| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00256534
|
Renewal
|
11/19/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | According to Enterprise Incident Management incident #9503195, Individual #1 purchased a lighter while on a community outing with Direct Service Worker #5 on 10/14/2024. Individual #1's restrictive procedure plan, last updated 8/16/2024, indicates that the individual cannot have access to lighters unless directly supervised by staff. After purchasing the lighter, staff did not confiscate the restricted item and Individual #1 proceeded to burn herself multiple times on her wrists. The agency failed to provide the individual protection from known hazards. According to Enterprise Incident Management incident #9497790, Chief executive Officer #1 continued providing direct supports to Individual #1 while the Chief Executive Officer was the target of an abuse investigation, EIM #9496296. The agency failed to take immediate actions to protect the health, safety, and well-being of Individual #1 following the discovery of EIM Incident #9496296. [Repeated violation: 8/13/2024 et al] | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Agency completed a room sweep of the individuals home and persons. CEO educated the individual on the restrictive plan and how and why she is not permitted lighters. |
12/20/2024
| Not Implemented |
| 6400.22(e)(3) | The financial management section of Individual #1's individual support plan, last updated on 11/14/2024, reads, "[Individual #1] is unable to appropriately manage her own finances. It is important for [Individual #1] to receive support when purchasing items in the community···She may need limited support to ensure she receives the correct change during a sales transaction." Interviews with agency staff revealed that the agency does not assist her with money management, retain receipts for purchases made that exceed $15.00, or keep a financial ledger to track the individual's purchases. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | CEO and PS have gone through the individuals ISP and assessment to ensure everything accurately reflects the individuals ability to manage there own funds. |
12/20/2024
| Not Implemented |
| 6400.43(b)(3) | According to Enterprise Incident Management incident #9497790, Chief executive Officer #1 continued providing direct supports to Individual #1 while the Chief Executive Officer was the target of an abuse investigation, EIM #9496296. Chief Executive Officer #1 failed to ensure the safety and protection of Individual #1 following the discovery on EIM Incident #9496296. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | CEO was removed from shift as soon as relief arrived. |
12/20/2024
| Implemented |
| 6400.64(a) | On 11/20/2024 at 11:07am, the HVAC vent in the dining room of the home was observed with a significant amount of dirt and debris on the vent slats and side of the vent. On 11/20/2024 at 11:08am, the seat cushions on the couch and love seat in the living room were observed with multiple stains of various sizes and colors. On 11/20/2024 at 11:24am, a substance that appeared to be a mold-like substance in the caulking around the second floor bathroom window. On 11/20/2024 at 11:44am, what appeared to be a mold-like substance was observed on the laundry room floor and wall to the left of the washing machine. On 11/20/2024 at 11:44am, the lint filter on the washing machine drain hose that empties into the washtub basin was observed clogged with lint, hair, and debris. | Clean and sanitary conditions shall be maintained in the home. | CEO has cleaned the vent and scheduled maintenance to service the vent so it is secured to the wall properly. |
12/20/2024
| Not Implemented |
| 6400.67(a) | On 11/20/2024 at 11:13am, the HVAC vent in the front entry of the home was observed with a gap between the top of the vent and the wall. The gap measured approximately one-half an inch in height and spanned the width of the vent. On 11/20/2024 at 11:26am, the paint on the wall, directly above the tiles in the second floor shower was peeling and lifting where the tiles meat the drywall. The peeling paint spanned the entire length of the shower. | Floors, walls, ceilings and other surfaces shall be in good repair. | CEO has cleaned the vent and scheduled maintenance to service the vent so it is secured to the wall properly. |
12/20/2024
| Not Implemented |
| 6400.72(b) | On 11/20/2024 at 11:44am, the screen in the window in the basement level laundry room was observed with a small tear in the bottom that was approximately the size of a dime. [Repeated violation: 4/9/2024 et al and 8/13/2024 et al] | Screens, windows and doors shall be in good repair. | CEO has scheduled maintenance to repair the hole in the basement screen window. |
12/20/2024
| Not Implemented |
| 6400.76(a) | On 11/20/2024 at 11:09am, the love seat in the living room was observed with a tear in the back cushion that measured approximately two inches wide. On 11/20/2024 at 11:20am, the grill on the second floor balcony was observed with an inordinate amount of rust on the grates and side burner. On 11/20/2024 at 11:26am, the shower head in the second floor bathroom was no longer secured to the wall. There was a gap between the shower head and the wall that measured approximately one-half of an inch. | Furniture and equipment shall be nonhazardous, clean and sturdy. | CEO has scheduled the snag/tear in the couch to be stitched and repaired if it cannot be repaired a new couch will be purchased. |
12/20/2024
| Not Implemented |
| 6400.81(k)(4) | On 11/20/2024 at approximately 11:27am, Individual #1's bedroom was observed without a chest of drawers. Individual #1's chest of drawers was observed in the vacant bedroom, located on the second floor of the home directly across from the staff office. Individual #1's support plan, last updated 11/14/2024, does not indicate that the individual chooses to have their chest of drawers in another room of the home. | In bedrooms, each individual shall have the following: A chest of drawers. | CEO has placed a bed in all rooms within the home. Individual can use any room as her bedroom. |
12/20/2024
| Implemented |
| 6400.81(k)(6) | On 11/20/2024 at approximately 11:27am, Individual #1's bedroom was observed without a mirror. Individual #1's mirror was observed in the vacant bedroom, located on the second floor of the home directly across from the staff office. Individual #1's support plan, last updated 11/14/2024, does not indicate that the individual chooses to have their mirror in another room of the home. [Repeated violation: 4/9/20024 et al] | In bedrooms, each individual shall have the following: A mirror. | CEO has placed a bed in all bedrooms of the home so the individual can use any room and move her dresser and mirror to whichever room she chooses. |
12/20/2024
| Implemented |
| 6400.112(c) | The fire drill logs for the drills occurring from 12/20/2023 through 11/1/2024 did not include a space for staff to document problems that were encountered during the fire drills. [Repeated violation: 4/9/2024, et al] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | CEO has updated the Fire Drill log form to reflect a space for staff to write if they encountered problems during the drill |
12/20/2024
| Not Implemented |
| 6400.112(e) | The fire drill logs for the drills occurring from 12/20/2023 through 11/1/2024 did not indicate if the individual was awake or sleeping at the time of the fire drill. The fire drill logs did not include documentation that any drills were conducted during normal sleeping hours. [Repeated violation: 4/9/2024, et al] | A fire drill shall be held during sleeping hours at least every 6 months. | CEO has updated the fire drill log form to reflect a space to document if the drill was completed during sleep or awake hours. |
12/20/2024
| Not Implemented |
| 6400.143(a) | Individual #1's annual vision examinations were scheduled for 8/20/2023 and 8/13/2024. Individual #1 refused to attend both of the scheduled appointments. The individual was trained on 8/20/2023 and 8/13/2024 on the need for health care; however, no subsequent trainings were completed to provide ongoing training of the importance of healthcare. [Repeated violation: 4/9/2024 et al] | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | CEO has reviewed the citation with the PS. CEO has shown the PS how we document all trainings and work done with the client on there refusal for appointments or treatment. |
12/20/2024
| Not Implemented |
| 6400.181(a) | Individual #1's assessment, last updated on 5/8/2024, indicated that the individual is supported at a 2:1 staff to client ratio and that Individual #1 can have up to 10 minutes of alone time in their bedroom, bathroom, and other areas inside and outside of the home. Individual #1's ISP, last updated on 11/14/2024, indicated that the individual must be within auditory range of staff at all times and that eyes on supervision is required when Individual #1 is utilizing sharps, the stove/oven, lighters, or other possible dangerous items. Interviews with agency staff revealed that Individua #1l's ISP indicates the correct level of supervision. Individual #1's assessment has not been updated to include a correct evaluation of the individual's supervision needs. [Repeated violation: 4/9/2024 et al] | 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. | CEO has reviewed the ISP and compared it to the assessment to ensure all information is accurate in regards to the individuals supervision. |
12/20/2024
| Not Implemented |
| 6400.212(b) | Program Specialist #2 completed individual #1's annual assessment and disseminated a copy to the individual plan team on 5/8/2024. Program Specialist #3 had previously written another entry on the date line to indicate when the assessment was disseminated to the team; however, the initial entry was scribbled out and no longer legible. [Repeated violation: 8/13/2024 et al] | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| CEO has shown the PS the violation and explained how to properly document a error on a release form. |
12/20/2024
| Not Implemented |
| 6400.18(f) | According to Enterprise Incident Management incident #9497790, Chief executive Officer #1 continued providing direct supports to Individual #1 while the Chief Executive Officer was the target of an abuse investigation, EIM #9496296. The agency failed to take immediate actions to protect the health, safety, and well-being of Individual #1 following the discovery of EIM Incident #9496296. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | CEO was removed from shift as soon as relief arrived. |
12/20/2024
| Implemented |
| 6400.24 | Human Rights Committee Member #3 and Human Rights Committee Member #4 were not trained on human rights and freedoms, relevant policies and interventions as designated by the provider, and other topics related to their responsibility to protect and promote rights prior to serving as members of the agency's Human Rights Team. According to page 6 of Human Rights and Restrictive Procedures Bulletin 00-21-01, "All members of the HRT should receive training on human rights and freedoms, any relevant policies and interventions as designated by the provider, and other topics related to their responsibility to protect and promote rights."
According to Enterprise Incident Management incident #9503195, Individual #1 purchased a lighter while on a community outing with Direct Service Worker #5 on 10/14/2024. Individual #1's restrictive procedure plan, last updated 8/16/2024, indicates that the individual cannot have access to lighters unless directly supervised by staff. After purchasing the lighter, staff did not confiscate the restricted item and Individual #1 proceeded to burn herself multiple times on her wrists. The Provider Administrative Review Section of the EIM indicated that Direct Service Worker #5 was retrained on the individual's BSP and protocols for when the individual purchases items in the community that they are not allowed to have in the home by Program Specialist #2 on 11/8/2024. Documentation of this training could not be provided. According to page 33 of Incident Management Bulletin 00-21-02, "Providers and SCOs are responsible for reviewing incident reports prior to finalizing them for accuracy and to ensure that the final report has all required elements to allow for the closure of the incident. In addition, providers and SCOs must ensure evidence of the implementation of corrective actions is available upon request by oversight entities···Specifically, the review must ensure: Corrective action(s) in response to the incident have, or will, take place, including those that involve actions related to the target(s)."
