Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00255984 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)The agency assumes the responsibility of maintaining Individual #1's financial resources, acting as their representative payee. On 11/6/24, the agency provided eleven receipts, spanning from 5/29/24 to 10/11/24, for purchases greater than $15. However, there were no ledgers or expense records kept for those months, including November 2024, to ensure all purchases greater than $15 had been accounted for. Therefore, receipts for purchases made by staff on behalf of Individual #1 or expense records for purchases greater than $15 have not been provided. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. On 11/13/2024, the agency implemented procedures to track individuals' expenses/transactions, including receipts, in addition to the current procedure individuals use to take out cash on hand. 11/13/2024 Implemented
6400.62(a)On 11/6/2024, at 9:47 AM, a 124-fluid ounce can of PPG interior latex paint was found unlocked and accessible on a shelf in the basement. Individual #1's assessment, completed 5/18/24, did not address if they are able to avoid or use poisonous substances. Individual #1's Individual Support Plan (ISP), last updated on 8/23/24, indicates that poisonous substances are kept locked in Individual #1's home.Poisonous materials shall be kept locked or made inaccessible to individuals. On 11/7/2024, all poisons in the basement (attachment A. 6) were discarded or placed in a locked storage closet at the home. 11/07/2024 Implemented
6400.64(f)On 11/6/2024, at 9:39 AM, one of outside trash receptacles located by the detached garage was uncovered, providing exposure to a crumpled-up Burger King fast food bag, a plastic Burger King cup, a plastic water bottle, a paper package of Pepperidge Farm cookies, and other refuse. The other outside trash receptacle located by the detached garage had a white garbage bag protruding out from its top, preventing the lid from closing.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The receptable's lid was closed on 11/6/24. The agency repositioned the trash receptables on the opposite side of the home's garage to prevent future unwanted openings of the receptible. 11/06/2024 Implemented
6400.66On 11/6/2024, at 10:08 AM, the attic did not have an operable light. On 11/6/2024, at 9:37 AM, the outside light receptacle above the kitchen door located on the side of the home was inoperable, and there was no other sufficient lighting source nearby.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 11/6/2024, the agency installed an operable light above the entrance on the side of the home. On 11/8/24, the light bulb was replaced in the attic of the home. 11/08/2024 Implemented
6400.72(a)On 11/6/2024, at 9:56 AM, the window located to the right of the full bathroom's doorway that is adjacent to the tub did not have a screen that was secure, leaving a one-foot-by-two-foot gap above the under-sized screen that is currently installed. On 11/6/2024, at 10:02 AM, both windows in the spare bedroom located directly across from the steps on the upper level did not have screens that was secure, leaving 1.5-foot-by-2-foot gaps above the under-size screens that are currently installed. On 11/6/2024, at 10:00 AM, there was a half-inch wide gap measuring about one foot in height, revealing exposure to the outside on both sides of the air conditioning unit installed in the window located to the right of the bedroom's entryway.Windows, including windows in doors, shall be securely screened when windows or doors are open. On 11/26/2024, the agency securely installed a new screen in the restroom window adjacent to the tub (see attachment A. 2). On 11/20/24, the agency ordered the installation of three new windows for the spare bedrooms' windows (See attachment B). On 11/8/24, the a/c unit was removed from the window in the bedroom. 11/26/2024 Implemented
6400.74On 11/6/2024, at 9:50 AM, each tread on the first interior set of four stairs and on the second set of seven interior stairs leading to the basement do not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. On 11/11/24, nonskid strips were placed on both sets of stairs in the basement stairway (see attachment a, 3 & 4). 11/11/2024 Implemented
6400.80(a)On 11/6/2024, at 9:37 AM, the home's side walkway was obstructed with overgrown vegetation, covering an area of approximately two feet in length. Outside walkways shall be free from ice, snow, obstructions and other hazards. On 11/11/24, the vegetation on the side of the house was removed so that the walkway on the side of the house was safe and free of hazards (attachment A. 11). 11/11/2024 Implemented
