Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238459 Renewal 01/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.50(a)Chief Executive Officer #1 was not included in the list of staff persons attending the following annual training for the following annual training topic: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse, and Recognizing and reporting incidents. The training documentation indicated "all staff." rather than a list of the individual staff persons in attendance.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.CDR Care annual training records are consistent with 6400.50(a) requirements, to include attendees, training source, content, dates, length of training, and certificates of training. Compliance date: 5 March 2024 03/05/2024 Implemented
SIN-00218770 Renewal 02/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home was completed 11/19/22. The Certificate of Compliance expires 2/20/23.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. CDR Investments LLC Certificate of Compliance Effective Date: 10 February 2014. The CFO sent out a memo on 9 February 2023 to the CEO, Sites Operations Manager and Directors that stated, "The Self-Assessment would be conducted between 10 August - 10 November, annually, in order to be in compliant with code 15(a) from the 55 PA Code Chapter 6400. When the time to assess the homes, the CEO will breakdown the categories into sections with dates to complete that will coincide with the compliant date of 10 November. 02/09/2023 Implemented
6400.106The furnace of the home was inspected and cleaned 9/22/21 and then again 11/11/22.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The CFO sent out a memo on 9 February 2023 to his secretary to remind himself and the Sites Operation Manager to schedule maintenance with the Boehmer Heating Company for the Furnaces at the beginning of the new Fiscal Year. 02/09/2023 Implemented
6400.141(c)(6)Individual #1's 11/4/22 physical examination did not include a space for the date the Tuberculin skin testing by Mantoux was read. Therefore, compliance could not be measured.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. The Annual Physical Form 34 has been updated to reflect the TB placed, TB read and TB result to comply with the 6400.15(a), 6400.141(c) from the 55 PA Code Chapter 6400. The Site Operations Manager will make sure that all Primary Care Physicians complete the Annual Physical Form 34 in its entirety. 02/10/2023 Implemented
6400.141(c)(14)Individual #1's physical examination completed 11/4/22 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Annual Physical Form 34 has been updated to reflect the Medical Information Pertinent to Diagnosis and treatment in case of Emergency to comply with the 6400.141(c) 14 from the 55 PA Code Chapter 6400. The Site Operations Manager will make sure that all Primary Care Physicians complete the Annual Physical Form 34 in its entirety. 02/10/2023 Implemented
SIN-00184286 Renewal 03/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(1)Program Specialist #1's annual training hours for training year 1/1/2020 to 12/31/2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program Specialist #1 on the training sited was conducted on 3/9/21. Training on Everyday Lives: Values in Action will be required for all staff. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit all staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
6400.52(c)(2)Program Specialist #1's annual training hours for training year 1/1/2020 to 12/31/2020 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. And Chief Executive Officer/Program Specialist #2's annual training hours did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. Direct Service Worker #2's annual training hours did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.and Chief Executive Officer/Program Specialist #2's annual training hours did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Program Specialist #1 on the training sited was conducted on 3/9/21. Training on Neglect, Abuse, and Exploitation. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit all staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
6400.52(c)(4)Program Specialist #1's annual training hours for training year 1/1/2020 to 12/31/2020 did not encompass recognizing and reporting incidents. Direct Service Worker #2's annual training hours for training year 1/1/2020 to 12/31/2020 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Program Specialist #1 on the training sited was conducted on 3/9/21.Training on Incident (Management) Reporting will be required for all staff. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit all staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
6400.52(c)(5)Program Specialist #1's annual training hours for training year 1/1/2020 to 12/31/2020 did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Program Specialist #1 on the training sited was conducted on 3/9/21.Training on Individual Health & Behavioral Emergency/Crisis will be required for all staff. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates.[Immediately, upon hire and at least quarterly, the CEO or designee shall audit all staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
6400.52(c)(6)Director Service Worker #2's annual training hours for training year 1/1/2020 to 12/31/2020 does not encompass implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Program Specialist #1 on the training sited was conducted on 3/9/21. Training on ISP Specifics will be required for all staff. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit all staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