According to Enterprise Incident Management incident #9497790, Chief executive Officer #1 continued providing direct supports to Individual #1 while the Chief Executive Officer was the target of an abuse investigation, EIM #9496296. The Provider Administrative Review Section of the EIM indicated that Chief Executive Officer #1 was retrained on the agency's policy and IM bulletin by Program Specialist #2 on 11/5/2024. Documentation of this training could not be provided. According to page 33 of Incident Management Bulletin 00-21-02, "Providers and SCOs are responsible for reviewing incident reports prior to finalizing them for accuracy and to ensure that the final report has all required elements to allow for the closure of the incident. In addition, providers and SCOs must ensure evidence of the implementation of corrective actions is available upon request by oversight entities···Specifically, the review must ensure: Corrective action(s) in response to the incident have, or will, take place, including those that involve actions related to the target(s)."
According to Enterprise Incident Management incident #9497790, Chief executive Officer #1 continued providing direct supports to Individual #1 while the Chief Executive Officer was the target of an abuse investigation, EIM #9496296. According to page 12 of Incident Management Bulletin 00-21-02, "When the alleged target is an employee, staff, volunteer, contractor, consultant, or intern of the provider or SCO, the target shall not be permitted to work directly with the victim or any other individual during the investigation process until the investigation determination is completed and corrective action(s) specific to the target are implemented (55 Pa. Code § 6100.46). | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | CEO has scheduled a date for all members to be trained on the required HRT trainings. |
12/20/2024
| Not Implemented |
| 6400.182(c) | Individual #1's annual assessment, completed on 5/8/2024, states that the individual cannot swim. Individual #1's individual support plan, last updated on 11/14/2024, does not indicate if the individual can swim; it only states that the individual has a deficient awareness of water safety. No documentation was provided to demonstrate that the agency had notified the individual's supports coordinator of the discrepancy. [Repeated violation: 4/9/2024 et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | CEO has reviewed the assessment and the ISP to ensure both accurately reflect the individuals ability to swim. |
12/20/2024
| Implemented |
| 6400.186 | According to Enterprise Incident Management incident #9503195, Individual #1 purchased a lighter while on a community outing with Direct Service Worker #5 on 10/14/2024. Individual #1's restrictive procedure plan, last updated 8/16/2024, and individual #1's support plan, last updated 9/17/2024, indicate that the individual cannot have access to lighters unless directly supervised by staff. After purchasing the lighter, staff did not confiscate the restricted item and Individual #1 proceeded to burn herself multiple times on her wrists. The agency failed to implement the individual plan as written.
The financial management section of Individual #1's individual support plan, last updated on 11/14/2024, reads, "[Individual #1] is unable to appropriately manage her own finances. It is important for [Individual #1] to receive support when purchasing items in the community···She may need limited support to ensure she receives the correct change during a sales transaction." Interviews with agency staff revealed that Individual #1 manages her spending money independently. The agency is not implementing individual #1's support plan as written as the agency does not assist her with money management or keep a financial ledger to track the individual's purchases.
Individual #1's individualized support plan, last updated 11/14/2024 states, "[Individual #1] IS AWARE OF THE DANGERS OF POISONS, SHARPS, HEAT SOURCES AND ELECTRICAL OUTLETS BUT CHOOSES AT TIMES TO PUT HERSELF IN DANGER IN ORDER TO SELF-HARM OR TO THREATEN SELF-HARM···EYES ON SUPERVISION IS NEEDED WHEN [Individual #1] IS UTILZING SOMETHING SHARP, THE STOVE OR OVEN, LIGHTER OR OTHER POSSIBLY DANGEROUS ITEMS." On 11/20/2024 at 11:24am, a hook and eye latch was observed on the inside of the bathroom door on the second floor of the home. An additional hook and eye latch was observed on the outside linen closet door in the bathroom on the second floor of the home. Individual #1 could potentially harm herself with the sharp edges of the latch. [Repeated violation 8/13/2024 et al] | The home shall implement the individual plan, including revisions. | CEO has educated the individual on her restrictive plan. CEO has completed a room sweep of the entire home as well as the individuals persons. |
12/20/2024
| Not Implemented |
| 6400.194(c) | The human rights committee members in attendance at the 5/22/2024 meeting to approve Individual #1's restrictive procedure plan included Chief Executive Officer #1, Program Specialist #2, and Human Rights Committee Member #3. The human rights committee members in attendance at the 8/10/2024 meeting to approve Individual #1's restrictive procedure plan included Chief Executive Officer #1, Program Specialist #2, and Human Rights Committee Member #3. The human rights committee members in attendance at the 11/11/2024 meeting to approve Individual #1's restrictive procedure plan included Chief Executive Officer #1, Program Specialist #2, Human Rights Committee Member #3, and Human Rights Committee Member #4. Chief Executive Officer #1 and Program Specialist both provide direct services to Individual #1; therefore, the human rights teams did not include a majority of persons who do not provide direct services to the individual. [Repeated violation: 4/9/2024 et al] | The human rights team shall include a majority of persons who do not provide direct services to the individual. | CEO has began recruiting new members for the HRT team that do not provide direct care services to the individua. |
12/20/2024
| Implemented |
|
|
|
SIN-00249887
|
Unannounced Monitoring
|
08/13/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1's individualized support plan, last updated 8/7/2024 states, "[Individual #1] IS AWARE OF THE DANGERS OF POISONS, SHARPS, HEAT SOURCES AND ELECTRICAL OUTLETS BUT CHOOSES AT TIMES TO PUT HERSELF IN DANGER IN ORDER TO SELF-HARM OR TO THREATEN SELF-HARM···EYES ON SUPERVISION IS NEEDED WHEN [Individual #1] IS UTILZING SOMETHING SHARP, THE STOVE OR OVEN, LIGHTER OR OTHER POSSIBLY DANGEROUS ITEMS." On 8/13/2024 at approximately 10:30am, Direct Service Worker #2 unlocked the staff office closet, containing the homes locked poisonous cleaners and sharps. After unlocking the closet, Direct Service Worker #2 went downstairs to the main floor of the home and left Individual #1 unattended with access to medications, a kitchen knife, and poisonous cleaners. Direct Service Worker #2 failed to provide Individual #1 with appropriate supervision to protect her from hazards.
The agency failed to provide Individual #1 with medication management. The following medications prescribed to Individual #1 had not be administered on 8/12/2024 at 4:00pm as prescribed: Clonazepam 1mg tab and Perphenazine 2mg tab. The following medications prescribed to Individual #1 had not be administered on 8/12/2024 at 8:00pm as prescribed: Clonazepam 1mg tab, Depakote ER 250mg tab, Divalproex ER 500mg tab, Fiber-lax 625mg tab, Perphenazine 4mg tab, and Vitamin D3 25mcg tab. The following medications prescribed to Individual #1 had not be administered on 8/13/2024 at 8:00am as prescribed: Atorvastatin 20mg tab, Cetirizine 10mg tab, Clonazepam 1mg tab, Depakote ER 250mg tab, Divalproex ER 500mg tab, Fiber-lax 625mg tab, Fluticasone propionate 50mcg nasal spray, Januvia 25 mg tab, Levothyroxine 50mcg tab, Polyethylene Glycol 3350 17 gram Powder, and Valacyclovir 500mg tab. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | CEO contacted staff ensure all items were currently locked as stated in the individuals RPP. |
08/20/2024
| Implemented |
| 6400.64(a) | On 8/13/2024 at 10:28am, the furnace vent located under the window on the left side of the staff office was observed with a significant amount of dirt and dust on the vent cover. On 8/13/2024 at 12:15pm, three white kitchen-sized garbage bags full of trash were observed in the garage. The trash was omitting a foul, sour odor and a milky white liquid was leaking out of the bag on the right. On 8/13/2024 at 12:25pm, trash to include dryer lint and clothing labels was observed on top of a blue plastic shopping bag in the laundry room. On 8/13/2024 at 12:26pm, at the rear basement exit, spider's webs and cobwebs were observed at the top of the doorway. Grass and lawn clippings were caught in the webs [Repeat violation: 9/25/2023, 11/9/2023, and 4/9/2024 et al]. | Clean and sanitary conditions shall be maintained in the home. | CEO spoke with the house manager and explained which vent/register needed cleaned. House Manager cleaned the register thoroughly. |
08/20/2024
| Not Implemented |
| 6400.64(d) | On 8/13/2024 at 12:18pm, the trash can in the half bathroom on the main floor of the home was overflowing. Trash to include paper hand towels were spilling out of the can and pieces of paper towel were observed of the floor behind the toilet [Repeat violation: 9/25/2023 and 4/9/2024 et al]. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | CEO contacted house manager and did a walk through of the home. CEO ensured the home was clean of trash, dirt, and film. |
08/20/2024
| Implemented |
| 6400.64(e) | On 8/13/2024 at 10:10am, the 13-gallon trash can in the kitchen was overflowing with trash and the lid of the trashcan could not close properly. | Trash receptacles over 18 inches high shall have lids. | CEO met with the house manager on site and ensured all trash was removed from the home. CEO ensured all trash can lids are in good working condition. |
08/20/2024
| Implemented |
| 6400.64(f) | On 8/13/2024 at 12:16pm, unbagged trash to include paper napkins, an empty 1-gallon zip-top bag, an empty potato chip bag, and other pieces of various food wrappers were strewn throughout the yard on the left side of the home, adjacent to the attached garage [Repeat violation: 4/9/2024 et al]. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | CEO met with the house manager at the home and ensured all trash within the home as well as outside of the home has been removed and stored properly. |
08/20/2024
| Not Implemented |
| 6400.67(b) | On 8/13/2024 at 10:27am, the phone jack located on the far side of the staff office was observed with a broken cover. The covered had clear tape on it and it appeared that the tape had been used to attempt to keep the cover in place, however, the cover was pulled away from the wall approximately 2 inches and was exposing wiring [Repeat violation: 9/25/2023 and 4/9/2024 et al]. | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO has ensured that all power is shut off to the open phone jack. CEO has ensured that the open phone jack is not a safety hazard. CEO has scheduled maintenance to replace/repair the open phone jack. |
09/03/2024
| Not Implemented |
| 6400.74 | On 8/13/2024 at 12:27pm, the exterior steps at the rear basement egress were observed with slippery moss on the top three steps. | Interior stairs and outside steps shall have a nonskid surface.
