Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231850 Renewal 09/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There was not a window or a mechanical ventilation fan in the bathroom adjacent to the staff office. There was not a window or a mechanical ventilation fan in the bathroom adjacent to the laundry room.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Why is the regulation important? This regulation is important because it prevents the buildup of moister in the bathroom area that can lead to potential hazards such as mold. What happened? The two bathrooms within the inspected apartment are surrounded by interior walls and do not contain a window. Key Life had an oscillating fan in each bathroom to create circulation instead of mechanical ventilation. Why did it happen? When Key Life originally licensed the location in 2013, it was advised to use fans in the bathrooms to meet the requirement of the regulation since there was no window or mechanical ventilation system. Key Life complied and there had been no violations upon physical site inspections annually since. Key Life was unaware of the modified interpretation of the regulation and the expectation that a fan did not meet the standard set forth in the regulation any longer. What do we do right now? Key Life will continue to utilize the fans to create circulation in the bathrooms until mechanical ventilation can be installed. Key Life¿s Facilities Director has been made aware of the need to install mechanical ventilation and the need to expedite the process. Plans have been drawn to map out the instillation of the ventilation system and construction is to begin as soon as possible. Key Life will inspect all other licensed homes in operation to ensure that mechanical ventilation or a window is in living areas, recreation areas, dining areas, individual bedrooms, kitchens, and bathrooms. If an area is found to be non-compliant, plans will be made to install proper ventilation as soon as possible. 11/30/2023 Implemented
SIN-00179982 Renewal 12/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain scissors. 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. What specific change will be made: Scissors will be available in the first aid kit. Who will make the change: the Medical Manager. When will the change be made: The scissors were purchased on 12/1/2020 at Walmart and were placed in the home on 12/4/2020 after the inspection took place. How will the change be made: Scissors will be purchased and kept in the first aid kit. What system have you implemented to make sure that the same violation will not occur again: Medical Manager will check the first aid kit monthly to make sure all supplies are available and keep documentation on Therap. What training will be provided to your staff: CEO trained Medical Manager on the proper protocol to follow, which includes monthly checks of the first aid kit, what it should contain as per 6400 regulations, and documentation on Therap.[Immediately, the CEO or designee shall educate all staff persons of the required contents of first aid kits and the agency's procedures for replacement and replenishment of items if items are depleted or missing throughout the course of their daily duties. Documentation of aforementioned monthly audits by the Medical Manager shall be kept. (DPOC by AES,HSLS on 12/29/20)] 12/15/2020 Implemented
6400.111(f)The fire extinguisher in the kitchen of the home was most recently inspected and approved by a fire safety expert in August 2019. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. What specific change will be made: Contract with Liberty Fire Solutions, LLC to annually inspect fire extinguishers Who will make the change: Residential Manager, When will the change be made: Immediately How will the change be made: Appointment made with Liberty Solutions for address 775 Main Street Coalport Apt 2 for fire extinguisher inspection. 12/11/2020 930am. What system have you implemented to make sure that the same violation will not occur again: KLHS is set up on a reoccurring appointment schedule with Liberty Fire Solutions, LLC to annually inspect the fire extinguishers. What training will be provided to your staff: Residential Manager and CEO reviewed the 6400 RCG where grace periods are discussed and saw that Fire drills are excluded from a 5-day grace period. [At least monthly, the CEO or designee shall audit all fire extinguishers to ensure fire extinguishers are inspected and approved timely and the date of the inspection is on the fire extinguisher; as well as, all requirements of fire extinguisher are met as per 6400.111a-111f. (DPOC by AES,HSLS on 12/29/20)] 12/15/2020 Implemented
6400.112(e)A fire drill was held during sleeping hours on 2/12/20 and then again on 7/16/20.A fire drill shall be held during sleeping hours at least every 6 months. What specific change will be made: Ensure that Fire drills are completed on the exact date or prior to the previous sleep hour fire drill within the six months. Who will make the change: Residential Manager, When will the change be made: Immediately How will the change be made: Residential Manager has entered reminders for fire drills in agency outlook calendar. What system have you implemented to make sure that the same violation will not occur again: Reminder set in office outlook calendar for residential manager that will generate monthly reminders of dates and times Fire Drills to be conducted in a timely manner. What training will be provided to your staff: Residential Manager and CEO reviewed the 6400 RCG where grace periods are discussed and saw that Fire drills are excluded from a 5 day grace period. [At least quarterly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drill are conducted and documented as required as per 6400.112a-112h. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/29/20)] 12/15/2020 Implemented
6400.151(c)(2)Direct Service Worker #1 had a Tuberculin Test completed on 9/27/17 and then again on 2/17/20. 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. What specific change will be made: Direct Service Workers will get a Tuberculin skin test by Mantoux method with negative results every 2 years. If for some reason the DSW is unable to have the test preformed via Mantoux method a chest X-Ray or blood work will be performed. Direct Service Worker #1 was given a Tuberculin skin test via Mantox method on 2/14/2020. Who will make the change: Direct Service Worker #1 When will the change be made: It was implemented on 2/19/2020 due to an inspection from Central Region. How will the change be made: Direct Service Worker #1 was given a Tuberculin skin test via Mantox method on 2/14/2020. What system have you implemented to make sure that the same violation will not occur again: On 2/19/2020 Direct Service Worker #1 verbally, and in writing via fax, notified Healthforce where KLHS employees complete their physical, to perform an X-ray or blood test if the DSW is unable to complete the Mantox method. What training will be provided to your staff: Residential Manager was instructed by CEO to ensure all staff receive a TB test by x-ray or blood test if unable to receive it by Mantox Method. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all staff persons have Tuberculin testing prior to hire and every two year. Immediately and upon completion, the CEO or designee shall audit all staff persons' current physical examinations to ensure all required information is included. Documentation of audits shall be kept. (DPOC by AES, HSLS on 12/29/20)] 12/15/2020 Implemented