SIN-00145937 Renewal 11/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)The most recent physical examination for Chief Executive Officer #1 was completed 7/30/15. Chief Executive Officer #1 has direct contact with individuals once weekly. 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 member #1 is scheduled to complete physical examination (PE) on 7 Dec 2018. On a monthly basis, Program Specialist will monitor PE dates, using excel spreadsheet for expirations. Site Operations Manager will notify all staff members of upcoming expiration dates. [Documentation of the audits of the tracking system by the Program specialist shall be kept to ensure all staff person have physical examinations completed timely and the tracking system is kept up-to-date. (DPOC by AES,HSLS on 12/7/18)] 12/04/2018 Implemented
6400.151(c)(2)The most recent Tuberculin Skin testing for Chief Executive Officer #1 was completed on 8/2/15. Chief Executive Officer #1 has direct contact with individuals once weekly. 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. Staff member #1 initiated TB Skin Test (TST) on 4 Dec 2018, with medical follow-up no later than 7 Dec 2018. On a monthly basis, Program Specialist will monitor TST dates, using excel spreadsheet for expirations. Site Operation Manager will notify all staff members of upcoming expiration dates. [Documentation of the audits of the tracking system by the Program specialist shall be kept to ensure all staff person have physical examinations including Tuberculin skin testing completed timely and the tracking system is kept up-to-date. (DPOC by AES,HSLS on 12/7/18)] 12/04/2018 Implemented
6400.186(a)The program specialist completed ISP reviews for Individual #1 and Individual #2 ending 9/30/18 on 10/21/18 and the ISP reviews ending 6/30/18 on 7/18/18.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. The Program Specialist created a form to track quarterly review dates. The tracking form will be placed inside each participant's program binder, along with the quarterly review form. The Site Operations Manager will ensure individual#1 and individual#2 reviews are completed no later than the 15th of the pertinent month. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 25% sample of ISP reviews to ensure the Program specialist has completed an ISP review with all individuals, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/7/18)] 12/04/2018 Implemented
SIN-00126567 Renewal 12/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #1's physical examination completed 2/3/17 did not include a review of previous medical history.The physical examination shall include: A review of previous medical history. PROGRAM SPECIALIST WILL ENSURE DOCUMENTATION OF PREVIOUS MEDICAL HISTORY REVIEW DATE UPON COMPLETION OF MEDICAL APPOINTMENT ON 25 JANUARY 2018, AND THEREAFTER.[On 1/25/18, Individual #1 had a physical examination completed to include a review of previous medical history. Immediately, the program specialist shall review or be educated on the what is required in individuals' physical examinations as per 6400.141(c)(1)-(15). Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall audit all individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of all audits shall be kept. (AS 1/19/18)] 01/25/2018 Implemented
6400.151(a)Direct Service Worker #1 had a physical examination completed on 8/6/15 and then again on 11/20/17. 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. DSW#1 COMPLETED PHYSICAL EXAMINATION AND TB SKIN TEST ON 22 DECEMBER 2017. PROGRAM SPECIALIST WILL CONDUCT MONTHLY REVIEW OF STAFF PHYSICAL EXAM REQUIREMENTS. HENCE, ANY STAFF WITHIN A 30-DAY WINDOW OF EXPIRED PHYSICAL EXAM AND/OR TB SKIN TEST WILL BE NOTIFIED AND DIRECTED TO COMPLETE REQUIREMENT(S), IMMEDIATELY. FAILURE TO MEET REQUIREMENT(S) RESULTS IN IMMEDICATE SUPSENSION. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of staff physical examinations. Documentation of aforementioned audits of staff physical examination shall be kept. (AS 1/19/18)] 12/22/2017 Implemented
6400.181(e)(12)Individual #1's assessment completed 12/15/17 not include any recommendations for specific areas of training, programming and services. Individual #2's assessment completed 9/30/17 did not include any recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. INDIVIDUAL 1 RECOMMENDATION: SELF-MEDICATION (DOCUMENTED 2 JANUARY 2018). INDIVIDUAL 2 RECOMMENDATION: NO CHANGES MADE (DOCUMENTED 2 JANUARY 2018). PROGRAM SPECIALIST WILL ENSURE PERTINET DOCUMENTATION IS COMPLETED IN ASSESSMENT RECOMMENDATION BLOCK OF SKILLS COMPETANCY FORM UPON ANNUAL REVIEW. [Within 30 days of receipt of the plan of correction the program specialist shall review the requirements for individuals' assessments as per 6400.181(e)(1)-(14). Documentation of the review shall be kept. At least quarterly for 1 year, the CEO or designee shall audit all individual assessment to ensure the program specialist included all required information. Documentation of audits shall be kept. (AS 1/19/18)] 01/02/2018 Implemented
6400.186(b)Individual #1 did not sign and date the ISP review for January through March 2017. Individual #2 did not sign and date the ISP review for January through March 2017.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Individual 1 and 2 signed (2 Jan 2018) first quarter review (Jan-Mar 2017). Quarterly Progress Notes form updated to include participant signature and date (2 Jan 2018). Program Specialist will confirm all signatures, to include participant signatures, upon end of quarterly ISP reviews.[Within 30 days of receipt of the plan of correction, the CEO or designee shall train the program specialist on the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall audit all individual quarterly reviews to ensure the program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Documentation of audits shall be kept. (AS 1/19/18)] 01/02/2018 Implemented