| CEO has scheduled the maintenance to clean/remove the moss from the steps in the back. |
09/03/2024
| Implemented |
| 6400.76(a) | On 8/13/2024 at 10:23am, the blind in Individual #1's bedroom, located directly across from her closet, was observed with 2 broken slats [Repeat violation: 9/25/2023 and 4/9/2023 et al]. | Furniture and equipment shall be nonhazardous, clean and sturdy. | CEO has scheduled maintenance to come tot he home and repair/replace the blinds in the individuals bedroom. |
09/03/2024
| Implemented |
| 6400.80(a) | On 8/13/2024 at 12:16pm the exterior walkway, at the rear garage egress was observed with a thick layer of moss that had the potential to create a slipping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | CEO has scheduled maintenance to come to the home and clean/remove the moss from the back landing of the garage door. |
09/03/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed on 7/15/2024, did not include a review of the individual's medication regimen. | 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. | CEO has reviewed the clients physical exam. CEO has had the consult form that lists all the clients current medications placed in the client file. |
08/23/2024
| Implemented |
| 6400.171 | On 8/19/2024 at 10:10am, an 18-count container of eggs with an expiration date of 7/28/2024 was observed in the refrigerator. On 8/19/2024 at 10:11am, the following foods were observed open to contamination in the refrigerator and freezer: a 1-gallow zip-top bag with approximately 7 slices of cucumber and a 32-ounce bag of frozen seasoned French fries. On 8/13/2024 at 10:13am, a whole watermelon with, what appeared to be a slice from a knife was observed on the kitchen counter. The partially sliced watermelon was not covered or refrigerated to protect it from contamination or spoilage. On 8/13/2024 at 10:58am, a disposable red plastic cup filled approximately halfway with, what appeared to be, iced tea was observed on the white dresser in the locked staff office. The tea was uncovered and it was unknown how long the beverage had been there [Repeat violation: 9/25/2023 and 4/9/2024 et al]. | Food shall be protected from contamination while being stored, prepared, transported and served.
| CEO and house manager went through all the food in the clients home and removed all expired items and labeled all items in the home with future expiration dates. |
08/20/2024
| Not Implemented |
| 6400.212(b) | On 8/13/2024 at approximately 11:30am, it was discovered that Program Specialist #1 was falsifying medication administration documentation by documenting that staff were administering medications to individual #1. The August 2024 medication administration record indicated that the following medications were administered to individual #1 by Direct Service Worker #3 on 8/12/2024 at 4:00pm: Clonazepam 1mg tab and Perphenazine 2mg tab. The August 2024 medication administration record indicated that the following medications were administered to individual #1 by Direct Service Worker #3 on 8/12/2024 at 8:00pm: Clonazepam 1mg tab, Depakote ER 250mg tab, Divalproex ER 500mg tab, Fiber-lax 625mg tab, Perphenazine 4mg tab, Vitamin d# 25mcg tab. These medications had not been popped from the current blister packs and there was no documentation to support that Direct Service Worker #3 administered the medications as documented by Program Specialist #1. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| CEO has terminated the program specialist. CEO has contracted with an investigator outside the agency to investigate the incident and find all areas of falsification. Individuals doctors were notified of the individual not receiving there medications. |
08/20/2024
| Implemented |
| 6400.163(h) | Acetamin Tab 500mg prescribed to Individual #1 with instructions to take one tablet by mouth every 4 hours as needed for pain or fever was observed in the second-floor staff office. The medication had expired on 6/30/2024; however, the medication was administered to Individual #1 on 8/5/2024 at 9:56pm [Repeat violation: 4/9/2024 at al]. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | CEO and house manager reviewed all medications in the home to ensure non are expired and the mar is up to date and accurate. |
08/20/2024
| Implemented |
| 6400.165(b) | On 8/13/2024, Direct Service Worker #3 indicated that she was unable to log into the agency's electronic medication administration record to complete medication administrations to Individual #1. When asked how the staff is completing their required checks prior to administering the medications, Direct Service Worker #3 presented a paper copy of Individual #1's medication administration record to licensing staff. The medication administration record was current as of April 1, 2024 and did not match Individual #1's current orders. | A prescription order shall be kept current. | CEO has removed all old paper MARs from the home. CEO has placed current months paper mars in the staff office for staff to review and use whenever the electronic mars are not able to be accessed. |
08/20/2024
| Implemented |
| 6400.165(c) | On 8/13/2024, Individual #1 reported that she is not receiving her polyethylene glycol 3350 powder every day as prescribed. The August medication administration record has initials documenting that the medication is being administered; however, the medication bottle had 7/3/2024 written on it in permanent marker to indicate when it was opened. The medication is to be administered everyday and the bottle indicates that it is thirty daily doses. The bottle is 510g and it include thirty 17g doses. If the medication was being administered as prescribed, the bottle should have been finished on 8/1/2024; however, the bottle was filled approximately one-eighth of the way with medication.
The following medications prescribed to Individual #1 had not be administered on 8/12/2024 at 4:00pm as prescribed: Clonazepam 1mg tab and Perphenazine 2mg tab. The following medications prescribed to Individual #1 had not be administered on 8/12/2024 at 8:00pm as prescribed: Clonazepam 1mg tab, Depakote ER 250mg tab, Divalproex ER 500mg tab, Fiber-lax 625mg tab, Perphenazine 4mg tab, and Vitamin D3 25mcg tab. The following medications prescribed to Individual #1 had not be administered on 8/13/2024 at 8:00am as prescribed: Atorvastatin 20mg tab, Cetirizine 10mg tab, Clonazepam 1mg tab, Depakote ER 250mg tab, Divalproex ER 500mg tab, Fiber-lax 625mg tab, Fluticasone propionate 50mcg nasal spray, Januvia 25 mg tab, Levothyroxine 50mcg tab, Polyethylene Glycol 3350 17 gram Powder, and Valacyclovir 500mg tab. | A prescription medication shall be administered as prescribed. | CEO has reviewed the clients current medications to ensure all medications are in the home. CEO has retrained all DSP staff within the home on the clients daily medications and how they need to be administered. |
08/20/2024
| Implemented |
| 6400.166(b) | On 8/13/2024 at approximately 11:30am, it was discovered that agency staff are not initialing Individual #1's medication administration record at the time the medications are being administered. On 8/12/2024, the August 2024 medication administration record indicated that Individual #1's Atorvastatin 20mg tab was administered at 8:00am by Direct Service Worker #3. This entry was made on the electronic medication administration record by Program Specialist #1 on 8/13/2024 at 10:36am. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | CEO has removed the Program specialist from there duties overseeing the clients files and medications. CEO has reviewed contracted with and outside the agency investigator to investigate the incident. |
08/20/2024
| Not Implemented |
| 6400.186 | Individual #1's individualized support plan, last updated 8/7/2024 states, "[Individual #1] IS AWARE OF THE DANGERS OF POISONS, SHARPS, HEAT SOURCES AND ELECTRICAL OUTLETS BUT CHOOSES AT TIMES TO PUT HERSELF IN DANGER IN ORDER TO SELF-HARM OR TO THREATEN SELF-HARM···EYES ON SUPERVISION IS NEEDED WHEN [Individual #1] IS UTILZING SOMETHING SHARP, THE STOVE OR OVEN, LIGHTER OR OTHER POSSIBLY DANGEROUS ITEMS." On 8/13/2024 at approximately 10:30am, Direct Service Worker #2 unlocked the staff office closet, containing the homes locked poisonous cleaners and sharps. After unlocking the closet, Direct Service Worker #2
went downstairs to the main floor of the home and left Individual #1 unattended with access to medications, a kitchen knife, and poisonous cleaners. Additionally, on 8/13/2024 at 10:24am, a hook and eye latch was observed on the inside of the bathroom door on the second floor of the home. Individual #1 could potentially harm herself with the sharp edges of the latch. [Repeat violation: 11/9/2023]. | The home shall implement the individual plan, including revisions. | CEO has spoken with DSP staff and explained that state inspectors are not to be considered staff. It was reviewed and explained that the clients protocols are to the followed as usual whenever state inspectors arrive at the home. |
08/20/2024
| Implemented |
|
|
|
SIN-00249512
|
Unannounced Monitoring
|
07/19/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 7/17/2024, Individual #1 was neglected when Direct Service Worker #1 failed to provide the individual with adequate supervision to remain safe from hazards. Individual #1's individualized support plan, last updated 6/10/2024 indicates that "[Individual #1] requires intensive staffing, 24hrs/day 7-days per week. Staff need to be within auditory range of [Individual #1] at all times. Staff must check in on [Individual #1] at least every half hour making visual and verbal confirmation that [Individual #1] is doing ok···every 15 minutes after a behavior for at least the next hour." According to witness testimony provided by Chief Executive Officer #1 and Direct Service Worker #2, Individual #1 had been in behaviors for a large portion of the morning on 7/17/2024 and was displaying attention seeking behavior. After exhibiting attention seeking behaviors, Individual #1 was unsupervised in the basement of the home, while Direct Service Worker #1 was cleaning on the upper level of the home, leaving Individual #1 without direct supervision and outside of auditory range. While Individual #1 was unsupervised, Individual #1's medications were delivered by Federal Express. Individual #1, whom according to the ISP last updated 6/10/2024 has a history of self-harm, gained access to these medications and took them to the basement of the home. Individual #1's ISP, lasted updated 6/10/2024, indicates that Individual #1 cannot self-medicate and that all poisonous materials must be locked to prevent Individual #1 from engaging in self-harm behaviors. Individual #1 had access to one blister pack with 28 doses of Valacyclovir tab 500mg and three blister packs with 28 doses each of Clonazepam tab 1mg. While hospital staff do not believe Individual #1 swallowed any of these medications, only 20 of the 28 Valacyclovir tablets were accounted for after the incident and 0 of the 84 Clonazepam tablets were accounted for. On 7/19/2024, Individual #1 reported to licensing staff that the individual heard Direct Service Worker #1 tell law enforcement officers that she has a herpes diagnosis. Individual #1 stated that she did not appreciate that Direct Service Worker #1 disclosed this information. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | CEO has terminated such staff member involved in this incident. |
08/20/2024
| Implemented |