6400.166(a)(7)Individual #1 is prescribed for Colace Clear CAP 50 MG, take 1 capsule by mouth daily as needed for constipation and Bisacodyl Tab 5MG EC, take 2 tablets (10 MG) by mouth daily as needed for constipation. The only medication present in Individual #1's medication storage area for constipation was Stool Softener 100MG Soft Gel capsules.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Who will make the change: Medical Manager. When will the change be made: The medication was disposed of on 12/4/2020 How will the change be made: The wrong dose medication was disposed of into the drug buster. What system have you implemented to make sure that the same violation will not occur again: Medical Manager will order the medications from the pharmacy when needed on her monthly checks to the residential home. She will document her inspection of medications in the home on the Therap form. What training will be provided to your staff: CEO trained Medical Manager on the proper protocol to follow, which includes monthly checks to the residential home and documentation on Therap. [Immediately and at least monthly and after medical appointments, a designated staff person who is certified to administer medications shall audit all individuals' current medication administration record, physician's orders, and medications to ensure all individuals are administered medications as prescribed and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/29/20)] 12/15/2020 Implemented
SIN-00141065 Renewal 08/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The most recent signed and dated statement acknowledging receipt of the information on individual right for Individual #1 was completed on 7/13/17.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. ¿ Who will make the change? The program Specialist will be responsible for reviewing the individual¿s rights with them within the required time frame. ¿ When will the change be made? Immediately ¿ How will the change be made? The program specialist will go to the individual¿s home to review the rights with the individual within the required time frame instead of doing it at the annual ISP meeting, which could fall outside of the time frame depending on the schedules of the team. ¿ What system have you implemented to make sure that the same violation will not occur again? The program specialist will be using the Therap online database system to track individual requirement due dates. She will be trained on the Therap system 10/2/18. ¿ What training will be provided to your staff? The Program Specialist reviewed the new expectation with the program director. [Individual #1 signed and dated a statement acknowledging receipt of the information on rights on 8/28/2018. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure individual(s) are informed timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/17/18)] 09/14/2018 Implemented
6400.113(a)The most recent fire safety training for Individual #1 was completed 7/13/17. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. ¿ What specific change will be made? Individuals will be trained in fire safety procedures annually to the exact date they either originally received the training or to the date they received the training the previous year. ¿ Who will make the change? The program Specialist will be responsible for ensuring training is completed within the required time frame. ¿ When will the change be made? Immediately ¿ How will the change be made? The program specialist will go to the individual¿s home to complete the training in the required time frame instead of doing it at the annual ISP meeting, which could fall outside of the time frame depending on the schedules of the team. ¿ What system have you implemented to make sure that the same violation will not occur again? The program specialist will be using the Therap online database system to track individual training due dates. She will be trained on the Therap system on 10/2/18. ¿ What training will be provided to your staff? The Program Specialist reviewed the new expectation with the program director. [Individual #1 was instructed in fire safety on 8/28/18. signed and dated a statement acknowledging receipt of the information on rights on 8/28/2018. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure individual(s) are instructed if fire safety, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/17/18)] 09/14/2018 Implemented
6400.151(c)(2)Direct Service Worker #2 had a Tuberculin skin test read on 9/10/15 and then again 7/11/18. 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. ¿ What specific change will be made? Employees will receive a physical complete with negative TB skin test every two years.¿ Who will make the change? Supervisor of Residential Services ¿ When will the change be made? Immediately ¿ How will the change be made? The Supervisor will review all physicals documentation to ensure that the TB test is completed as part of the physical. She has called Healthforce to make sure they document that the TB is part of every physical for KLHS employees.¿ What system have you implemented to make sure that the same violation will not occur again? The Supervisor of Residential Services will use the Therap App calendar and reminders for employee physical examinations. ¿ What training will be provided to your staff? The Supervisor of Residential services has review the expectation with the Program Director. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and the all staff persons physical examination documentation to ensure all staff person have physical examination including Tuberculin skin testing completed, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/17/18)] 09/14/2018 Implemented
6400.168(d)Direct Service Worker #1 completed Medication Administration training on 2/2/17 and then again 6/12/18. Direct Service Worker #1 administered medications to Individual #1 on 3/1/18, 3/6/18, and 3/8/18.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. ¿ What specific change will be made? The Medication Administration Trainor will complete the Medication Administration Course Practicum before the annual training date. ¿ Who will make the change? The Medication Administration Trainor ¿ When will the change be made? Immediately ¿ How will the change be made? The trainor will base the annual training on the date at which the person was first trained instead of on the agencies training year. ¿ What system have you implemented to make sure that the same violation will not occur again? We are implementing an online database system called Therap which helps to maintain training schedules. Each person¿s original training date will be put into the system and reminders will be set to ensure the practicum is completed before the annual date. ¿ What training will be provided to your staff? On 10/2 the trainer has a meeting with the Therap Specialist to be trained on using the training scheduling system. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and the all staff persons qualifications and/or documentation of training for administering medications to ensure only staff persons who are certified to administer medications are administering medications. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/17/18)] 09/14/2018 Implemented