6400.101On 11/6/2024, at 10:15 AM, there was a door to a room located in the basement, measuring six feet by ten feet, that was locked with a metal latch secured by a Master pad lock requiring a key for disengagement. This creates a possible entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The pad lock was removed from the storage room on 11/13/24 (Attachment A. 5). 11/13/2024 Implemented
6400.111(a)On 11/6/2024, at 10:08 AM, the attic did not have an operable fire extinguisher with a minimum 2-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. On Friday, 11/15/24, the agency's fire extinguisher contractor installed an extinguisher in the attic (attachment A. 7). 11/15/2024 Implemented
6400.181(e)(6)Individual #1's assessment, completed on 5/18/24, did not address their ability to safely use or avoid poisonous materials when in the presence of such substances.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. On 11/10/24, the assessment was amended to reflect the individual's ability to recognize, avoid, and use poisonous substances by the CCO/COO. The assessment was sent to the individual's support's coordinator to append the ISP. (Attachment C). 11/10/2024 Implemented
6400.181(e)(12)Individual #1's assessment, completed on 5/18/24, did not address recommendations for specific areas of training, programming, and services. Under this section, the assessment reads, "No recommendations of any further training, programming, or vocational services for [Individual #1]."The assessment must include the following information: Recommendations for specific areas of training, programming and services. On 11/10/24, the assessment was amended to include recommendations for specific areas of training, programming, and services by the CCO/COO. The assessment was sent to the individual's support's coordinator to append the ISP. (Attachment C). 11/10/2024 Implemented
6400.181(e)(14)Individual #1's assessment, completed on 5/18/24, displayed the following contradictory information regarding their ability to swim, therefore, leaving this safety domain unaddressed: Under the section, "Progress Report of the Past Year," the assessment explains that Individual #1 "can swim on [their] own." However, under the section entitled, "Strengths," the assessment informs that Individual #1 "cannot swim on [their] own."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. On 11/10/24, the assessment was amended to include the individual's progress over the last year and current level in knowledge of water safety and ability to swim by the CCO/COO. The assessment was sent to the individual's support's coordinator to append the ISP. (Attachment C). 11/10/2024 Implemented
6400.32(r)(4)On 11/6/2024, at 10:01 AM, Individual#1's bedroom door was equipped with a key lock on its entry side. However, since direct service workers who provide services to Individual #1 did not have possession of the key or entry device to lock and unlock the door to allow easy and immediate access by staff persons in the event of an emergency.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.On 11/25/24, the door handle was replaced with a key lock door handle. Keys to the door were copied and labeled by the program specialist. One key was given to the individual. One was placed on the staff keys in the home. One key was placed in the on-call bag. A master copy is kept at the administrative office. 11/25/2024 Implemented
6400.32(r)(5)On 11/6/2024, at 10:01 AM, Individual #1's bedroom door was equipped with a key lock on its entry side. However, direct service workers who provide services to Individual #1 did not have possession of the key or entry device to lock and unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.On 11/25/24, the door handle was replaced with a key lock door handle. Keys to the door were copied and labeled by the program specialist. One key was placed on the staff key ring. 11/25/2024 Implemented
6400.163(d)On 11/6/2024, at 9:55 AM, the home's first aid kit located in the living room had the following unlocked over-the-counter medications: five packets of Aspirin, each containing two 325 mg tablets; and four packets of Acetaminophen, each containing two 325 mg tablets.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On 11/6/24, the medications were removed from the first aid kit at this location and all other service locations by the House Manager or Site Supervisor. 11/06/2024 Implemented