| 6400.43(b)(3) | On 7/17/2024, Individual #1 was neglected when Direct Service Worker #2 failed to provide the individual with adequate supervision to remain safe from hazards. Report #9451340 failed to identify a suspected target; however, Direct Service Worker #2 was the only staff person present in the home at the time of the incident. Following notification of the incident, Chief Executive Officer #1 reported to the home. After initial examination by Emergency Medical Services, it was recommended that Individual #1 be taken to the Emergency Department at Forbes Hospital for further evaluation. Chief Executive Officer #1 allowed the suspected target, Direct Service Worker #2, to continue working with the victim as she escorted Individual #1 to the hospital. Section V of the agency's incident management policy states, "[Agency] point person must ensure separation of the victim from the alleged target(s) for incidents involving abuse or sexual abuse. This separation shall continue until the investigation is completed···When the alleged target is an employee, staff, volunteer, contractor, consultant, or intern of [agency], the target shall not be permitted to work directly with the victim or any other individual during the investigation process until the investigation determination is completed and corrective action(s) specific to the target are implemented. Additionally, Chief Executive Officer #1 allowed Direct Service Worker #2 to remain on the agency's scheduled and provide direct services to Individual #1 for the remainder of their shift on 7/17/2024, 7/18/2024, and 7/19/2024. Chief Executive Officer #1 failed to provide safety and protection to Individual #1. [Repeat violation: 3/17/2023 and 4/3/2023] | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | CEO has assured no alleged targets are working with the individual and are suspended pending the investigation. |
08/20/2024
| Implemented |
| 6400.63(a) | On 7/19/2024 at 10:59am, Individual #1 showed licensing staff that they had moved their clothing out of the upper-level bedroom into the basement of the home. Individual #1 is utilizing a shelf in the utility closet to store their clothing. Located in the utility closet, approximately 3-feet from the individual's clothes are the hot water tank and furnace. According to Individual #1's individualized support plan, last updated 6/10/2024, Individual #1 is aware of heat sources but must be supervised when near them due to a history of self-harm. [Repeat violation: 5/23/2024 et al.] | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | CEO has scheduled maintenance to place locks on furnace room doors. CEO has placed shelves in the finished part of the basement for individual to store her items of choice. |
08/20/2024
| Implemented |
| 6400.67(a) | On 7/19/2024 at 10:53am, the paneling in the closet under the basement steps was observed with a hole in the ceiling, measuring approximately 8-inches by 10-inches in size. On 7/19/2024 at 10:56am, the paneling in the basement, in the room across from the basement egress, was observed with a hole near the floor behind the couch, measuring approximately 6-inches in length. [Repeat violation: 2/14/2023, 3/17/2023, 6/29/2023, 9/25/2023, 11/9/2023, and 4/9/2024 et al.] | Floors, walls, ceilings and other surfaces shall be in good repair. | CEO has scheduled maintenance to complete a repair of the paneling inside the closet storage in the basement. |
09/04/2024
| Not Implemented |
| 6400.67(b) | On 7/19/2024 at 10:54am, the floor in the basement laundry room was observed with a slimy film. According to Individual #1, this film has been on the floor since the floor drain backed up in May 2024 and has never been properly cleaned. On 7/19/2024 at 11:00am, an electrical junction box was observed without a cover, exposing electrical wiring, on the right side of the room in the basement that is located across from the rear basement exit. [Repeat violation: 5/23/2023, 6/29/2023, 7/25/2023, 9/25/2023, and 4/9/2024 et al.] | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO has scheduled maintenance to inspect the plumbing in the basement to ensure everything is functioning properly. CEO has cleaned the film that was left on the floor. |
09/04/2024
| Not Implemented |
| 6400.72(b) | On 7/19/2024 ay 10:49am, the door on the spare bedroom, located across the hallway from the locked staff office was observed with a metal plate around the doorknob. The plate catches on the door frame and will not allow the door to close properly. [Repeat violation: 2/14/2023, 5/23/2023, and 4/9/2024 et al.] | Screens, windows and doors shall be in good repair. | CEO has scheduled maintenance to repair the door plate. CEO has ensured the plate is not a hazard to the individual. |
09/03/2024
| Implemented |
| 6400.86 | On 7/19/2024 at 10:14am, Individual #1 reported that, on 7/15/2024 at approximately 5:00pm, she discovered a gun magazine with a bullet on the top shelf in the living room located to the left of the decorative fireplace. Individual #1 stated that she hid the magazine and ammunition in her purse until 7/16/2024 at approximately 1:30am. Individual #1 stated that at approximately 1:30am on 7/16/2024, she removed the magazine and ammunition from her pure and took a picture of them. Individual #1 sent a photograph of the magazine and ammunition to Direct Service Worker #3, who verbally confirmed that she received with photograph via text message. Individual #1 showed the image to licensing personnel. The photograph was time stamped 7/16/2024 at 1:35am with latitude and /longitude coordinates of the agency home. The photograph of the magazine was taken on fabric that appeared to match the fabric of the couch in the basement in the room across from the basement egress. Individual #1 confirmed that she took the picture of the magazine while seated on the couch. | Firearms and ammunition are not permitted in the home or on the property of the home.
| CEO has inspected the entire home to ensure there are no weapons of any kind within the home or surrounding areas of the home such as the shed. |
08/20/2024
| Implemented |
| 6400.141(c)(7) | Individual #1's most current gynecological examination did not include the physician's signature or the date of the examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Program Specialist contacted the physician to ensure the individual attended the appointment and the physician reviewed the consult form. Agency is attempting to obtain a signed consult form from the physician. |
08/20/2024
| Implemented |
| 6400.142(a) | Individual #1's most recent dental examination was scheduled for 12/19/2023. Individual #1 refused to attend this appointment and the next available appointment was made for 5/10/2024. No paperwork could be provided to document that Individual #1 attended the appointment on 5/10/2024 and refusal documentation was provided. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | CEO has audited individual file to ensure all appointments are up to date and scheduled. Individual was counseled on the importance of attending appointments. |
08/21/2024
| Implemented |
| 6400.144 | Individual #1 was seen by the podiatrist on 1/8/2024 for diabetic foot care. On the appointment paperwork, the physician indicated a recall in 4 months. Individual #1 was seen by the nephrologist on 3/19/2024. On the appointment paperwork, the physician indicated follow-up appointments on 6/5/2024 and 6/26/2024. No documentation of Individual #1 attending these follow-up appointments could be provided. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| CEO has audited the client flies and appointments to ensure all appointments are scheduled. CEO has councelled the individual on the importance of attending all appointments. |
08/22/2024
| Implemented |
| 6400.151(a) | Direct Service Worker #2, date of hire 7/13/2024, did not have a physical examination completed within 12 months prior to hire. No documentation of a physical examination for Direct Service Worker #2 was provided. | 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. | CEO has terminated/suspended staff pending completion of proper physical. |
08/22/2024
| Implemented |
| 6400.18(f) | On 7/17/2024, Individual #1 was neglected when Direct Service Worker #2 failed to provide the individual with adequate supervision to remain safe from hazards. Report #9451340 failed to identify a suspected target; however, Direct Service Worker #2 was the only staff person present in the home at the time of the incident. Following the incident, Individual #1 was taken to the Emergency Department at Forbes Hospital for further evaluation. The suspected target, Direct Service Worker #2, was not separated from the victim as she escorted Individual #1 to the hospital. Additionally, Direct Service Worker #2 remained on the agency's schedule and provided direct services to Individual #1 for the remainder of her shift on 7/17/2024, 7/18/2024, and 7/19/2024. The agency failed to take immediate actions to protect the health, safety, and well-being of Individual #1. [Repeat violation: 4/3/2023] | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | CEO suspended the staff member/terminated them pending the investigation. The investigation was not able to be changed to indicate the staff member as the target and remove the agency as the target. |
08/20/2024
| Implemented |
| 6400.163(a) | On 7/19/2024 at 12:56pm, Hydrocortisone Ointment USP 1%, prescribed to Individual #1, was not kept in the original container with the label issued by the pharmacy. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | CEO removed the discontinued medication from the home and disposed of it per agency policy. |
08/22/2024
| Implemented |
| 6400.165(c) | On 7/19/2024 at 12:55pm, Ketoconazole Sha 2%, prescribed to Individual #1 had instructions on the July 2024 Medication Administration Record to use to wash scalp up to four times weekly as needed for scaling/redness/irritation. The instructions on the pharmacy label and doctor's order indicate to apply topically twice weekly for scaling/redness/irritation. According to the July 2024 Medication Administration record, the medication had not been administered between 7/1/2024 and 12:55pm on 7/19/2024. The prescription medication had not been administered as prescribed. [Repeat violation: 2/21/2023] | A prescription medication shall be administered as prescribed. | CEO has ensured the medication is being administered as prescribed. The CEO has trained all DSP staff on the individuals specific medications and how and when they need to be administered. |
08/22/2024
| Implemented |
| 6400.165(g) | Individual #1's most recent psychiatric medication review was completed on 2/20/2024. [Repeat violation: 4/9/2024 et al.] | 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. | CEO has trained the individual on the importance of maintaining her medical appointments. CEO will train new program specialist on psych med review regulations. This client has stated they do not want to take the medication any longer. The medication is discontinued at the end of august. There is a team meeting being scheduled to discuss the situation and a medical appointment will be made after the meeting. |
08/22/2024
| Implemented |
| 6400.166(a)(4) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the name of this medication. [Repeat violation: 5/23/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | CEO removed the medication from the home and disposed of the medication per the agency policy. |
08/22/2024
| Implemented |
| 6400.166(a)(5) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the strength of this medication. [Repeat violation: 5/23/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | CEO removed the medication from the home and disposed of the medication per the agency policy. |
08/22/2024
| Implemented |
| 6400.166(a)(6) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the dosage form of this medication. [Repeat violation: 5/23/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | CEO removed the discontinued medication to from the home and disposed of it per agency policy. |
08/22/2024
| Implemented |
| 6400.166(a)(7) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the dose of the medication. [Repeat violation: 5/23/2023 and 7/25/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | CEO has removed the discontinued medication from the home and disposed of it per agency policy. |
08/22/2024
| Implemented |
| 6400.166(a)(8) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the route of administration. [Repeat violation: 5/23/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | CEO has removed the medication from the home and disposed of it per agency policy. |
08/22/2024
| Implemented |