6400.186(a)The program specialist completed the ISP reviews for Individual #1 for the periods of 3/1/18 to 5/31/18 on 6/19/18 and the period of 12/1/17 to 2/28/18 on 3/20/18.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.¿ What specific change will be made? The program Specialist will complete the ISP review and review it with the individual no later than 15 days after the end of the 3 month period. ¿ Who will make the change? The program Specialist ¿ When will the change be made? Immediately ¿ How will the change be made? The Program Specialist will not review the ISP review with the individual at the monthly team meeting, due to the fluctuation in when the meeting is held throughout the month based on the schedules of the team. The Program Specialist will complete the ISP review and schedule a home visit within 15 days to review it with the individual, then present it at the monthly team meeting. ¿ What system have you implemented to make sure that the same violation will not occur again? The Program Specialist has been notified in writing of the due date to have ISP reviews completed and reviewed with the individual. She has signed the notice indicating her understanding of her responsibility. ¿ What training will be provided to your staff? The Program Specialist reviewed the new expectation with the program director. [At least quarterly for one year, the CEO or designee shall audit all ISP review to ensure the program specialist has completed an ISP review every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/17/18)] 09/14/2018 Implemented
SIN-00121198 Renewal 09/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(f)The most recent dental hygiene plan for Individual #1 was completed 2014. Individual #1's ISP, last updated on 7/10/17, in the Adaptive/Self-Help Section states "[S/he] can preform self-care tasks with verbal prompting such as bathing, getting dressed, tooth brushing, etc."An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. -What specific change will be made? The individual¿s ISP and assessment will be corrected to reflect the individual¿s current self-care abilities. She does not require prompting for brushing her teeth twice a day, or attending bi-annual dental appointments. -Who will make the change? The Program Specialist will update the assessment and the SC will update the ISP. The program specialist will remove the previous dental plan from the individual¿s current record books. The Program specialist will train staff on how to complete a daily log showing the need or lack of need for a dental plan. -When Will the change be made? The assessment was corrected and the dental plan was removed immediately. The SC confirmed she will update the individual¿s ISP immediately and we will discuss the change at the ISP meeting on 10/17/17. -How will the change be made? The program specialist emailed the SC requesting the change to the ISP. The program specialist corrected the selfcare section in the individual¿s annual assessment that was due on 9/20/17. -What system has been implemented to make sure the same violation will not occur again? A dental plan requirement has been added to the list of annual documentation that is to be completed for an individual. This is to ensure that any future person receiving services from KLHS will have a current dental plan completed annually if needed. -What training will be provided to staff? Staff will be asked to record in the daily log if an individual required prompting for self-care via memo. All staff will have to sign that they read the memo and any questions or concerns will be discussed at the staff meeting on 10/13/17. This will aid in ensuring the individual does not require a dental plan and that the self-care section on and assessment is always reflecting the individual's current needs/abilities. 09/29/2017 Implemented
6400.181(e)(12)The assessment completed 9/20/16, for Individual #1, did not include recommendations for specific areas of training, programming and services. This section of the assessment was left blank. The assessment must include the following information: Recommendations for specific areas of training, programming and services. -What specific change will be made? A section for recommendations has been added to the individual assessment. -Who will make the change? The program specialist -When Will the change be made? Immediately -How will the change be made? The section for recommendations has been added to individual 1¿s updated assessment which was due to be completed 9/20/17 and emailed to the team. -What system has been implemented to make sure the same violation will not occur again? The section for recommendations has been added to the blank assessment form to ensure that it will be included in all future assessments. -What training will be provided to staff? The CEO reviewed with the program specialist the specifications for recommendation sections in an individual¿s annual assessment. 09/29/2017 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment, completed 9/20/16 to all plan team members including Individual #1's family and mental health therapist. (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). -What specific change will be made? The program specialist will email the assessment to the team upon completion to ensure the entire team receives the assessment even if they are not in attendance at the annual meeting. -Who will make the change? The program specialist -When Will the change be made? Immediately -How will the change be made? The program specialist will email the assessment as opposed having it signed at the annual meeting. -What system has been implemented to make sure the same violation will not occur again? The due date for the completion of the assessment has been added to an electronic calendar including a reminder to email the assessment to the team. The requirement to email the assessment to the entire team has been added to the program specialist¿s jo description. -What training will be provided to staff? CEO reviewed the program specialist¿s job description with the program specialist which includes the individual¿s assessment should be emailed to the entire team.[Prior to the program specialist providing the assessment to all plan team members, the program specialist shall review the individuals' record to include the invitation letter, ISP and other documentation to ensure all plan team members are provided the individuals' assessments as required and documentation of the correspondence is kept. (AS 10/3/17)] 09/29/2017 Implemented
6400.186(d)The program specialist provided Individual #1's ISP review documentation, for review period 3/1/17-5/31/17 to the SC and plan team members on 5/8/17.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. -What specific change will be made? The program specialist will provide the ISP review documentation to the SC and plan team members within 30 calendar days after the ISP review meeting. -Who will make the change? The program specialist -When Will the change be made? Immediately -How will the change be made? The program specialist will complete the ISP review at the end of each quarter. The quarterly will be emailed to the team to ensure it is received within 30 calendar days after the review meeting. A copy of the email receipt will be kept on file with each quarterly. -What system has been implemented to make sure the same violation will not occur again? The Quarterly due dates were added onto an electric calendar with reminders set three days prior to the due date to ensure it is emailed at the correct time. -What training will be provided to staff? CEO reviewed ISP quarterly review due dates with the program specialist to ensure accuracy as per policies and procedures. [At least quarterly, for 1 year the CEO shall review ISP review correspondence documentation to ensure the program specialist provided the individuals" ISP reviews to the plan team members within 30 calendar days after the ISP review. Documentation of the audits shall be kept. (AS 10/3/17) 09/29/2017 Implemented