SIN-00105384 Renewal 12/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)The physical examination completed 2/17/16 for Individual #2 did not include medical history. This section was left blank.The physical examination shall include: A review of previous medical history. Residential Manager faxed exam form to PCP office for completion of Individual #2 previous medical history on 19 Jan 2017, and received completed medical history on 20 Jan 2017. Residential Manager will ensure PCP completion of medical history during annual visits. Residential Manager will train staff to review medical history section for completion during annual visit.[Within 30 days of receipt of the plan of correction, the CEO shall train all staff responsible for ensuring that all required information is included in individuals' physical examination on what is required as per 6400.141.(c)(1)-(15) and that no required areas shall be left blank. The CEO or designated management staff person will review all individuals' physical examinations upon completion to ensure all required information is present and will return incomplete physical examination to the completing physician as needed to obtain all required information. Documentation of trainings and reviews shall be kept. (AS 2/7/17)] 01/27/2017 Implemented
6400.141(c)(3)The physical examination completed 2/17/16 for Individual #2 did not include immunizations. This section was left blank.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Residential Manager faxed exam form to PCP office for completion of Individual #2 immunizations on 19 Jan 2017, and received completed immunizations on 20 Jan 2017. Residential Manager will ensure PCP completion of immunizations during annual visits. Residential Manager will train staff to review immunizations section for completion during annual visit.[Within 30 days of receipt of the plan of correction, the CEO shall train all staff responsible for ensuring that all required information is included in individuals' physical examination on what is required as per 6400.141.(c)(1)-(15) and that no required areas shall be left blank. The CEO or designated management staff person will review all individuals' physical examinations upon completion to ensure all required information is present and will return incomplete physical examination to the completing physician as needed to obtain all required information. Documentation of trainings and reviews shall be kept. (AS 2/7/17)] 01/27/2017 Implemented
6400.141(c)(14)The physical examination completed 10/21/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. [Repeated violation-1/12/15]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Residential Manager faxed exam form to PCP office for completion of Individual #1 medical information pertinent to diagnosis and treatment in case of emergency on 19 Jan 2017 & 24 Jan 2017. Residential Manager will ensure PCP completion of medical information pertinent to diagnosis and treatment in case of emergency during annual visits. Residential Manager will train staff to review medical information pertinent to diagnosis and treatment in case of emergency section for completion during annual visit. Staff member (Program Specialist) responsible for repeat violation has been removed from position.[Within 30 days of receipt of the plan of correction, the CEO shall train all staff responsible for ensuring that all required information is included in individuals' physical examination on what is required as per 6400.141.(c)(1)-(15) and that no required areas shall be left blank. The CEO or designated management staff person will review all individuals' physical examinations upon completion to ensure all required information is present and will return incomplete physical examination to the completing physician as needed to obtain all required information. Documentation of trainings and reviews shall be kept. (AS 2/7/17)] 01/27/2017 Implemented
6400.141(c)(15)The physical examination completed 2/17/16 for Individual #2 did not include special instructions for the individual's diet. This section was left blank. [Repeated violation-1/12/15)The physical examination shall include:Special instructions for the individual's diet. Residential Manager faxed exam form to PCP office for completion of Individual #2 diet special instructions on 19 Jan 2017, and received completed special instructions for individual's diet on 20 Jan 2017. Residential Manager will ensure PCP completion of special instructions for individual's diet during annual visits. Residential Manager will train staff to review special instructions for individual's diet section for completion during annual visit. Staff member (Program Specialist) responsible for repeat violation has been removed from position.[Within 30 days of receipt of the plan of correction, the CEO shall train all staff responsible for ensuring that all required information is included in individuals' physical examination on what is required as per 6400.141.(c)(1)-(15) and that no required areas shall be left blank. The CEO or designated management staff person will review all individuals' physical examinations upon completion to ensure all required information is present and will return incomplete physical examination to the completing physician as needed to obtain all required information. Documentation of trainings and reviews shall be kept. (AS 2/7/17)] 01/27/2017 Implemented