| 6400.166(a)(9) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the frequency of administration. [Repeat violation: 5/23/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | CEO has removed the medication from the home and disposed of it per agency policy. |
08/22/2024
| Implemented |
| 6400.166(a)(10) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the administration times. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | CEO has removed the medication from the home and disposed of it per agency policy. |
08/15/2024
| Implemented |
| 6400.166(a)(11) | On 7/19/2024 at 12:56pm, Hydrocortisone Oin 1%, prescribed to Individual #1, was observed in the locked staff office without a pharmacy issued label. The current physician's order or discontinuation order was not provided. The July 2024 Medication Administration Record did not include the diagnosis or purpose for the medication. [Repeat violation: 5/23/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | CEO has removed the medication from the home and disposed of it per agency policy. |
08/22/2024
| Implemented |
| 6400.167(a)(1) | On 7/19/2024 at 12:55pm, Ketoconazole Sha 2%, prescribed to Individual #1 had instructions on the July 2024 Medication Administration Record to use to wash scalp up to four times weekly as needed for scaling/redness/irritation. The instructions on the pharmacy label and doctor's order indicate to apply topically twice weekly for scaling/redness/irritation. According to the July 2024 Medication Administration record, the medication had not been administered between 7/1/2024 and 12:55pm on 7/19/2024. The agency failed to administer the medication as prescribed. [Repeat violation: 5/23/2023] | Medication errors include the following: Failure to administer a medication. | CEO is administered as prescribed by the doctor. |
08/22/2024
| Implemented |
| 6400.167(c) | On 7/19/2024 at 12:55pm, Ketoconazole Sha 2%, prescribed to Individual #1 had instructions on the July 2024 Medication Administration Record to use to wash scalp up to four times weekly as needed for scaling/redness/irritation. The instructions on the pharmacy label and doctor's order indicate to apply topically twice weekly for scaling/redness/irritation. According to the July 2024 Medication Administration record, the medication had not been administered between 7/1/2024 and 12:55pm on 7/19/2024. The agency failed to administer the medication as prescribed. Chief Executive Officer #1 was aware of the medication error on 7/26/2024 at 1:14pm. As of 8/9/2024 at 12:00pm, the medication error had not been reported through the department's Enterprise Incident Management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | CEO is administered as prescribed by the doctor. |
08/22/2024
| Implemented |
| 6400.188(b) | The agency is not providing Individual #1 opportunities and support for participation in community life, including volunteer or civic-minded opportunities and membership in National or local organizations. According to daily notes completed by agency staff, Individual #1 requested to attend church services on 6/16/2024 and 7/21/2024; however, Individual #1 was never provided opportunities to attend such services. Additionally, on 7/8/2024, Individual #1 indicated to staff that they would like to work and would like to hold a job. Individual #1 reiterated this desire to licensing staff on 7/19/2024. The agency is not providing the individual with opportunities to develop the skills necessary to obtain or hold a job. [Repeat violation: 2/14/2023] | The home shall provide opportunities and support to the individual for participation in community life, including volunteer or civic-minded opportunities and membership in National or local organizations. | CEO has counseled the individual that they can attend community outings regularly outside the 2 weekly scheduled activities. |
08/22/2024
| Implemented |
|
|
|
SIN-00246097
|
Unannounced Monitoring
|
05/23/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | On 5/23/2024 at approximately 11:34am, the cordless phone located on the floor adjacent to the couch in the living room was observed with no operable outside line. No operable phone could be produced for licensing. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| CEO contacted the phone company who sent out a tech the next day after inspection. The tech stated that the phone line was plugged into the wrong spot on the phone box. The tech plugged everything in correctly and called the CEO from the house phone. |
06/21/2024
| Implemented |
| 6400.181(c) | Individual #1's assessment, completed on 5/8/2024 by Program Specialist #1, has sections to include individual's functional strengths, individual's preferences, individual's likes, individual's dislikes, individual's interests, acquisition of functional skills, and recommendations that have been copied verbatim from the individual's ISPs that was last updated 8/4/2023. The assessment was not based on the results of assessment instruments, interviews, progress notes and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | CEO has personally updated all assessments to ensure and reflect the accurate description of the individuals functionality. |
06/21/2024
| Implemented |
|
|
|
SIN-00242665
|
Renewal
|
04/09/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 4/10/2024 at 11:46am, poisons were observed in an unlocked cabinet in the unlocked garage to include a 5 pound bottle of Moss Out Spot Treater and a 5 gallon bucket of Amstone Foundation Coating. Both substances instruct to contact Poison Control or to seek medical attention if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | CEO Immediately placed the poisons in the locked cabinet |
05/10/2023
| Not Implemented |
| 6400.64(a) | On 4/10/2024 at 12:16pm, the carpet in basement located in front of the sectional was observed with multiple stains of various sizes and colors. [Repeat violation: 5/23/2023, 6/29/2023, 7/25/2023, 9/25/2023, and 11/9/2023]. | Clean and sanitary conditions shall be maintained in the home. | CEO has scheduled a professional carpet cleaning company to service the carpets in the basement. |
05/01/2024
| Not Implemented |
| 6400.65 | On 4/10/2024 at 11:49am, the first floor half-bathroom was observed without mechanical ventilation. The window in this bathroom is non-operable and cannot provide proper air flow. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| CEO has scheduled a maintenance services to install a ventilation system in the restroom. |
05/01/2024
| Implemented |
| 6400.67(a) | On 4/10/2024 at 11:48am, the appearance of moisture intrusion was observed on the ceiling of the garage. Water was dripping from the ceiling onto the floor of the garage. [Repeat violation: 6/29/2023 and 9/25/2023] | Floors, walls, ceilings and other surfaces shall be in good repair. | CEO immediately cleaned and dried the wet floor. |
05/09/2024
| Implemented |
| 6400.67(b) | On 4/10/2024 at 11:43am, water was observed on the floor in garage measuring approximately three feet in length, spanning the width of the garage. The water was creating a potential slipping hazard for staff and individuals. | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO immediately cleaned and dried the floor and ceiling in the garage. |
05/09/2024
| Not Implemented |
| 6400.72(b) | On 4/10/2024 at 11:48am, the man door in rear of garage was observed with the bottom portion rusted and broken. The door was not providing a tight seal to prevent against infestation of insects and rodents. On 4/10/2024 at 12:07pm, the screen in the three windows on the right side of the dining room were observed with multiple holes and tears of various sizes. The torn screens were not providing a tight seal to prevent against infestation. | Screens, windows and doors shall be in good repair. | CEO has scheduled maintenance to services the screens in the dining room. CEO has inspected to remaining screens in the home to ensure all are in good repair. |
05/01/2024
| Not Implemented |
| 6400.81(k)(6) | On 4/10/2024 at 11:40am, Individual #1's bedroom was observed without a mirror. According to Chief Executive Officer #2, Individual #1 should not have a mirror in their bedroom as a preventative measure. Individual #1 has a history of self-injurious behaviors and if the individual were to break the mirror, she could use it to cut herself. Individual #1's mirror was being stored in the locked staff office. Individual #1's ISP last updated 2/20/2024 and RPP last updated on 2/18/2024 did not indicate that she could not have a mirror in her bedroom. [Repeat violation: 5/23/2023]. | In bedrooms, each individual shall have the following: A mirror. | CEO has placed the mirror in the individuals bedroom. |
05/01/2024
| Not Implemented |
| 6400.82(f) | On 4/10/2024 at 11:49am, the first floor full bathroom was observed without clean paper or cloth towels. [Repeat violation: 7/25/2023] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | CEO placed the paper towels in the bathroom. CEO purchased cloth towels to be placed on the towel holders in the restroom. |
05/01/2024
| Implemented |
| 6400.112(c) | For all fire drills completed from 4/10/2023 through 3/22/2024, the fire drill record did not include the time the fire drills were conducted nor did it include whether or not problems were encountered during the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | CEO has retrained himself on the regulations for fire drill documentation. CEO has developed a new fire drill log that will be used in all the homes. |
05/01/2024
| Not Implemented |
| 6400.143(a) | Individual #1's annual dental examinations and cleanings were scheduled for 5/26/2023 and 12/19/2023. Individual #1 refused to attend these appointments. The individual's refusals to attend the dental examinations were documented; however, continued attempts to train the individual about the need for dental care was not provided. [Repeat violation: 5/23/2023] | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | CEO has developed a program to train the individuals within the agency on the importance of maintaining scheduled appointments. Documentation for this training will be developed. The individual will be trained on this topic immediately. |
05/01/2024
| Implemented |
| 6400.145(1) | The emergency medical plan for individual #1 does not include the hospital or source of healthcare to be used in the event of an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | CEO will discuss with the individual on there preference of emergency medical treatment center. The CEO will update the individual emergency medical binder in the home. |
05/01/2024
| Implemented |
| 6400.171 | On 4/10/2024 at 12:01pm, multiple food were observed in the refrigerator and freezer that were not properly sealed to prevent from contamination to include: a 30 ounce bag of Pickwell Farms frozen corn, a 16 ounce box of Bremer frozen corn dogs, a 25 ounce bag of Kirkwood Buffalo Style chicken strips, and a 25 ounce bag of Kirkwood crispy chicken strips. On 4/10/2024 at 12:02pm, multiple foods in the refrigerator and freezer were expired to include a 40 ounce bag of Kirkwood Boneless Skinless Chicken Tenderloins that expired on 3/2/2024, a 32 ounce bottle of Friendly Farms Heavy Whipping Cream that expired on 3/31/2024, a 17.25 ounce jar of Smucker's Natural Strawberry Fruit Spread that expired on 3/28/2024, a 30 fluid ounce jar of Burman's Real Mayonnaise that expired on 1/25/2023, a 4-pack of Friendly Farms Probiotic Lowfat Yogurt that expired on 3/30/2024, and what appeared to be a head of brown rotting cabbage. On 4/10/2024 at 12:03pm a 1-gallon bag was observed in the freezer filled roughly one quarter of the way with an unidentified light-orange colored powder. The bag was not labeled or dated. On 4/10/2024 at 12:04pm, a 28 ounce box of Earthly Grains Instant White Rice and a 16 ounce bag of So Natural Jasmine Rice were observed open to contamination in the upper kitchen cupboard adjacent to the refrigerator. [Repeat violation: 6/29/2023, 7/25/2023, 9/25/2023] | Food shall be protected from contamination while being stored, prepared, transported and served.