SIN-00097758 Renewal 07/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-inspection dated 2/9/16 by the agency was not fully completed. [Repeated Violation - 7/8/15.]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. What specific change will be made: A self-assessment of each home the agency operates serving eight or fewer individuals will be completed, 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. Who will make the change: The Supervisor of Residential Services is responsible to ensure the self-assessment is fully completed. When will the change be made: The change will be implemented immediately. How will the change be made: The CEO will meet with the Supervisor of Residential Services to review proper completion of the form and a training record will be kept on file What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: The Program Specialist will review the self-assessment at least one month prior to the expiration date of the agency¿s Certificate of Compliance to ensure the self-assessment is fully completed. It has been added to the annual requirement checklist that the program specialist must check the self-assessment one month in advance. (See Annual Requirements Checklist)[Immediately, the agency will completed the self assessment dated 2/9/16. Upon receipt of the current license, the CEO will review the expiration date and develop and implement a tracking system to ensure the self-assessment is competed in full 3-6 months prior to the expiration date. within 1 week of completion the CEO shall review the Self assessment to ensure full completion. documentation of the review shall be kept. (AS 12/6/16)] 08/26/2016 Implemented
6400.46(g)Program Specialist #1, Direct Service Worker #2, and Direct Service Worker #3 completed fire safety training on 8/13/14 and then again on 8/31/15.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). What specific change will be made: Annual fire safety training will be completed by for before the exact annual date. Who will make the change: The Supervisor of Residential Services is responsible for scheduling the annual fire safety training. When will the change be made: The change will be implemented immediately. How will the change be made: The supervisor of residential services will schedule all trainings within the first month of the new training year, to ensure compliance with timelines. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: A memo has been sent out to all KLHS personnel that annual trainings must be completed by the same date each year. It is the responsibility of the Supervisor or Residential Services to ensure compliance with fire drill regulations and the role has been added to the job description. The supervisor of residential services will add the previous year¿s training date and the date the training is scheduled for the current year to the list of annual requirements, within the first month of the new training year (September) and have the form reviewed and signed by the CEO. (See KLHS memo to All Personnel and List of Annual Requirements). [Program Specialist #1, Direct Service Worker #2, and Direct Service Worker #3 completed fire safety training on 8/11/16. At least quarterly for 1 year, the CEO shall review training documentation to ensure staff trainings are completed, timely. (AS 12/6/16)] 08/26/2016 Implemented
6400.112(a)The monthly 2016 calendar located on the wall of the staff office listed the day the fire drill was to be completed each month. An unannounced fire drill shall be held at least once a month. What specific change will be made: The fire drill schedule has been removed from the office. Who will make the change: The Supervisor of Residential Services will be responsible for preforming unannounced fire drills to staff or individuals, or informing one staff member they are responsible for preforming a fire drill unannounced to other staff and individuals in the home. When will the change be made: The change will be implemented immediately. How will the change be made: The supervisor of residential services will either go to the home unannounced and preform a fire drill on the spot or will call and inform staff on duty that they are to do a fire drill immediately. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: The procedure for fire drills has been added to policies and procedures. The responsibility for scheduling or completing unannounced fire drills has been added to the Supervisor of Residential Services job responsibility form and signed. The Supervisor of Residential Services will schedule fire drills within the first month of the new training year and enter them with reminders and instructions as to who will complete the fire drill, into the office electronic calendar. (See Policies and Procedures ¿ Fire Drills section and Supervisor of Residential Services job responsibilities).[On 11/8/16, the aforementioned fire drill calendar was removed from the staff office by the program specialist. Prior to submitting a plan of correction, the CEO or program specialist will ensure accurate information is being provided. Within 30 days or receipt of the plan of correction the Program specialist will observe a fire drill to include aforementioned procedures to ensure fire drill are unannounced to all staff and individual(s) who are participating in fire drill. Immediately and at least quarterly for 1 year the program specialist shall complete a walk through of the home to ensure there is no documentation of when fire drills are to be completed. (AS 12/6/16)] 08/26/2016 Implemented
6400.113(a)Individual #1 received fire safety training on 8/13/14 and then again on 8/31/15. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. What specific change will be made: Annual fire safety training for individuals will be completed on or before the exact annual date. Who will make the change: The supervisor of residential services is responsible for scheduling the annual fire safety training. When will the change be made: The change will be implemented immediately. How will the change be made: The supervisor of residential services will schedule all trainings within the first month of the new training year, to ensure compliance with timelines. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: A memo has been sent out to all KLHS personnel that annual trainings must be completed by the same date each year. It is the responsibility of the Supervisor of Residential Services to ensure compliance with fire drill regulations and the role has been added to the job description. The supervisor of residential services will add the previous year¿s training date and the date the training is scheduled for the current year to the list of annual requirements, within the first month of the new training year (September) and have the form reviewed and signed by the CEO. (See KLHS memo to All Personnel and List of Annual Requirements). [Individual #1 had fire safety training on 8/12/16. Immediately, the CEO shall develop and implement a tracking system to ensure timely completion individual's fire safety training. (AS 12/6/16)] 08/26/2016 Implemented
6400.141(c)(6)Individual #1 had a Tuberculin skin test read on 7/14/13 and then again on 9/14/15.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. What specific change will be made: Individuals will have a Tuberculin skin test on or before the exact date every two years. Who will make the change: It is the responsibility of the program specialist to schedule the individual¿s Tuberculin skin tests to achieve compliance with regulation. When will the change be made: The change is implemented immediately. How will the change be made: The program specialist has sent out a memo to all KLHS personnel that Tuberculin skin tests must be completed by the same date every 2 years. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: A statement explaining the time frames for individual Tuberculin skin tests has been added to the policies and procedures for physical examinations to ensure future compliance. The responsibility to ensure compliance with staff physicals has been added to the program specialist¿s job description. The Program specialist will add the individual¿s previous year¿s Tuberculin skin test and the date the test must be completed by to the list of annual individual requirements, within the first month of the new training year (September) and have the form reviewed and signed by the CEO. (See Policies and Procedures ¿ Physical Examinations section and List of Annual Employee Requirements form). [Immediately, the CEO shall develop and implement a tracking system to ensure Tuberculin skin test are scheduled and completed timely. Upon completion the program specialist shall review the individual's physical examination to ensure timely completion of the Tuberculin skin test. Documentation of reviews of physical examination shall be kept. AS 12/6/16)] 08/26/2016 Implemented