6400.182(c)Individual #1's assessment, completed on 5/18/24, and their Individual Support Plan, last updated on 8/23/24, differed in the safety domains of poisonous substances and water safety. Individual #1's Individual Support Plan (ISP) states that poisonous substances are kept locked in the home, while their assessment does not. Individual #1's assessment informs that they do not understand knowledge of general water safety, while their Individual Support Plan explains, Individual #1 knows basic water safety rules. Individual #1's assessment contains contradictory information on their ability to swim, stating in different sections that they both can and cannot swim, while their Individual Support Plan informs, they are "able to swim but should receive monitoring within line of sight around swimming pools and large bodies of water."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 11/10/24, the assessment was amended to correct the discrepancies in information in the assessment and the ISP by the CCO/COO. The assessment was sent to the individual's support's coordinator to append the ISP. (Attachment C). 11/10/2024 Implemented
SIN-00198564 Renewal 12/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #2, date of hire 7/6/21, resides in Ohio. The agency does not have a FBI criminal check completed by the Pennsylvania Department of Aging.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. The corrective action in regard to this violation is due to the Direct Service Worker #2 not having a FBI criminal check completed, THRIVE immediately notified this staff member, providing them the information on how to obtain the FBI criminal check, where to have this check completed and what to do once the results of the FBI check comes in. All employees of THRIVE who reside in Ohio were given the information as well in which a deadline was given to schedule their appointment with the PA department of Aging in Grove City to have this completed. Upon the hiring process, THRIVE Director of Human Resources will review all applicants, checking to see if they are an Ohio resident and prior to hiring all Ohio residents will need to have the FBI check completed and results returned to THRIVE Human Resource Director prior to Orientation. Moving forward THRIVE Chief of compliance has added a Quarterly audit to of all employees to ensure any Ohio residents FBI check has been completed and in file. 01/18/2022 Implemented
6400.151(a)the most recent physical examination for Direct Service Worker #1 was completed 9/19/19. 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. Due to Direct Service Worker #1 not having a 2 year physical examination completed, THRIVE Human Resource Director immediately took this worker off of the schedule until this employee was able to have his physical examination and TB completed and returned. Once this employee was off of the schedule he did have his physical examination completed and returned to THRIVE's Human Resource Director with all of the information needed to return to work. In the future THRIVE will notify all employees who are due for their physical exam 30 days prior to when it is due to ensure the staff is notified and in timely manner and is given the opportunity to have this completed prior to its due date. THRIVE Chief of compliance will also conduct Quarterly staff physical exam audits that will be reviewed at its Quality Management meetings to ensure this is completed as well. Any 2 year physical exams not completed in a timely manner will result in that employee having to be taken off of the schedule and treated as a new hire once the physical exam is completed. 01/18/2022 Implemented
6400.151(c)(2)The most recent Tuberculin skin testing by Mantoux method with negative results for Direct Service Worker #1 was completed 9/21/19. 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. Due to Direct Service Worker #1 not having a 2 year TB Mantoux completed, THRIVE Human Resource Director immediately took this worker off of the schedule until this employee was able to have his TB Mantoux completed and returned. Once this employee was off of the schedule he did have his TB Maxoux completed and returned to THRIVE's Human Resource Director with all of the information needed to return to work. In the future THRIVE will notify all employees who are due for their TB Mantoux 30 days prior to when it is due to ensure the staff is notified and in timely manner and is given the opportunity to have this completed prior to its due date. THRIVE Chief of compliance will also conduct Quarterly staff physical exam and TB Mantoux audits that will be reviewed at its Quality Management meetings to ensure this is completed as well. Any 2 year physical exams and Mantoux not completed in a timely manner will result in that employee having to be taken off of the schedule and treated as a new hire once the physical exam and TB is completed. 01/18/2022 Implemented