| DSP staff have gone through the food throughout the entire home and removed all expired food. |
05/01/2024
| Not Implemented |
| 6400.181(e)(1) | Individual #1's assessment completed on 1/18/2024 did not include the strengths, needs, and preferences of the individual. This section was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Not Implemented |
| 6400.181(e)(2) | Individual #1's assessment completed on 1/18/2024 did not include the likes, dislikes, and interests of the individual. This section was left blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Not Implemented |
| 6400.181(e)(3)(i) | Individual #1's assessment completed on 1/18/2024 did not include the current level of performance and progress in the acquisition of functional skills. This section was left blank. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's assessment completed on 1/18/2024 did not include the current level of performance and progress in communication. This section was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment completed on 1/18/2024 did not include the current level of performance and progress in personal adjustment. This section was left blank. | The individual's current level of performance and progress in the following areas: Personal adjustment. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's assessment completed on 1/18/2024 did not include the current level of performance and progress in personal needs without assistance from others. This section was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 1/18/2024 did not include recommendations for specific areas of training, programming and services. This section was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Not Implemented |
| 6400.214(b) | Individual #1's current plan in HCSIS was last updated on 2/20/2024. On 4/9/2024 at approximately 11:10am, the most current plan that was available in the residential home was last updated on 6/16/2023. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Program Specialist has uploaded the clients most recent ISP in the Electonic file system Therap. |
04/18/2024
| Not Implemented |
| 6400.163(h) | On 4/10/2024 at 11:26am expired PRN medications prescribed to Individual #1 were observed in the second floor staff office to include: Ketaconazole 2% Shampoo that expired 1/2024 and Refresh Optiv eye drops that expired 2/2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | CEO removed and disposed of the medications in the home per agency policy ad procedure. |
05/09/2024
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication reviews were completed on 5/15/2023 and again on 9/26/2023. | 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. | The CEO has trained the Program Specialists on the required quarterly psych medications review regulations. The CEO has trained the Program specialist on the proper documentation required for each of these reviews (Agency form and consult forms). The CEO has trained the Program Specialist on the proper way to document if there are any unavoidable delays in these medications reviews. |
05/01/2024
| Not Implemented |
| 6400.166(a)(13) | Sodium Bicarbonate 650mg tablet, prescribed to Individual #1, was not documented as administered on 4/1/2024 at 8:00am. [Repeat violation: 6/29/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The CEO has trained the program specialist on how to review the MAR for documentation errors. |
05/01/2024
| Not Implemented |
| 6400.169(a) | Chief Executive Officer #2's most recent medication administration training was completed on 10/13/22. On 4/1/2024 at 8:00AM, Chief Executive Officer #2 administered the following medications to Individual #1: Atorvastatin 20mg, Cetirizine 10mg, Depakote ER 250, Divalproex ER, Fiber lax 625mg, Fluticasone 50mcg, Januvia 25mg, levothyroxine 50mcg, Polyethylene Glycol 3350, Valacyclovir 500mg. On 4/2/2024 at 4:00pm, Clonazepam 1mg and Perphenazine 2mg was administered to Individual #1 by Chief Executive Officer #2. On 4/7/2024 at 4:00PM, Clonazepam 1mg was administered to Individual #1 by Chief Executive Officer #2. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The agency's training coordinator will have completed the train the trainer medication administration course on 4/25/24. At that time the training coordinator will complete the required medication observations to bring the CEO's certificate into compliance. |
04/25/2024
| Implemented |
| 6400.181(f) | Individual #1's annual assessment, completed on 1/18/2024, was sent to the plan team on 1/10/2024. The assessment was sent to the plan team prior to the completion of the assessment. | 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 CEO has trained the Program specialist on the requirements for when the assessments need to be sent to the team and the proper releases that need documented and signed to ensure these regulations is satisfied. |
05/01/2024
| Implemented |
| 6400.182(c) | Individual #1's annual assessment that was completed on 1/18/2024 states that she is unable to sense and move away from heat sources. In the water safety section of Individual #1's individual plan that was last updated on 2/20/2024 reads, "[Individual #1] has the ability to quickly remove herself from heat sources. In the general health and safety risks section of Individual #1's individual plan that was last updated on 2/20/2024 reads, "[Individual #1] is aware of the dangers of poisons, sharps, heat sources, and electrical outlets...". Individual #1's annual assessment that was completed on 1/18/2024 states that she requires assistance to adjust the water temperature. In the water safety section of Individual #1's individual plan that was last updated on 2/20/2024 reads, "[Individual #1] regulates her own shower water temperature. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Program specialist will be completing a new assessment on the client to ensure all areas of the ISP match the agencies assessments. |
05/01/2024
| Implemented |
| 6400.194(c) | The human rights committee member that approved Individual #1's restrictive procedure plan at the meetings held on 8/15/2023, 11/1/2023, and 2/1/2024 included of Program Specialist #1, Chief Executive Officer #2, and House Manager #3. All of the committee members provide direct services to the individual. | The human rights team shall include a majority of persons who do not provide direct services to the individual. | The CEO will identify and add a member from outside the agency who is not affiliated with the client. |
05/01/2024
| Not Implemented |
|
|
|
SIN-00234349
|
Unannounced Monitoring
|
11/09/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | on 11/9/23 the carpet located in the stairwell going from the kitchen to the basement, was spotted and covered with numerous stains. [Repeat violation-5/23/23, 6/29/23, 7/25/23 an 9/25/23] | Clean and sanitary conditions shall be maintained in the home. | The CEO instructed the house lead to sweep all the carpets in the home. The cleaning company has been contacted and we are working on scheduling a date for the carpets to be scrubbed. |
11/28/2023
| Implemented |
| 6400.64(c) | on 11/9/23 several sheets of clear plastic were located in the closet of the bedroom leading outside to the deck. [Repeat violation 9/25/23] | Trash shall be removed from the premises at least once per week. | The House Lead removed the trash from the closet and disposed of it properly. |
11/20/2023
| Implemented |
| 6400.80(b) | On 11/9/23, the deck located above the garage, had an excessive amount of leaves piled against the wall connected to the main house and under the exit from the bedroom to the deck which could pose a slipping hazard when wet. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The CEO contacted the maintenance man and he is scheduled to come clean the leaves off the property on 11/28/23. |
11/28/2023
| Implemented |
| 6400.18(a)(5) | Incident #9311970 was discovered 11/8/23 at 4:30 AM and reported 11/10/2023 01:12 PM. Individual #1 and staff went to UPMC East, via ambulance, for what was reported by Individual #1 as "marijuana use". Individual #1 did test positive for marijuana. Direct Service Worker #1 did not report the incident. [Repeat violation 3/17/23] | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| CEO immediately sent the information onto the certified investigator who reported the incident through the EIM system. |
11/21/2023
| Implemented |
| 6400.165(b) | Individual #1 is prescribed Benzonatate 100mg capsule, take 1 capsule by mouth 3 times daily as needed for cough. The medication is listed on Individual #1's November 2023 Medication Administration Record but was not in the home at the time of inspection. [Repeat violation 5/23/23 and 9/25/23] | A prescription order shall be kept current. | The medication was immediately removed from the MAR as it was a discontinued. |
11/21/2023
| Implemented |
| 6400.186 | On 11/9/23 Individual #1 removed a Bic lighter from their pocket, showed it to both Licensing Representatives and stated, "I'm not allowed to have this." Per Individual #1's 8/18/23 Restrictive Procedure Support Plan "all lighters will be safely secured in an identified location (e.g., lock box). When [Individual #1] requests to smoke a cigarette, staff will hold the lighter and will light the cigarette. It should then be returned to the safe location." [Repeat violation 1/5/23 and 3/17/23] | The home shall implement the individual plan, including revisions. | The Program Specialist retrained the House Manager and House staff on the individuals BSP. All lighters were confirmed to be locked. |
11/21/2023
| Implemented |
|
|
|
SIN-00231971
|
Unannounced Monitoring
|
09/25/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of inspection, the carpet located on the second floor of the home and in the staff office was spotted and covered with numerous stains. [Repeat violation-5/23/23, 6/29/23 and 7/25/23] | Clean and sanitary conditions shall be maintained in the home. | The CEO scheduled the carpets to be cleaned by a professional company. The CEO purchased cups with lids for the individual to use. Staff will work with the individual on using the lidded cups to help prevent the individuals drinks from spilling. |
10/25/2023
| Implemented |
| 6400.64(c) | At the time of inspection several empty cardboard boxes and sheets of plastic were located in the closet of the bedroom leading outside to the deck. | Trash shall be removed from the premises at least once per week. | The staff have been trained that when the individual receives a package in of any sort it is there responsibility to first notify management so the agency can keep track of the individuals inventory. Thay are to also contact maintenance if the item needs assembled. They are responsible for removing any boxes and debris from the home immediately. |
10/19/2023
| Implemented |
| 6400.67(a) | At the time of inspection, the blind covering the window in the 2nd floor bathroom had several slats at the bottom broken. [Repeat violation-3/17/23 and 6/29/23] | Floors, walls, ceilings and other surfaces shall be in good repair. | The staff and house manager were trained on how to submit a maintenance request for any items found broken in the home. The CEO scheduled maintenance to replace the blind in the bathroom. |
10/19/2023
| Implemented |
| 6400.76(a) | At the time of inspection, the tables and the arms of the couch, located on the deck of the home, were in disrepair. One of the tables was missing the glass inlay on the top, the couch and other table were made of a woven resin type material that looked like wicker, this material was broken causing jagged edges. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The contacted the maintenance department and all furniture on the back deck was removed. |
10/19/2023
| Implemented |
| 6400.80(b) | At the time of inspection, the outside steps, leading from the basement to the backyard were covered in a green, moss-like substance. The gutter, in the front of the home, over the garage had multiple clumps of a green, moss-like substance growing. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The CEO contacted the maintenance department, and the steps were cleaned and cleared of debris as well as treated to prevent future growth of moss or any other fungi's. The homes gutters were cleaned and cleared of all debris. |
10/19/2023
| Implemented |