6400.141(c)(10)Individual #1's physical examination, completed 3/7/16, did not have a section to address communicable disease; therefore, compliance could not be measured.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. What specific change will be made: A section including specific precautions that must be taken if the individual has a communicable disease has been added to the physical examination form Who will make the change: The individual physical examination form will include specific precautions that must be taken if the individual has a communicable disease. When will the change be made: The change was implemented immediately. How will the change be made: The program specialist has added the section to the individual physical examination form. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: This form will be used for all individuals going forward to ensure compliance. The responsibility to ensure compliance has been added to the program specialist¿s job description. Biannually the CEO will review all the individual physicals that were performed during that time period. (See Physical Examination form). [Individual #1's physical examination was updated to address communicable disease on 11/9/16. Upon completion, the program specialist shall review all individuals' physical examination to ensure completion with all required information including addressing communicable disease and will immediately obtain missing information from the completing physician. Documentation of the review shall be kept. (AS 1/3/17)] 08/26/2016 Implemented
6400.141(c)(11)Individual #1's physical examination, completed 3/7/16, did not include the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals; these sections were left blank. [Repeat Violation - 7/8/15.]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. What specific change will be made: KLHS will ensure the individual physical examination forms will be completed fully by the doctor. Who will make the change: The program specialist will be responsible for ensuring the physical examination form is filled out completely by the doctor. When will the change be made: The change will be implemented immediately. Training will be completed by October 31, 2016. How will the change be made: The CEO will meet with the program specialist to review proper completion of the physical examination form and a training record will be kept on file. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: The responsibility has been added to the Program Specialist¿s roles and responsibility agreement and signed by the acting program specialist. Biannually the CEO will review all the individual physical examination forms for physicals performed during that time period (See attached training record form). [Individual #1's physical examination was updated to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals on 11/9/16. Upon completion, the program specialist shall review all individuals' physical examinations to ensure completion with all required information including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals and will immediately obtain missing information from the completing physician. Documentation of the review shall be kept. (AS 1/3/17)] 08/26/2016 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 3/7/16, did not include medical information pertinent to diagnosis and treatment in case of an emergency; these sections were left blank. [Repeat Violation - 7/8/15.]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. What specific change will be made: Medical information pertinent to diagnosis and treatment in case of an emergency sections will be completed by the doctor. Who will make the change: The program specialist will be responsible for ensuring the physical examination form is filled out completely by the doctor When will the change be made: The change will be implemented immediately. Training will be completed by October 31, 2016. How will the change be made: The CEO will meet with the program specialist to review proper completion of the physical examination form and a training record will be kept on file What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: This responsibility has been added to the Program specialist¿s roles and responsibility agreement and signed by the acting program specialist. Biannually the CEO will review all the individual physical examination forms for physicals performed during that time period (See attached training record form). [Individual #1's physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency on 11/9/16. Upon completion, the program specialist shall review all individuals' physical examinations to ensure completion with all required information including medical information pertinent to diagnosis and treatment in case of an emergency and will immediately obtain missing information from the completing physician. Documentation of the review shall be kept. (AS 1/3/17)] 08/26/2016 Implemented
6400.151(a)Direct Service Worker #2 had a physical examination completed on 10/4/13 and then again on 10/21/15. [Repeat Violation - 7/8/15.] A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. What specific change will be made: Direct service workers will have a physical examination on or before the exact date every two years after hire. Who will make the change: It I the responsibility of the Supervisor of Residential Services to communicate with staff when they need to schedule and complete physicals to achieve compliance with regulation. When will the change be made: The change is implemented immediately. How will the change be made: The program specialist has sent out a memo to all KLHS personnel that physicals must be completed by the same date every 2 years (see the attached memo to KLHS personnel). What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: A statement explaining the time frames for physicals has been added to the policies and procedures for physical examinations to ensure future compliance. The responsibility to ensure compliance with staff physicals has been added to the Supervisor of Residential Services¿ job description. The supervisor of residential services will add the employee¿s previous year¿s physical date and the date the physical must be completed by to the list of annual employee requirements, within the first month of the new training year (September) and have the form reviewed and signed by the CEO (see attached Policy and Procedures ¿ Physical Examinations section and List of Annual Employee Requirements form). [Immediately, the CEO will review all staff physical examination to ensure all staff person have a current physical examination and do not work in the home until completion. Immediately, the CEO will develop and implement a tracking and notification system to ensure all staff person have physical examinations completed, timely. (AS 12/6/16)] 08/26/2016 Implemented