6400.142(g)Individual #1's most recent dental hygiene plan was dated 8/31/15. Individual #2's most recent dental hygiene plan was dated 11/17/15.A dental hygiene plan shall be rewritten at least annually. Administration staff added annual signature page to Dental hygiene plan to be reviewed and signed by dentist, as of 29 Dec 2016. Dental hygiene plan shall be reviewed by dentist at individual annual exam. Any changes to plan will be updated (handwritten) by dentist, and form modifications made by staff. Program Specialist will train staff on dentist review requirement upon annual exam. [Immediately, the CEO or designated management staff person shall develop and implement a tracking system to ensure all individual have a dental hygiene plan at least annually. (AS 2/7/17)] 01/19/2017 Implemented
6400.181(d)The program specialist did not sign the assessment completed 9/3/16 for Individual #1. The program specialist did not sign the assessment completed 12/17/16 for Individual #2.The program specialist shall sign and date the assessment. The program specialist signed assessment 19 Jan 2017. The ISP assessment form will be signed and dated by program specialist upon completion. An additional signature block (Residential Manager) has been added to confirm required signatures. Program Specialist will train Residential Manager on additional signature block. 01/19/2017 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment dated 9/3/15 to the plan team members for the ISP meeting on 4/12/16. The program specialist did not provide Individual #2's assessment dated 12/17/16 to the plan team members for the ISP meeting on 4/6/16. (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). Program specialist emailed Individuals #1 and #2 assessments to plan team members, as of 19 Jan 2017. The assessment forms will be emailed to plan team members at least 30 calendar days prior to ISP meeting. Email account was created specifically for ISP plan team members as proof of mode of receipt. No additional training needed.[At least quarterly for 1 year the CEO or designated management staff person shall review correspondence showing the program specialist provided assessments to all individuals' plan team members at least 30 calendar days prior to the ISP meetings. (AS 2/7/17)] 01/19/2017 Implemented
6400.186(b)The ISP reviews for Individual #1 completed for review periods: January to March 2016, April to June 2016 and October to December 2016 were not signed by Individual #1 or dated by program specialist. The ISP reviews for Individual #2 completed for review periods: October to December 2015, January to March 2016 and April to June 2016 were not signed by Individual #1 or dated by program specialist. [Repeated violation-1/12/15]The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. As of 19 Jan 2017, Indidvidual #1 and Individual #2 have signed and dated ISP reviews. Staff member (program specialist) responsible for repeat violation has been removed from position. The ISP review form will be signed and dated by current program specialist and individuals 1 & 2 upon completion. An additional signature block (Residential Manager) has been added to confirm required signatures and dates. Program Specialist will train Residential Manager on additional signature block.[At least quarterly for 1 year the CEO or designated management staff person shall review all individuals' ISP reviews to ensure the program specialist have signed and dated the ISP reviews upon review. Documentation of the reviews shall be kept. (AS 2/7/17)] 01/19/2017 Implemented
6400.186(d)The program specialist did not provide Individual #1's ISP review documentation for review period January to March 2016, April to June 2016 and October to December 2016 to the SC and the plan 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. Program Specialist emailed SC review documentation for Jul-Sep and Oct-Dec 2016 on 9 Jan 2017 and the team members on 19 Jan 2017. After each quarterly ISP review Program Specialist will email ISP review to SC and team members, and document mode of receipt on ISP review form. Email account was created specifically for ISP plan team members as proof of mode of receipt. No additional training needed. [At least quarterly for 1 year the CEO or designated management staff person shall review correspondence showing the program specialist provided ISP review documentation to individuals' plan team members as required. (AS 2/7/17)] 01/19/2017 Implemented
SIN-00088478 Renewal 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(10)Program Specialist #2 did not sign and date the monthly documentation from September 2015 to December 2015 of Individuals #1's participation and progress toward outcomes. Program Specialist #2 did not sign and date the monthly documentation for December 2015 of Individual #2's participation and progress toward outcomes.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.On 26 Feb 2016, the Program Specialist reviewed/signed/dated the corrected monthly documentations of individual #1 and #2 participation progress toward outcome. Moving forward on a monthly basis, Program Specialist will organize a meeting with the Residential Manager to review the monthly documentation of the individual¿s participation and progress towards outcomes and will make sure that the appropriated documents will be completed and signed by the Program Specialist.[Documentation of meetings and reviews shall be kept and reviewed at least quarterly by the CEO to ensure completion and that the program specialist reviews, signs and dates the monthly documentation for all individuals' participation and progress towards outcomes. (AS 3/10/16) 03/10/2016 Implemented