| 6400.114(b) | At the time of inspection, located in the bedroom closet of the bedroom leading outside to the deck, was an ashtray with the end of a smoked cigar, 4 ends of smoked cigarettes and ashes. [Repeat violation-6/29/23 and 7/25/23] | Written smoking safety procedures shall be followed. | The staff and the individual were trained on the agencies safe smoking policy. The CEO purchased a outdoor smokestack for the individual to use when smoking on the balcony. |
10/19/2023
| Implemented |
| 6400.171 | At the time of inspection, a container of Little Salad Bar Fresh pineapple slices best if enjoyed by 9/24/23, two-3-ounce boxes of sugar-free strawberry Jello with an expiration date 8/16/23 and a 15 ounce can of yellow cling peaches with a best if used by date 9/1/23 were located in the home. [Repeat Violation-2/14/23, 3/17/23, 5/23/23, 6/29/23 and 7/25/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| All items in the home were checked for expiration dates to ensure there were no expired food items within the home. |
10/25/2023
| Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed Clonazepam tablet, 2 mg, take ½ tab, 1 mg, by mouth, 4 times/day as needed for anxiety. There was no documentation for symptoms in which the PRN can be given or documentation that staff are to contact the CEO or designee to administer the medicaiton. [Repeat violation-2/21/23] | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | The Program Specialist contacted the prescribing doctor to ensure they agreed with the hospital discharge papers to changing the medication to a PRN. The Prescribing doctor did not agree with the medication being a PRN and ordered the medication to be administered as a routine medication. |
10/19/2023
| Implemented |
|
|
|
SIN-00228229
|
Unannounced Monitoring
|
07/25/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The small sitting room and the furnace room, both located next to the downstairs family room, do not have a light source. [Repeat Violation-3/17/23, 5/23/23 and 6/29/23] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The CEO contacted the maintenance man to have all basement lights and switches assessed. Maintenance will replace all non working light bulbs and switches. |
08/11/2023
| Implemented |
| 6400.82(f) | The bathroom located on the ground level floor of the home, at the bottom of the staircase leading to the top floor of the home, did not have soap. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The individual in this home requires all poisonous materials to be locked all soap is locked one of the designated areas. The Program specialist is assessing the individuals ability to use hand soap without ingesting it. If the individual is deemed to be able to use hand soap the team will update the ISP to reflect this. |
08/11/2023
| Implemented |
| 6400.110(e) | The home is three floors. The smoke detector, located on the ground level floor of the home, is not interconnected with the detectors located in the basement and the top floor of the home. [Repeat Violation-6/29/23] | 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. | The CEO contacted the maintenance man and the maintenance team will be recalibrating the smoke detectors to ensure they all operate as required. |
08/11/2023
| Implemented |
| 6400.171 | On 7/25/23 the following items were identified: a half gallon of 2% milk with a best buy date of 7/13/23, a 1-ounce package of sugar free vanilla Jell-o pudding-expiration date 4/15/23 and a 12-ounce container of Hills Brothers Cappuccino-French Vanilla with a best before date of 2/17/21. [Repeat Violation-2/14/23, 3/17/23, 5/23/23 and 6/29/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The House Manager assessed the remaining food items in the home and no additional expired food was found. Labels have been purchased for staff to label food items with the expiration date. The CEO is monitoring the House Managers weekly house checks to ensure all food items are being checks as required. |
08/04/2023
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Vitamin D 1000 IU. Individual #1's July 2023 medication administration record states "take 2 tablets by mouth at bedtime." The medication blister pack states, "take 1 tablet by mouth once daily." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Program Specialist reviewed all medications on the MAR to ensure everything on the MAR matched the labels on the scripts. The CEO is retraining the Program Specialist on Medications administration. |
08/11/2023
| Implemented |
|
|
|
SIN-00226905
|
Unannounced Monitoring
|
06/29/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Located in the second-floor hallway, near the Individual's bedroom, was a shopping bag full of trash. In the spare bedroom at the top of the stairs to the left, the carpet was stained and soiled. The carpet on the basement floor, near the TV stand and sectional, is covered with various stains. [Repeat Violation: 5/23/23] | Clean and sanitary conditions shall be maintained in the home. | The DSP staff immediately removed all trash from the home. The House Manager trained the DSP staff on proper cleaning routines and specifically that trash cannot be left out unattended. Trash is removed daily from the home.
The CEO scheduled a cleaning company to come and clean the carpets at the home. All carpets in the home have been cleaned. |
07/11/2023
| Implemented |
| 6400.67(a) | The blind covering the window in the second-floor full bathroom is broken. In the basement, on the backside of the stairs, there is a hole in the drywall approximately 12 inches by 3 inches. | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO has scheduled maintenance to come and repair the hole in the wall as well as the broken blind in the bathroom. All other windows and surfaces have been checked and have been deemed in good working condition. |
07/17/2023
| Implemented |
| 6400.69(a) | At approximately 10:15 am, 6/29/23, the temperature inside the home was 61 degrees Fahrenheit. | The indoor temperature may not be less than 65°F during nonsleeping hours while individuals are present in the home. | The CEO has set the temperature in the home at 71 degree. The CEO has scheduled a maintenance company to come and install guard over the thermostat. The CEO has trained the House Manager who trained the DSP staff on the regulations surrounding the temperature within the home. |
07/17/2023
| Implemented |
| 6400.114(b) | In the spare bedroom, at the top of the stairs, to the right, near the exit door to the rooftop deck, there was the end of a smoked cigarette on the floor. | Written smoking safety procedures shall be followed. | The DSP staff in the home removed the cigarette from the floor. The DSP staff ensured that the individual does not smoke on the outside balcony nor in the house. The house manager trained the individual and DSP staff on the designated smoking areas in the home. |
07/11/2023
| Implemented |
| 6400.171 | During the inspection, the following items were identified: as 18 carton of eggs with a use by date of 6/17/23; Nesquik chocolate powder with an expiration date of 3/19/23; Coffee mate chocolate creamer with an expiration date of 5/28/23; a 30 ounce package of strawberry Jell-O with an expiration date of 12/5/22; Hamburger Helper Stroganoff 64 ounce package with an expiration date of 1/27/23; Italian Style Bread Crumbs 15 ounce can with a best used by date of 5/29/23; a 7.25 ounce box of macaroni & cheese with an expiration date of 6/11/23; Campbell's Cream of Chicken Soup 10.5 ounce can with an expiration date of 11/21/22; Cannellini Beans white kidney beans 15.5 ounce can with an expiration date of 1/1/23; sliced carrots 15 ounce can with an expiration date of 4/7/23; Manwich Sloppy Joes 24 ounce can with a best by date of 3/20/23; Creamy Peanut Butter 16 ounce jar with a best by date of 8/19/21. Complete pancake & Waffle Mix 32-ounce box was open and not sealed; and instant mashed potatoes-13.75-ounce box was open and not sealed. [Repeat Violation: 2/14/23, 3/17/23, and 5/23/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The Program Specialist and House Manager completed a full audit of all food items in the home and exposed of all expired food items. The CEO purchased additional storage containers for food that is opened. |
07/17/2023
| Implemented |
| 6400.166(a)(13) | Individual 1's June 2023 medication administration record was not initialed as administered for the following medications: Clonazepam tablet, 2mg, take ½ tablet (1mg) by mouth four times a day for anxiety, 6/4/2023 12:00pm and 4:00 PM. Hydroxyzine pamoate, 50mg, oral capsule, take 1 capsule every morning and 1 capsule every afternoon, 6/4/2023 4:00pm. Lithium carb Tablet, 450mg ER, take 1 tablet by mouth three times a day for bipolar disorder, 6/4/2023 4:00pm. Perphenazine, 2mg tablet, take one tablet by mouth every day at 4:00 PM for bipolar/schizoaffective disorder, 6/4/2023, 4:00pm. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The CEO immediately contacted the staff on duty during those identified times of medication administration. The staff on duty stated they passed all medications for that day. The staff that was on duty then went into the MAR and marked for the medications that needed initialed. |
07/11/2023
| Implemented |
|
|
|
SIN-00225318
|
Unannounced Monitoring
|
05/23/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | The CEO placed an order through amazon for a freestanding mirror which will be delivered to the individuals address on 6/22/23. Once the mirror is delivered the House Manager will install the mirror in the individuals room. Weekly house checks will be completed to ensure the mirror is in good working condition. |
06/24/2023
| Implemented |
| 6400.82(e) | The bathtub, located in the bathroom on the 2nd floor near the bedrooms, did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | The CEO has trained the House Manager and the DSP staff on the regulation requiring the anti skid mat in the shower/tub. The DSP staff and house manager have been trained/educated that once the mat is removed for cleaning purposes it needs to be reinstalled immediately. The DSP and House Manager have been trained on how to request additional supplies in the event that the mat needs replaced.
The House Manager removed the tub mat from the linen closet and installed it in the shower/tub again. |
06/24/2023
| Implemented |
| 6400.105 | During the inspection, there were approximately two handfuls of lint in the inside dryer lint trap. [Repeat Violation: 2/14/23 and 3/17/23] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The CEO immediately trained the DSP and House staff on where the lint catcher is located in the dryer. As well as when the lint catcher needs to be emptied/cleaned out. The House Manager has made spot checks to ensure the lint catcher is clear and free from debris. |
06/24/2023
| Implemented |
| 6400.110(e) | At 1:30PM on 5/23/2023, the interconnected smoke detector on the second floor of the three-story home tested inoperable. The two independent smoke detectors, also located on the second floor, were also inoperable. | 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. | The smoke detector was missing a battery. The DSP staff and House Manager have been trained on the house smoke detector requirements. Additional batteries have been purchased and placed in the home. The house has additional smoke detectors in it which have been made operable as a back up. The DSP and House staff have been trained to ensure the interconnecting smoke detectors are ALL operable during monthly fire drills. |
06/20/2023
| Not Implemented |
| 6400.143(a) | Individual #1 is prescribed weekly Blood Sugar Checks. The last recorded Blood Sugar Check recorded was 2/10/23. It was reported that Individual #1 continuously refuses. Individual #1's record does not include the refusals and continued attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The PS contacted the PCP and requested an evaluation of the need for this script as the individual continued to refuse the treatment. The individual has been educated and trained on the importance of the complying the prescribed treatment from the physician.
The individual indicated that they understood the importance of the treatment but they stated they did not like getting their sugar checked and would continue to refuse treatment. |
06/22/2023
| Implemented |
| 6400.181(d) | Individual #1's 1/18/23 assessment was not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | The CEO is working with Therap to discuss possible storage options for the assessment. Currently an electronic version of the assessment has been uploaded in therap. The CEO and PS are working on how to store an electronic version of the "signed" assessment.