SIN-00182217 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected and cleaned by a professional furnace cleaning company most recently on 05/28/2020. There was not documentation of prior inspection and cleaning of the furnace; therefore, compliance could not be measured.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. Corrective Action Plan-THRIVE Program Director will now begin managing and checking THRIVEs furnace checks . This will be completed by the program director adding a reminder to his monthly calendar to have all furnaces check on a quarterly basis of every home. CEO will then follow up with the Program Director during monthly quality management meetings to ensure this is completed. [Immediately, the CEO or Designee, shall train the Program Director on the requirement that furnaces be inspected and cleaned by a professional furnace cleaning company annually, as required by 6400.106. Documentation of the training shall be kept. The Program Director shall document the aforementioned quarterly audits of furnace inspections. Documentation of monthly Quality Management meetings, to include the review of annual furnace inspections, shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] 02/11/2021 Implemented
SIN-00165319 Renewal 10/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The label was removed from the old phone and placed on the new phone. The Program Manager will use the Physical Site Monitoring Tool for weekly inspections of the home to ensure all emergency telephone numbers are on the telephone. [At least monthly for 1 year and continuing at least quarterly thereafter, the CEO or designee shall audit a 25% sample of weekly checklist to ensure completion and review and revise as needed. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] 10/25/2019 Implemented
6400.82(e)The bathtub located in the main bathroom of the home did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. A new bath mat was purchased and placed in the tub. The Program Manager will use the Physical Site Monitoring Tool when completing weekly site inspections to ensure the bath mat is in the tub. Should an individual refuse to use the bath mat, he/she will be given a waiver to sign.[Nonskid surface was placed in the bathtub the day of the inspection. Documentation of the weekly site inspections to include that bathtubs and showers shall have a nonslip surface shall be kept. At least monthly for 1 year and continuing at least quarterly thereafter, the CEO or designee shall audit a 25% sample of weekly checklist to ensure completion and review and revise as needed. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] 10/25/2019 Implemented
6400.141(a)Individual #2, date of admission 5/1/19, did not have a physical examination.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual is scheduled for his annual physical on 11/22/19 with Shelly Somers which will be documented on the new physical form that meets all chapter regulations. Manager of Operations will complete monthly audits of individual records to ensure compliance. [Individual #2 had a physical examination signed by the physician on 11/22/19. Immediately and upon completion the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included, missing information shall be obtained immediately. Documentation of audits shall be kept. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals have physical examinations completed, timely. (DPOC by AES,HSLS on 12/6/19)] 11/15/2019 Implemented
6400.181(a)Individual #1's assessment was most recently completed on 5/14/18. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The annual assessment has been completed for individual #1 on 10/28/19. Program Specialist will complete the assessment no later than 60 days after individual's admission date. The Program Specialist will review the assessment bi-annually, and update the assessment annually thereafter. [Immediately and upon competition for at least one year, the CEO shall audit all individuals' current assessments to ensure completion, timely, with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] 10/28/2019 Implemented
6400.15(b)The agency completed a self-assessment on a Self Inspection/Declaration Tool, a document used for opening new homes.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The self assessment was redone on the correct tool; the Department's licensing inspection instrument. The Program Manager will complete self assessments 3-6 months prior to expiration of certificate on the Department's licensing inspection tool. The Director will review the tool and sign off after each inspection. [Prior to completion of the self-assessment, the CEO or designee shall locate the most recent self-assessment tool on the Departments web site to ensure the correct self-assessment is completed. Immediately and upon completion, the CEO or designee shall audit all self-inspection completed for each home to ensure all regulations are addressed and all information is completed and there are not any areas left blank. (DPOC by AES,HSLS on 12/6/19)] 11/08/2019 Implemented