6400.112(g)Of the six fire drills held between 8/1/15 and 12/28/15, five of the fire drills were conducted between 6:00 PM and 9:00 PM. Fire drills shall be held on different days of the week and at different times of the day and night. Of the six fire drills held between 8/1/15 and 12/28/15, five of the fire drills were conducted between 6:00 PM and 9:00 PM. Starting in January 2016, the last three monthly fire drills were conducted at different times of the day: 1. Monday, 18 January 2016 at 2:00 AM; 2. Tuesday, 9 February 2016 at 12 noon; and 3. Wednesday, 24 Mach 2016 at 4:00 PM. Moving forward, the Residential Manager will utilize CDR Form 69 to keep track of fire drills and fill out dates, times, hypothetically locations of fires, monthly. Moreover, the monthly fire drills will be conducted without warning, ensuring no month-to-month overlap with overnight fire drills, every 6 months. Finally, every 6 months, the Program Specialist will oversee the fire drill entries in order to make sure no times and dates month-to-month overlap, in accordance with Chapter 6400 regulations.[Documentation of the PS review of monthly fire drills shall be kept. (AS 3/10/16)] 03/10/2016 Implemented
6400.141(c)(4)The physical examination, dated 5/17/15, for Individual #3 does not include vision and hearing screening. Individual #3 is over 18 years of age.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual#3 did not get a chance to go back for the vision and hearing screening because she was discharge on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician." The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrected violation on file. Prior to admission, the Program Specialist will issue CDR Form 34 to be completed by the participant's physician prior to residency.[Immediately, CEO or designated staff person will review all current individuals' physical examination to ensure all required information including vision and hearing screenings are competed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examinations upon receipt to ensure all required information including vision and hearing screenings are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/07/2016 Implemented
6400.141(c)(6)The physical examination, dated 5/17/15, for Individual #3 does not include Tuberculin skin testing by Mantoux method with negative results.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual#3 did not get a chance to go back for the TB skin testing because she was discharge on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "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." The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrected violation on file. Prior to admission, the Program Specialist will issue CDR Form 34 to be completed by the participant's physician prior to residency.[Immediately, CEO or designated staff person will review all current individuals' physical examination to ensure all required information including Tuberculin skin testing are competed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examinations upon receipt to ensure all required information including Tuberculin skin testing are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/10/2016 Implemented
6400.141(c)(10)The physical examination, dated 5/17/15, for Individual #3 does not include specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals.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. Individual#3 did not get a chance to go back for specific precautions that must be taken if the individual has a communicable disease because she was discharge on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals." The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrected violation on file. Prior to admission, the program specialist will issue CDR Form 34 to be completed by the participant's physician prior to residency.[Immediately, CEO or designated staff person will review all current individuals' physical examination to ensure all required information including specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals are competed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examinations upon receipt to ensure all required information including specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/10/2016 Implemented
6400.141(c)(11)The physical examination, dated 5/17/15, for Individual #3 does not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.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. Individual#3 did not get a chance to go back for individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals because she was discharge on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals." The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrected violation on file. Prior to admission, the Program Specialist will issue CDR Form 34 to be completed by the participant's physician prior to admission.[Immediately, CEO or designated staff person will review all current individuals' physical examination to ensure all required information including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals are completed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examinations upon receipt to ensure all required information including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/10/2016 Implemented
6400.141(c)(12)The physical examination, dated 5/17/15, for Individual #3 does not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. Individual#3 did not get a chance to go back for physical limitations of the individual because she was discharged on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "Physical limitations of the individual." The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrective violation on file. Prior to admission, the Program Specialist will issue CDR Form 34 to be completed by the participant's physician prior to admission.[Immediately, CEO or designated staff person will review all current individuals' physical examination to ensure all required information including physical limitations of the individual are competed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examinations upon receipt to ensure all required information including physical limitations of the individual are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/10/2016 Implemented