6400.151(c)(2)Direct Service Worker #2 had a Tuberculin skin test read on 4/17/13 and then again on 10/23/15. 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. What specific change will be made: Direct service workers will have a Tuberculin skin test on or before the exact date every two years after hire. Who will make the change: It I the responsibility of the Supervisor of Residential Services to communicate with staff when they need to schedule and complete Tuberculin skin tests to achieve compliance with regulation. When will the change be made: The change is implemented immediately. How will the change be made: The program specialist has sent out a memo to all KLHS personnel that Tuberculin skin tests must be completed by the same date every 2 years. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: A statement explaining the time frames for Tuberculin skin tests has been added to the policies and procedures for physical examinations to ensure future compliance. The responsibility to ensure compliance with staff physicals has been added to the Supervisor of Residential Services¿ job description. The supervisor of residential services will add the employee¿s previous year¿s Tuberculin skin test and the date the test must be completed by to the list of annual employee requirements, within the first month of the new training year (September) and have the form reviewed and signed by the CEO. (See Policies and Procedures ¿ Physical Examinations section and List of Annual Employee Requirements form).[Immediately, the CEO will review all staff physical examinations to ensure all staff person have a current Tuberculin skin testing and do not work in the home until completion. Immediately, the CEO will develop and implement a tracking and notification system to ensure all staff person have Tuberculin skin testing completed, timely. (AS 12/6/16)] 08/26/2016 Implemented
6400.181(e)(14)Individual #1's assessment, dated 12/3/15, does not include the individual's knowledge of water safety including the ability to temper water.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. What specific change will be made: The individual¿s knowledge of water safety including the ability to temper water will be added to Individual #1¿s assessment Who will make the change: The program specialist has corrected the assessment form. When will the change be made: The change will be implemented immediately. How will the change be made: The individual¿s knowledge of water safety including the ability to temper water will be added to Individual #1¿s assessment by the program specialist. An assessment will be completed by the program specialist using the new form which includes the individual¿s knowledge of water safety including the ability to temper water. The newly completed assessment will be reviewed with and signed by the individual and a copy will be given to the SC, as well as a copy kept on file in the KLHS office. What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: The corrected form will be used going forward to ensure that the individual¿s knowledge of water safety including the ability to temper water is included in the assessment. [Individual #1's assessment was updated to include knowledge of water safety including the ability to temper water on 9/20/16. Within 30 days of receipt of the plan of correction, the CEO will review with the program specialist the information required in individuals' assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. (AS 12/6/16)] 08/26/2016 Implemented
6400.186(a)The program specialist completed an ISP review for Individual #1 on 9/2/15 and then again 12/23/15.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. What specific change will be made: ISP reviews will be completed on or before the exact quarterly date. Who will make the change: The program specialist is responsible to complete the ISP review on or before the exact quarterly date. When will the change be made: The change will be implemented immediately. How will the change be made: What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: The program specialist sent a memo to all KLHS personnel that ISP reviews must be completed by the same date each period beginning immediately. A statement explaining time frames for ISP reviews has been added to the policies and procedures for ISP reviews. The requirement for ISP review completion has been added to the Program Specialist job requirement form and has been signed by the program specialist. The program specialist will add reminders to the office electronic calendar as an ongoing reminder of when ISP reviews must be completed for the month. The ISP review will now have to be signed and dated by the CEO who will ensure the program specialist has completed the ISP review on or before the exact quarterly date. [The program specialist completed an ISP reviews for Individual #1 on 6/14/16 and 9/15/16. (AS 12/6/16)] 08/26/2016 Implemented
6400.186(d)The program specialist did not provide Individual #1's ISP reviews with end dates of 8/31/15, 11/30/15, 2/29/16 and 5/31/16 to the entire plan team members including the behavior support specialist. 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. What specific change will be made: All plan team members will receive the ISP review documentation within 30 calendar days of the ISP review meeting. Who will make the change: The program specialist is responsible to ensure that all team member receive the ISP review documentation within 30 calendar days of the ISP review meeting. When will the change be made: The change will be implemented immediately. How will the change be made: Plan team members who attend meetings in person will sign the ISP review and KLHS will keep it on file. ISP reviews shall be sent via email to team members who do not attend regular meetings in person and a record of the emails will be kept on file. If email is not available, it will be mailed Certified Mail What system will be implemented to make sure that the same violation will not occur again and what training will be provided to your staff: A record of ISP reviews will be kept in the administrative office. The ISP review form has been edited to include team member signatures. The CEO will sign off on all ISP reviews after inspecting each one to ensure they have been signed by or sent to the entire team. The procedure for disbursing the ISP review and the CEO¿s signature of inspection of the ISP review has been added to the policy on ISP Reviews in the KLHS policies and procedures (see attached CEO Review and Approval Form and KLHS Policy & Procedures ¿ ISP Reviews). [On 11/8/16, the program specialist provided Individual #1's ISP reviews with end dates of 8/31/15, 11/30/15, 2/29/16 and 5/31/16 to the entire plan team members including the behavior support specialist. The program specialist provided the ISP review completed 8/31/16 to the plan team members on 9/15/16. Prior to providing the ISP reviews, the program specialist shall review the individual's record including invitation letter, ISP and other documentation to ensure all plan team members are provided the ISP review as required. Immediately, the CEO shall develop and implement procedures to ensure the program specialist provides the ISP review documentation to all plan team members, timely and documentation of the correspondence is kept. At least quarterly, for 1 year, the CEO shall review the correspondence to ensure provides the ISP review documentation to all plan team members, timely. Documentation of the reviews shall be kept. (AS 12/6/16)] 08/26/2016 Implemented
