on 2/5/19, but the individual has refused going to future appointments within the 90-day period. The refusal and continued attempts to train the individual about the need for health care services and appointments was not documented. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1 was refusing his psychotropic that was originally prescribed 2/5/19. The provider did not adequately document the attempts to train the individual about the need for health care services. When the individual refused to attend his follow up appointment, there should have been documentation about the appointment refusal/cancellation. A medical appointment cancellation consult sheet will be used if he or she refuses health care services and appointments. The provider will document how the individual was educated and trained, and continued attempts will be documented in the individual¿s record on a cancelled medical appointment form. If an individual refuses in the future, he or she will be trained by a different team member (staff, house manager, nurse, program specialist, etc) to see if there is a different outcome. A training will be completed with staff on how to facilitate the conversation after an appointment has been cancelled/refused, and how to complete the document or form. The program specialist will complete the training for the staff and will do on going training as necessary. |
08/15/2019
| Implemented |
| 6400.181(d) | The initial assessment for individual #1 dated on 3/1/19 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | In order to address the non-compliance, the program specialist made an addendum to the assessment. The assessment addendum was dated for 8/15/19 after the non-compliance was cited and attached to the end of the 3/1/19 assessment. In the future, the program specialist will sign and date the assessment upon it being completed and printed. The assessment be review for the program specialist¿s signature and date during quarterly audits. A copy of the assessment addendum is included for review. |
08/15/2019
| Implemented |
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SIN-00114617
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Renewal
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05/23/2017
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | There was no documentation notifying the local fire department of indivduals who need assistance while evacuating. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| There was a notification to the fire department; however the notification did not include the exact location of the bedrooms in the event of an actual fire. Both individuals in this home are fully ambulatory and able to evacuate independently, however the notification has been updated to include more information about the residents in the home and the location of their respective bedrooms. Please see attachment for updated notification. |
08/17/2017
| Implemented |
| 6400.163(c) | Individual # 1's previous psychiatric review was dated 09/09/2016 and the most recent psychiatric review was dated 03/10/2017. | 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. | It is essential that individuals who receive psychiatric care receive a medication review every 90 days or more frequently if needed. As a result of a cancellation with the doctor¿s office, there was a lapse in psychiatric care. Please see attachment to note that this is currently being followed up on and addressed to ensure compliance. |
08/17/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual # 1's annual assessment dated 12/01/2016 did not document progress and growth in the area of motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Progress needs to be noted in the assessment on the individual¿s motor and communication skills. This was included in the assessment but not in the required detailed to give a clear picture of progress and growth in this area. A.C. Morano is highly developed in this area, and so detail will focus on specifics related to the content of his communication versus his ability to do so, as he communicates very effectively and clearly. His motor skills are also highly evolved but clearer documentation will be added to demonstrate his capabilities in this area. |
08/17/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual # 1's annual assessment dated 12/01/2016 did not document progress and growth in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Progress needs to be noted in the assessment of the individual¿s recreation skills. This was included in the assessment but not in the required detailed to give a clear picture of progress and growth in the area of recreation. Additional information has been added to the assessment to ensure that an accurate picture of progress and growth in the area of recreation is clearly demonstrated. |
08/17/2017
| Implemented |
| 6400.181(e)(13)(viii) | Individual # 1's annual assessment dated 12/01/2016 did not document progress and growth in the area of managing personal property | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Progress needs to be noted in the assessment of the individual¿s skills around maintaining personal property. This was included in the assessment but not in the detailed to give a clear picture of progress and growth in the individual¿s ability to maintain his personal property. Additional information has been added to the assessment to ensure that an accurate picture of progress and growth in the area of maintaining one¿s personal property is clearly demonstrated. |
08/17/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual # 1's annual assessment dated 12/01/2016 did not document progress and growth in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Progress needs to be noted in the assessment of the individual¿s skills around community integration. This was included in the assessment but not in the detailed to give a clear picture of progress and growth in the individual¿s access and ability to integrate into the community. Additional information has been added to the assessment to ensure that a clear picture of progress and growth in the area of community integration is accurately represented. |