6400.141(c)(14)The physical examination, dated 10/14/15 for Individual #1 and the physical examination dated 5/17/15, for Individual #3 do not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual#3 did not get a chance to go back for Medical information pertinent to diagnosis and treatment in case of an emergency because she was discharged on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "Medical information pertinent to diagnosis and treatment in case of an emergency." On 3 Mar 2016, the updated CDR Form was faxed over to Individual#1 doctor¿s office for completion. Once received, the Program Specialist would look it over to see if the updated form was completed correctly according to Chapter 6400 regulations. The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrective violation on file. Prior to admission, the Program Specialist will issue CDR Form 34 to be completed by the participant's physician prior to admission.[Immediately, CEO or designated staff person will review all current individuals' physical examination to ensure all required information including medical information pertinent to diagnosis and treatment in case of an emergency are competed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examination upon receipt to ensure all required information including medical information pertinent to diagnosis and treatment in case of an emergency are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/10/2016 Implemented
6400.141(c)(15)The physical examination, dated 5/17/15, for Individual #3 does not include special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. Individual#3 did not get a chance to go back for special instructions for the individual's diet because she was discharge on 23 Sep 2016. On 12 Jan 2016, an updated CDR Form 34 stated, "Special instructions for the individual's diet." The Program Specialist on a quarterly basis will check to see that the agency would have the most updated form on file. Prior to admission, the Program Specialist will issue CDR Form 34 to be completed by the participant's physician prior to admission.[Immediately, CEO or designated staff person will review all current individuals' physical examinations to ensure all required information including special instructions for the individual's diet are competed and will obtain missing information. CEO or designated staff person will review all individuals' initial and annual physical examinations upon receipt to ensure all required information including Special instructions for the individual's diet are present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 3/9/16)] 03/10/2016 Implemented
6400.151(a)Program Specialist #2, date of hire 8/1/15, Direct Service Worker #1, date of hire 8/1/15 and Direct Service Worker #3, date of hire 11/10/15 pre-employment physical examinations were completed on 1/6/14, 8/29/13 and 11/11/15 respectively. 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. Program Specialist#2 updated his physical/TB on 16 Feb 2016/19 Feb 2016. Direct Service Worker#1 updated her physical/TB on 12 Jan 2016/19 Feb 2016. On 14 Jan 2016, an excel spreadsheet was created for the CEO, who will check on a monthly basis that the employees are in compliance with their physicals and TB results. Prior to hire, a Terms of Agreement form would be given to potential staff members by the CEO of which will state the following: "Physical Exam (PE) & TB Skin Test (TST) (on or prior to date of hire)." In addition to, the CEO will hand over CDR Form 56 to the potential employee in order give to their physician, prior to employment within 12 months of the first hire date. Once completed, the CEO would then look the form over to see if the doctor completed it correctly according to 6400 regulations. 03/10/2016 Implemented
6400.151(c)(3)The physical examination completed on 11/11/15 for Direct Service Worker #3's, hired 11/10/15, did not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. On 12 Jan 2016, an updated CDR Form 56 stated, "a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals." CEO on a quarterly basis will check to see that the agency would have the most updated form along with the corrected violation on file. Prior to hire, a Terms of Agreement form would be given to potential staff members by the CEO of which will state the following: "Physical Exam (PE) & TB Skin Test (TST) (on or prior to date of hire)." In addition to, the CEO will hand over CDR Form 56 to the potential employee in order give to their physician, prior to employment within 12 months of the first hire date. Once completed, the CEO would then look the form over to see if the doctor completed it correctly according to 6400 regulations.[Staff Person #3 had a physical examination completed that included a statement that staff person is free from communicable disease. Immediately, CEO or designated management will review all staff physical examinations form include all required information including a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals and will immediately obtain missing information. CEO will review all initial and annual staff physical examinations to ensure all required information is present including a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals and will immediately obtain missing information. Documentation of reviews shall be kept. (AS 3/11/16)] 03/10/2016 Implemented