SIN-00085663 Unannounced Monitoring 10/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 9/24/2015, at 4:05 PM, Individual #1 expressed that s/he did not want participate in a scheduled outdoor walk. Direct Service Worker #1 stated to Individual #1, "Fine, be fat and overweight." Individual #1 began to cry and pace around the home, repeatedly saying, "I'm sorry." At approximately 5:00 PM, at dinner, Individual #1 filled two glasses and began to drink from both of them. Direct Service Worker #1 then stated, "Chug, chug, chug, chug." Individual #1 began to cry. Direct Service Worker #1 and Direct Service Worker #2 remained in the home with the Individual #1 until the Supervisor #3 and Program Specialist #4 arrived at approximately 7:30 PM. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Direct service worker #1, was sent home from her shift on 9/24/15, immediately upon the arrival of the KLHS house supervisor, as to maintain 2:1 staff ratio. The target was suspended on 9/24/15 and terminated after investigation. All direct service workers were retrained on 10/15/15, on positive approaches, the individual¿s BSP, and the set responses that are to be used with individual #1.[Within 3 months of receipt of the plan of correction, all direct service work will be trained by an outside source on abuse, neglect and mistreatment to include prevention, recognition and reporting. In addition, within three months after receipt of the plan of correction and continuing at least every 3 months for 1 year, all direct service workers will be trained on the aforementioned trainings (positive approached, behavior support plan and responses specific to Individual #1) will be completed. Documentation of all training shall be kept.(AS 2/26/16)] 02/01/2016 Implemented
SIN-00066054 Renewal 07/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance expires on 7/29/15. The self-assessment was completed on 6/19/15. 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. Effective immediately, the completion of the self-inspection 3-6 months prior to the annual inspection has been added to the form of annual tasks to be completed by administration (see attached). The supervisor of residential services has corrected the form and will complete the self-inspection annually. The program specialist will continue to oversee the completion of the annual checklist. [As per conversation with program specialist on 8/10/15, supervisor of residential services will immediately add the self-assessment due date to the agency common calendar. Program specialist will ensure self-assessment is completed timely. (AS 8/10/15)] 07/20/2015 Implemented
6400.46(c)The Chief Executive Officer #1 completed 3 hours of training for training year, 8/1/13 through 7/31/14. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.The CEO completed a master¿s level course entitled Brain Based Teaching and Learning on July 17, 2015, at Gratz College. This master¿s course is equivalent to 90 credit hours. The credit hours obtained fulfill the 24 hours continuing education requirement for 2014 and 2015. The CEO is working toward a master¿s degree from LaSalle University. Additionally, the CEO will continue to utilize the HICU for continuing training. Attached is the grade confirmation for the course. [As per conversation with Program Specialist on 8/10/15, the CEO has completed college courses to make up the missed training for training year 8/1/13 to 7/31/14 and also for training year 8/1/14 to 7/31/15. Documentation of all training with all required information including training by hours will be kept for review by the Department. (AS 8/10/15)] 07/20/2015 Implemented
6400.110(b)Individual #1's bedroom is located off the main hallway in the second floor apartment; this hallway does not have a smoke detector. Another smoke detector is located in the entrance hallway leading up to the main hallway which is behind a steel fire door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. A smoke detector has been installed in the hallway between the resident¿s bedroom and the front door, within 15 feet of the bedroom. The smoke detector has been installed by the director of facilities on August 4, 2015. This smoke detector has been added to the monthly fire drill form (see attached) to ensure it is inspected monthly for proper operation and functioning batteries. 07/20/2015 Implemented
6400.141(c)(4)The physical examinations dated 5/6/14 and 4/30/15 for Individual #1 did not include a hearing screening. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The Program Specialist has added a section to the physical examination form for vision and hearing screening for individuals 18 years or older (see attached). [The program specialist and the residential supervisor will review physical examination documentation to ensure the required information is present. (AS 8/10/15)] 07/20/2015 Implemented
6400.141(c)(11)The physical examinations dated 5/6/14 and 4/30/15 for Individual #1 did not include an assessment of the individual's health maintenance needs. 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. The Program Specialists has added a section to the physical examination form for the assessment of the individuals health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section to be completed by the individual¿s physician. (see attached)[The program specialist and the residential supervisor will review physical examination documentation to ensure the required information is present. (AS 8/10/15)] 07/20/2015 Implemented
6400.141(c)(14)The physical examinations dated 5/6/14 and 4/30/15 for Individual #1 did not include a medical information pertinent to treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Program Specialist has added a section to the physical examination form for medical information pertinent to diagnosis and treatment in case of an emergency. This section to be completed by the individual¿s physician. (see attached)[The program specialist and the residential supervisor will review physical examination documentation to ensure the required information is present. (AS 8/10/15)] 07/20/2015 Implemented
6400.151(a)Direct Service Worker #2, date of hire 6/4/15, had a physical examination on 6/9/15. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Effective immediately employee physicals will be completed before the employee¿s employment date. The stipulation has been added to the ¿New Employee Checklist¿ (see attached). The supervisor of residential services will ensure the physical and checklist documentation are completed before the employment of the individual. 07/20/2015 Implemented
SIN-00061449 Renewal 05/30/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1 was not informed of the following rights at the time of admission on 8-23-13: the right to not be required to participate in research projects, the right to manage personal financial affairs, the right to be informed of the right to vote and shall be assisted to register and vote in elections, and the right to be free from excessive medications.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 program specialist reviewed the rights with individual #1 and individual #1 signed the rights on June 2, 2014. Key Life will keep the 6400.31 (a) Bill of Rights on file in the office to review with and be signed by any new individual and/or their parent/guardian prior to moving into the Key Life Residence. Additionally, a Consumer Intake Checklist has been created to include all required documentation for new consumers transitioning to Key Life Human Services. 06/26/2014 Implemented