08/17/2017
| Implemented |
| 6400.181(e)(14) | Individual # 1's annual assessment dated 12/01/2016 did not document 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 assessment failed to address the individual¿s ability to swim. While the assessment did document details around water safety, this point was not noted and should be included in all assessments to give a clear picture of the individual¿s abilities. In addition to noting a baseline of this skill, progress and growth in this are shall be documented. |
08/17/2017
| Implemented |
| 6400.186(a) | Individual # 1's three month ISP review documentation dated 12/19/2016 through 03/18/2017 was completed on 04/24/2017. | 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. | The program specialist must complete quarterly ISP reviews of the services and outcomes every 3 months or more frequently. There should not be a lapse in completion of the ISP reviews, of more than 2 weeks at the end of the quarter. The provider incorrectly completed an ISP review over a month after the quarter was complete. To ensure that documentation is relevant, current and outcomes are accurately followed, completing ISP reviews in a timely manner is essential. Please see attached most recent ISP review and accurate dates of completion. |
08/17/2017
| Implemented |
| 6400.186(c)(4)(iii) | The methodology used to track progress towards Individual # 1's outcome of budgeting remained the same over two plan years and was not modified. | The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. | Methodology to ensure the successful completion of outcomes should be modified in the event that outcome success is not being noted and there is a lack progress or growth. Individual #1 had a budgeting goal that had an unchanged methodology over the course of 2 ISP years. It is essential that the methodology be adjusted to support achievement of the outcome. As a result of this error being brought to the provider¿s attention, the methodology for this specific outcome has been adjusted to help assist in progress, growth and eventual achievement in this area. |
08/17/2017
| Implemented |
| 6400.186(d) | There is no documentation Individual # 1's three months ISP review documentation dated 03/19/2016, 06/19/2016, 09/19/2016 and 12/19/2016 were sent to team members. | 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. | ISP reviews should be sent to team members to include the Supports coordinator within 30 calendar days of the ISP review. Email correspondence of the distribution of ISP reviews will be filed into books to show the accurate distribution of documentation. |
08/17/2017
| Implemented |
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SIN-00089223
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Renewal
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01/14/2016
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill on 10/8/15 did not document the exit route and if there were any problems encountered. | 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. | This was documentation error. The manager failed to note the meeting place and exit route on the fire drill form, but did accurately document the time, the individuals, length of time of evacuation, equipment check, and any problems. Manager re-ran drills properly in January including the exit route and meeting place. It is essential that all details be noted on fire drill logs to always include route of exit and meeting place. Quality Manager or Program Designee will audit all submitted monthly fire drills to ensure that all logs include the required documentation (dd 4.4.16) |
01/16/2016
| Implemented |
| 6400.112(h) | The fire drill on 10/8/15 did not document evacuation to a designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | This was documentation error. The manager failed to note the meeting place and exit route on the fire drill form, but did accurately document the time, the individuals, length of time of evacuation, equipment check, and any problems. Manager re-ran drills properly in January including the exit route and meeting place. It is essential that all details be noted on fire drill logs to always include route of exit and meeting place. Quality Manager or Program Designee will audit all submitted monthly fire drills to ensure that all logs include the required documentation (dd 4.4.16)
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01/19/2016
| Implemented |
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SIN-00043224
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Initial review
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09/27/2012
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.164(a) | STAFF # 2 DID NOT SIGN WITH FULL SIGNATURE ON THE MED LOG FOR INDIVIDUAL # 1 | (a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.
| The staff person placed his signature on the back of the medication log. All staff were reminded to follow this practice, and management was re-trained in providing supervision over this practice |
09/29/2012
| Implemented |
| 6400.183(5) | INDIVIDUAL #1 HAS A PLEDGE AGREEMENT DATED 7/19/12 CONCERNING SEVERAL BEHAVIORAL ISSUES. THESE ISSUES WERE NOT BEING ADDRESSED IN THE PLAN. | (5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.
| The program specialist developed a new, more comprehensive plan to include additional information regarding historical and current behavioral issues. |
10/01/2012
| Implemented |
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SIN-00138785
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Renewal
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06/18/2018
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Compliant - Finalized
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