6400.163(c)The medication review by a licensed physician was completed 12/9/15 for Individual #1, date of admission 8/31/15 who is prescribed medication to treat symptoms of a psychiatric illness. 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.As of January 2016, CDR Form would be taken to every Quarterly Psychotropic Review by the attending Direct Service Worker to be completed by the psych doctor in its entirely. After completion, the Direct Service Worker would then be instructed to place the form into the Residential Manager¿s mail box for review and to be put into the Program Binder for reference. This action will be followed up every six months by the Program Specialist to ensure proper procedures from the Quarterly Psychotropic Review have been completed in accordance with Chapter 6400 regulations.[Immediately, CEO will develop and implement and train staff on a tracking system to be followed to ensure all individuals' medications reviews will be scheduled and completed within required timeframes. CEO will review tracking system at least monthly to ensure medication reviews are completed timely. (AS 3/10/16)] 03/10/2016 Implemented
6400.186(b)Program Specialist #2 did not sign and date the ISP review for Individual #1 for review period of 9/15 to 11/15. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. On 7 March 2016, the Program Specialist #2 and Individual #1 signed and dated the ISP review signature sheet that was for review period of 9/15 to 11/15. Once signed, the Program Specialist will send out the Quarterly Review Sheet to all team members of Individual #1 within 30 days of the signed document. Moving forward, the Program Specialist on a quarterly basis will check to see that the agency would have the most updated form along with the corrected violation on file. Furthermore, for every 6-month period, the CEO will look over the completed ISP review signature sheet forms to see if both Program Specialist and Individual's signatures were dated and signed.[CEO will review all individuals' quarterly ISP reviews for at least 1 year to ensure the program specialist and the individuals sign and date the IPS reviews upon review. Documentation of the reviews shall be kept. (AS 3/10/16)] 03/18/2016 Implemented
6400.186(e)Program Specialist #2 did not inform plan team members of the option to decline the ISP review documentation for Individuals #1, #2 and #3. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. On 3 Mar 2016, each member of the plan team of Individual¿s #1 and #2 has been sent a "Opt out to decline letter" of the ISP review details as well as documentation on the upcoming ISP meeting scheduled 30 calendar days prior to review. Individual#3 plan team members did not get a chance to receive an opt out letter because she was discharge on 23 Sep 2015. On a quarterly basis, Program Specialist will inform each member of the plan team of the option to decline the ISP review documentation meeting. Moving forward on a quarterly basis, the Program Specialist will review documentation as well as make a spread sheet of each member of the plan team who is planning to come to the meeting verses who opted out.[Individual #3 was discharge. The plan team members for Individual #1 were notified of the option to decline on 3/11/16 and the plan team member for Individual #2 was notified of the option to decline ISP review documentation on 3/3/16. Immediately and upon admission of individuals, the Program Specialist will review all individuals invitation letters, ISP and other documentation to ensure the entire plan team members for all individuals are notified of the option to decline ISP reviews. The Program Specialist will keep documentation of the individual, date and name and relation or organization of all plan team members who are notified of the option to decline. The CEO or designated management staff person will review all options to decline documentation to ensure all team member were notified as required. Documentation of reviews shall be kept. (AS 3/11/16)] 03/10/2016 Implemented
SIN-00074039 Renewal 01/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain tape. 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. DCS will check on an on going basis the first aid kit to see that it contains tape and all other first aid requirements. 01/29/2014 Implemented
6400.101The door between the kitchen and the garage had a double keyed lock which prevents egress from the garage to the kitchen. The garage does not have a man door.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. DCS will check on an ongoing basis the door between the kitchen and the garage to see if its unobstructed and has a way out. 01/29/2014 Implemented
6400.110(e) The home has 3 levels and the smoke detectors on each floor were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. DCS will test on an on going basis the smoke detectors on each floor interconnected and audible throughout the home. 01/29/2014 Implemented
6400.111(a)The fire extinguishers on the basement and second floor had a 1A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. DCS will check on an on going basis to see if the fire extinguishers on the basement and second floors are operable with correct codes. 01/29/2014 Implemented
6400.111(c)The fire extinguisher in the kitchen had a 1A-10BC rating. 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). DCS will check on an on going basis to see if the kitchen fire extinguisher is operable with correct codes. 01/29/2014 Implemented
SIN-00213820 Renewal 02/24/2022 Compliant - Finalized
SIN-00166506 Renewal 11/18/2019 Compliant - Finalized
SIN-00057443 Initial review 01/06/2015 Compliant - Finalized