6400.46(e)Staff person #1, date of hire 6-30-13, was not trained within 30 days of hire any of the required areas. Staff person #2, date of hire 3-29-14, was not trained within 30 days of hire in any of the required areas. Staff person #3, date of hire 1-17-14, was not trained within 30 days of hire in any of the required areas.Program specialists and direct service workers shall have training in the areas of mental retardation, 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. All current staff persons received additional Normalization training through HICU on April 30, 2014 by Northwest Health Connections. Rights and Program Planning and Implementation training occurred as follows: Staff person #1 on 1-18-14; Staff person #2 on 3-31-14 and Staff person #3 on 1-18-14. Individuals with Disabilities (ID) training occurred as follows: Staff person #2 on 3-31-14; Staff person #3 on 2-7-14; and Staff person #1 will receive the training upon her return to work from disability and prior to working with the consumer. An employment checklist has been created and will be monitored by the Supervisor of Residential Services to ensure all required pre-employment documents and training have been completed. 06/26/2014 Implemented
6400.68(b)The hot water temperature in the bathtub was 123.3 degrees Fahrenheit at 2:55 pm. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water heater has been adjusted by Key Life's Facility Director and the temperature is below 120 degrees F. The Facilities Director inspects the residence twice a month to make sure it is in compliance and meets the 6400 codes. The hot water temperature has been added to the inspection checklist and is now monitored every two weeks. 06/26/2014 Implemented
6400.151(a)Staff person #4 had a physical examination on 5-7-14; however, the staff person was hired on 8-19-13. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff person #4 had a physical examination on May 7, 2014 and will continue to get a physical examination at least once every 2 years while employed with Key Life Human Services. Physical examinations are required for all employees prior to the commencement of employment at Key Life Human Services. An employment checklist has been created and will be monitored by the Supervisor of Residential Services to ensure all required pre-employment documents and training have been completed. 06/26/2014 Implemented
6400.163(c)Individual #1, date of admission 8-23-13, takes the following medications to treat symptoms of a diagnosed psychiatric illness: Lorazepam 2 mg, Chlorpromazine 100 mg, Chlorpromazine 25 mg, Lithium 300 mg, Tegretol XR 200 mg and Seroquel 50 mg. Individual #1 had a review of these psychiatric medications on 1-27-14 and 5-19-14. The reviews did not include the reason for the medication, the dosage, and the need to continue the medication. 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.The Program Specialist has contacted individual #1's Psychiatrist to complete a new Team Review of Psychotropic Medications form to include the reason, dosage and need to continue all of the medications that are prescribed for individual #1's diagnosed psychiatric illness. Key Life Human Services in conjunction with NHS's Dual Diagnosis Treatment Team (DDTT) will have the Team Review of Psychotropic Medications form completed at each psychiatrist visit every two months. 06/26/2014 Implemented
6400.181(e)(10)A lifetime medical history was not included with Individual #1's assessment completed on 12-5-13.The assessment must include the following information: A lifetime medical history. The Program Specialist, in conjunction with individual #1's primary care physician, have completed a lifetime medical history which will be included with individual #1's current assessment. KLHS will ensure that the lifetime medical history is completed by the PCP and Program Specialist and included with the current assessment for each consumer. KLHS will include the lifetime medical history to the consumer documentation checklist. 06/26/2014 Implemented
6400.186(c)(1)Individual #1's Annual Review Update Date is 11-20-13. A review of the monthly documentation of Individual #1's participation and progress was completed for March, 2014 only and no other monthly reviews were completed.The ISP review must include the following: 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. The Program Specialist is completing all monthly and quarterly documentations for individual #1 and all documents are being presented to individual #1's Supports Coordinator. KLHS CEO will monitor that the ISP review includes 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. 06/26/2014 Implemented
6400.213(1)(i)Individual #1's record does not include identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.The Program Specialist has updated individual #1's records to include identifying markings. A Consumer Intake Checklist has been created to include all required documentation for new consumers transitioning to Key Life Human Services. 06/26/2014 Implemented
6400.213(10)(iv)The plan team members of Individual #1 were not notified that they may decline the ISP review documentation.Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation. The Program Specialist has notified all of individual #1's plan team members that they have the right to decline the ISP review documentation. All of individual #1's plan team members have received, signed and returned a copy of the ISP Review declination letter. The ISP Review declination letter will be sent to individual #1's team members with each ISP review. 06/26/2014 Implemented
SIN-00044740 Initial review 01/11/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65On 1-11-13, the bathroom did not have a window or any mechanical ventilation. Fully Implemented - 1/29/13 - CSLiving areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Facility Director will maintain state requirements for having a minimum of one operable window or mechanical ventilation in all living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms. The Facility Director will also ensure either windows or mechanical ventilation is present and operable. A mechanical fan was installed to satisfy the requirements listed under 6400.65. Pictures and receipts were sent for verification of correction action plan (CAP). 01/11/2013 Implemented
6400.101On 1-11-13, egress from the closets in the front and middle bedrooms was obstructed by locking mechanisms on the closet doors. Closets were large enough for a person to fit inside, and the doors could not be unlocked from the inside of the closets. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Partially Implemented - Adequate Progress -1/29/13 - CS The locking mechanisms on closets were removed by the Facility Director on 1-11-2013. To ensure that Key Life Human Services is in compliance with unobstructed egress, the Facility Director will engage in monthly reviews of stairways, halls, doorways, passageways, and exits. The Board of Directors will also conduct a review or retraining to ensure compliance with ( 6400.101). Pictures were taken of closet doors to verify removal of outside locks and compliance with (6400.101) 01/11/2013 Implemented
6400.111(c)On 1-11-13, the fire extinguisher in the kitchen did not have a minimum 2A-10BC rating. The rating on the extinguisher was 1A. (c) 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). Partially Implemented - Adquate Progress - 1/29/13 - CS A fire extinguisher with a minimum 2A-10BC rating was installed in the kitchen by Facility Director on 01/11/2013 to meet the minimum state requirement rating of fire extinguishers on each floor. The Facility Director will also ensure on a monthly basis that any fire extinguisher installed ,has a minimum of 2A-10BC rating and is fully operational . Additionally, the Board of Directors will conduct a fire safety review of facility to maintain fire safety regulations and equipment are parallel with state regulations and requirements (6400.111(c)). A receipt was scanned and emailed as verification of POC. 01/11/2013 Implemented
SIN-00251322 Renewal 09/10/2024 Compliant - Finalized
SIN-00214163 Renewal 10/12/2022 Compliant - Finalized
SIN-00197217 Renewal 11/16/2021 Compliant - Finalized
SIN-00160576 Renewal 08/13/2019 Compliant - Finalized