6400.32(i)The agency is locking "snack" food in a cabinet in the kitchen of the home. The individuals do not have access to the keys to the locked cabinet.An individual has the right of access to and security of the individual's possessions.All food was removed from the locked pantry. Each individual put their snacks in their own room. On the Physical Site monitoring tool, another bullet has been added which reads: the home is free of locked food. The Program Manager will continue to utilize this tool when completing weekly house inspections. [Within 30 days of receipt of the plan of correction, upon hire and continuing at least annually, the CEO or designee or outside source shall educate all staff persons on all individual rights as per 6400.31a-34b. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/6/2019)] 11/07/2019 Implemented
6400.165(g)Individual #2 had a review of medication prescribed to treat symptoms of psychiatric illness on 5/13/19 and then again on 9/25/19. [Repeat Violation-11/19/18- regulation 163(c)]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.A Monitoring Tool has been created to mange when quarterly reviews are needed. The Manager of Operations will be responsible for overseeing this tracking tool and ensuring the Quarterly Psych-Med Reviews are being completed on time. Should an individual not attend his/her appointment in which the Med-Review is to be completed, the Manager of Operations will submit a request via fax to the prescribing doctor to ensure the Quarterly Med-Review is completed on time. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking document and all individuals' medication reviews to ensure timely completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] 11/11/2019 Implemented
6400.181(f)The program specialist did not provide Individual #2's assessment completed on 5/9/19 to the plan team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The assessment completed on 5/9/19 has been provided to the team members. The Program Coordinator will request the assessment from the Program Specialist at least 30 days prior to the individual plan meeting to disperse to the team.[Documentation of the correspondence showing the program specialist provide the assessments to the individuals' plan team members shall be kept and available upon request by the Department. Immediately, the CEO shall educate the program specialist of the responsibilities of the program specialist position including providing assessments to individual plan team members at least 30 calendar days prior to then individuals' plan team meetings. Documentation of the training shall be kept. (DPOC by AES,HSLS on 12/6/19)] 11/11/2019 Implemented
6400.186Individual #2's ISP last updated 9/3/19 states Individual #2 "NEEDS ASSISTANCE AND SUPERVISION WHEN USING THE STOVE OR OVEN". Individual #2's assessment completed 5/9/19 states "knowledgeable of danger of heat sources." Individual #2's ISP, last updated 9/3/19 reports Individual #2 "KNOWS HOW TO USE CLEANER APPROPRIATELY. HE WOULD NEED SOME SUPERVISION WHEN UPSET AS HE COULD THEN TRY TO USE IT IN AN INAPPROPRIATE MANNER." Individual #2's assessment completed 5/9/19 states "should not use poisonous materials. Can use cleaning products with supervision." Individual #2's ISP, last updated 9/3/19 reports Individual #2 "REGULATES HIS OWN BATH WATER AND SHOWERS INDEPENDENTLY. [Individual #2] DOES NOT KNOW HOW TO SWIM AND WILL ONLY STAY IN WATER WHERE HE IS ABLE TO TOUCH THE BOTTOM". Individual #2's assessment completed 5/9/19 states "likes swimming, but needs supervision." Individual #2's ISP last updated 9/3/19 states "WOULD NEED PROMPTING AND MAYBE ASSISTANCE TO EXIT QUICKLY". Individual #2's assessment completed 5/9/19 states "quickly evacuates."The home shall implement the individual plan, including revisions.Program Specialist has requested a team meeting to address changes/progress to individual's ISP. Program Specialist will continue to complete assessment with individual as required. Program Specialist will request team meeting 60-90 days after individuals admission date to revise ISP. [Immediately, upon revisions and continuing at least quarterly, the Program specialist shall audit all individuals' current assessments and current ISP to ensure consistency and accuracy that reflects the individuals' needs. The program specialist shall coordinate development of the ISP including the revisions with the individuals and the plan team members. Immediately and upon hire, the CEO shall educate the program specialist of the responsibilities of the program specialist position including providing assessments to individual plan team members at least 30 calendar days prior to then individuals' plan team meetings. Documentation of the training shall be kept. (DPOC by AES,HSLS on 12/6/19)] 11/15/2019 Implemented
6400.213(7)The record for Individual #1 did not include an invitation and signature page from annual ISP meetings. The record for Individual #2 did not include an invitation and signature page from annual ISP meetings.Each individual's record must include the following information: Individual plan documents as required by this chapter.The invitation and signature page has been put in both individual's records. A Monitoring Tool has been created which has a list of content required in each individual's file. The Manager of Operations will utilize this tool when completing weekly audits of the individual records. [Documentation of the monthly audits shall be kept. Immediately, the CEO shall educate the program specialist and the manager of operations to ensure all required information is included in all individuals' records. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/6/19)] 11/08/2019 Implemented
SIN-00145700 Renewal 11/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The home which has three stories including the basement, first floor and second floor does not have interconnected smoke detectors or an automatic fire alarm system.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. VIVINT security system is currently installed in the home. This system includes security, interconnected smoke detectors and motion sensors. On Wednesday 12/5/18 VIVINT is scheduled to come to the house to reactivate this system. Each month during fire drills the staff conducting the drill will check the system to ensure it is functioning properly. The program manager will be responsible for reviewing documentation monthly to ensure the system is being checked monthly. 12/05/2018 Implemented
6400.111(f)The fire extinguishers in the home were most recently inspected and approved by a fire safety expert in August 2017. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguisher was inspected on 11/26/2018. A spreadhseet has been created to better monitor dates of when the inspection is needed. The Program Manager is responsible for reviewing the spreadsheets and keeping track of when to schedule the next inspection. It has also been set up with J.H.Reiter that all of the fire extinguishers are on the same inspection cycle and they will notify the agency with a reminder call of when extinguishers need to be inspected. 11/26/2018 Implemented
6400.112(d)The evacuation time for the fire drill conducted by the home on 10/27/18 was 3 minutes 24 seconds. The home does not have an extended evacuation time designated by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Friday 11/30/2018 a fire drill was conducted by the home at 12:15 am. The evacuation time was 2 minutes and 6 seconds. Staff was given another training on fire safety 11/30/18. The Program Manager has created a calendar specific to managing fire drills and fire stafety. The Program Manager will review the fire drill log monthly and re-train as needed to ensure evacuation time does not exceed 2 minutes and 30 seconds. 11/30/2018 Implemented
6400.113(a)Individual #1, date of admission 05/14/18, was not instructed in general fire safety upon admission to the home. 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. Individual #1 has been educated on general fire safety in the home on 11/30/18; a video as well as questionnaire have been completed. Moving forward, all individuals who move into the home will be educated on general fire safety the day they move into the home by means of a fire safety video and a questionnaire. The questionnaire will be kept in the individual's file. The Program Manager will be responsible for making sure all individuals are educated on fire safety upon moving into the home. 11/30/2018 Implemented
6400.141(c)(6)Individual #1's most recent Tuberculin skin test by Mantoux method with negative result was completed on 07/07/16.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 is scheduled for a physical with his PCP on 12/5/18 at 11:00 AM. A Spreadsheet has been created to monitor Physical/dental/vision of all individuals serviced by T.H.R.I.V.E. The Program Manager will be responsible for reviewing this spreadsheet monthly and updating it as appointments occur. The Program Manager will also be responsible for notifying Direct Care Workers at least 30 days prior to the date an annual physical/TB/dental/vision is needed. 12/05/2018 Implemented
6400.151(a)Direct Service Worker #1, date of hire 5/15/18, does not have a physical examination. 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. Direct Service Worker #1 is scheduled for a physical for 12/4/18. Moving forward, T.H.R.I.V.E. has created a New Hire Checklist which will include all necessary documents/requirements to start employment. The first portion of this New Hire Checklist will be requirements before hire. Of these requirements is a current physical. The Program Manager will be responsible for reviewing this New Hire Checklist and making sure all forms/documents are in the new hires employee file. 12/04/2018 Implemented
SIN-00215871 Renewal 12/06/2022 Compliant - Finalized
SIN-00125878 Initial review 12/14/2017 Compliant - Finalized