The PS has placed a paper copy of the assessment in the for the interim until an electronic version figured out. |
06/22/2023
| Implemented |
| 6400.214(a) | Individual #1's records at the home did not include medical appointments or incident reports involving the Individual. [Repeat Violation: 1/5/23] | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | The CEO spoke with the Program Specialist who manages the individuals appointments. The PS informed the CEO that all appointments are in therap under the medical appointment section. The PS trained the CEO on how to navigate therap to access these appointments. The PS confirmed that the House Manager and DSP staff are aware of how to access all the appointments in therap. |
06/20/2023
| Implemented |
| 6400.165(b) | Located in Individual #1's medication box were two Albuterol Inhalers with two different labels on two different boxes. Box #1 stated 2 puffs, three times per day as needed and Box #2 states 2 puffs, every 4 hours as needed. | A prescription order shall be kept current. | The PS contacted the prescribing physician to get clarification on which script was active. Both medications were the same dose but had a different frequency on the label. The frequency indicated on the MAR was the correct script. The PS and the House Manager audited the medications and removed the wrongfully labeled medication from the group of meds. |
06/16/2023
| Implemented |
| 6400.166(a)(4) | Individual #1's May 2023 Medication Administration Record did not include the prescribed Fluticasone and Stomach Relief over the counter medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The PS and contacted the individuals PCP to get an active script for the PRN Pepto-Bismol. ThePCP stated there was not an active script for this medication and they would need to see the individual in the office to prescribe one.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/16/2023
| Implemented |
| 6400.166(a)(5) | Individual #1's May 2023 Medication Administration Record did not include the prescribed Fluticasone and Stomach Relief over the counter medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The PS and contacted the individuals PCP to get an active script for the PRN Pepto-Bismol. ThePCP stated there was not an active script for this medication and they would need to see the individual in the office to prescribe one.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/16/2023
| Implemented |
| 6400.166(a)(6) | Individual #1's May 2023 Medication Administration Record did not include the prescribed Fluticasone and Stomach Relief over the counter medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The PS and contacted the individuals PCP to get an active script for the PRN Pepto-Bismol. ThePCP stated there was not an active script for this medication and they would need to see the individual in the office to prescribe one.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/16/2023
| Implemented |
| 6400.166(a)(7) | Individual #1's May 2023 Medication Administration Record did not include the prescribed Fluticasone and Stomach Relief over the counter medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The PS and contacted the individuals PCP to get an active script for the PRN Pepto-Bismol. ThePCP stated there was not an active script for this medication and they would need to see the individual in the office to prescribe one.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/16/2023
| Implemented |
| 6400.166(a)(8) | Individual #1's May 2023 Medication Administration Record did not include the prescribed Fluticasone and Stomach Relief over the counter medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The PS and contacted the individuals PCP to get an active script for the PRN Pepto-Bismol. ThePCP stated there was not an active script for this medication and they would need to see the individual in the office to prescribe one.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/16/2023
| Implemented |
| 6400.166(a)(9) | Individual #1's May 2023 Medication Administration Record did not include the prescribed Fluticasone and Stomach Relief over the counter medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The PS and contacted the prescribing doctor to confirm if there was an active prescription for the Fluticasone. The prescribing doctor confirmed that the Fluticasone was discontinued and forward the discontinue paperwork to the office.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/16/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's May 2023 Medication Administration Record did not include the reason or diagnosis for Melatonin. [Repeat Violation: 2/21/23] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Program Specialist obtained a copy of the script from the pharmacy. The script had the reason for diagnosis of the medication. The Script was forward onto the RN whom updated the MAR with the diagnosis for the medication. |
06/24/2023
| Implemented |
| 6400.166(b) | Individual #1's 8:00 PM dose of Perphenazine was not initialed as administered on 5/22/2023. Individual #1's 8:00 AM dose of Lithium Carb was a not initialed as administered on 5/23/2023. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The PS and House Manager looked at the house schedule to see who was on shift during these times of administration. The DSP staff on duty was contacted and they went into the MAR and initialed that the medications were passed. |
06/16/2023
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Fluticasone was filled on 1/6/2023 with directions to, "instill 2 sprays into each nostril daily for allergic rhinitis." There is no record of it ever being administered. | Medication errors include the following: Failure to administer a medication. | The PS and contacted the prescribing doctor to confirm if there was an active prescription for the Fluticasone. The prescribing doctor confirmed that the Fluticasone was discontinued and forward the discontinue paperwork to the office.
The PS and the Nurse updated the MAR to reflect the discontinuation of the medication. The PS and the House manager removed the medication from the home and disposed of it as of company policy and procedure. |
06/22/2023
| Implemented |
|
|
|
SIN-00221222
|
Unannounced Monitoring
|
03/17/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The stairs leading from the kitchen to the basement of the home were not lighted and pose a tripping/falling hazard. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The provider has reinstalled the push lights at the top of the steps. The lights had been removed when the light at the bottom of the steps was repaired. But the lighting did not cover the entire stairwell. The light at the top of the steps has been replaced and operates off a push button or a remote. |
03/31/2023
| Not Implemented |
| 6400.67(a) | There is a 12-inch by 3-inch hole in the wall under the stairs in the basement of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO has contacted a local maintenance provider who is repairing the hole in the wall. The maintenance provider will do an overall assessment of the home to ensure no other floors, walls, or surfaces need repaired. |
04/07/2023
| Not Implemented |
| 6400.77(b) | Included in the first aid kit was a bottle of eye wash solution that expired May 2020. | 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. | The Program Specialist and House lead have gone through the first aid kit to ensure all items are up to date and not expired. The PS and House lead have updated the first aid kit to ensure all items required by regulations are avaliable and in good condition within the kit. |
03/31/2023
| Not Implemented |
| 6400.107 | On 3/17/2023 a Pelonis space heater was located in a closet in the basement and a Lasko space heater located in the main room of the basement, near the television. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The CEO removed the space heaters immediately. The CEO and Program Specialist assessed the entire home and ensured no other space heaters were in the home nor being used. |
03/31/2023
| Not Implemented |
| 6400.111(f) | On 3/17/2023 the fire extinguishers located on the top floor by the bedrooms, on the ground floor in the kitchen and in the basement were not inspected and approved by a fire safety expert. | 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 extinguishers in the home were purchased on 12/1/22. The CEO could not identify the who removed the extinguishers tags. The CEO has contacted Cintas who will be on contract to inspect all current extinguishers as well as conduct annual inspections on the extinguishers. |
04/07/2023
| Not Implemented |
| 6400.181(a) | Individual #1, date of admission 12/5/22, does not have an assessment. | 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 individuals initial assessment was completed but was not in the individuals file located in the home. The Program Specialist has printed the assessment and placed it in the individuals file which is located in the individual home. |
03/31/2023
| Not Implemented |
| 6400.18(a)(4) | Incident #9169370 for Individual #1 for Psychological Abuse was discovered 2/13/2023 and reported 2/16/2023. Incident #9182206 for Individual #1 for Sexual Abuse was discovered 1/26/2023 and reported 3/14/2023. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. |
03/20/2023
| Not Implemented |
| 6400.18(a)(5) | Incident #9169352 for Individual #1 for Neglect, Failure to Provide Protection from Hazards, was discovered 2/13/2023 and reported 2/16/2023. Incident #9171164 for Individual #1 for Neglect, Failure to Provide Protection from Hazards, was discovered 1/31/2023 and reported 2/20/2023. Incident # 9171158 for Individual #1 for Neglect, Failure to Provide Needed Care, was discovered 1/25/2023 and reported 2/20/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| The CEO and Program Specialist have been retrained on the IM bulletin and the required time frames for reporting incidents. The CEO and Program Specialist will review incidents each day at the morning meeting to ensure all incidents are reported in the required time frames. |
03/20/2023
| Not Implemented |
| 6400.18(a)(6) | Incident #9169330 for Individual #1 for Exploitation, Misuse/Theft of Funds was discovered 1/31/2023 and reported 2/16/2023. Incident #9169308 for Individual #1 for Exploitation, Misuse/Theft of Funds was discovered 1/25/2023 and reported 2/16/2023. Incident #9156557 for Individual #1 for Exploitation, Misuse/Theft of Funds was discovered 1/3/2023 and reported 1/26/2023. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Exploitation
. | The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. |
03/20/2023
| Not Implemented |
| 6400.18(a)(9) | Incident #9181953 for Individual #1 for Serious Injury, Illness was discovered 12/18/2022 and reported 3/13/2023. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. |
03/20/2023
| Not Implemented |
| 6400.18(g) | The certified investigation for Incident #9169352 for Individual #1 for Neglect, Failure to Provide Protection from Hazards, discovered 2/13/23, was initiated 3/7/2023 and submitted 3/14/2023. The certified investigation for Incident #9169370 for Individual #1 for Abuse, Psychological discovered 2/13/23, was initiated 3/7/23 and submitted 3/14/2023. The certified investigation for Incident # 9171164 for Individual #1 for Neglect, Failure to Provide Protection from Hazards discovered 1/3/23, was initiated 3/7/23 and submitted 3/14/2023. The certified investigation for Incident # 9169330 for Individual #1 for Exploitation, Misuse/Theft of Funds
discovered 1/31/2023, was initiated 3/7/23 and submitted 3/14/2023. The certified investigation for Incident #9182206 for Individual #1 for Sexual Abuse, Other discovered 1/26/2023, had yet to be initiated as of 3/16/2023 at 4:24pm. The certified investigation was due 2/25/23. The certified investigation for Incident #9169308 for Individual #1 for Exploitation, Misuse of Funds discovered 1/25/2023, was initiated 3/7/23 and submitted 3/14/2023. The certified investigation for Incident # 9171158 for Individual #1 for Neglect, Failure to Provide Needed Care discovered 1/25/23, was initiated 3/7/23 and submitted 3/14/2023. The certified investigation for Incident #9156557 for Individual #1 for Exploitation, Misuse/Theft of Funds discovered 1/3/23, was initiated 1/26/23 and submitted 1/31/23. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. |
03/20/2023
| Not Implemented |
| 6400.18(b)(2) | Incident #9182494 for Individual #1 for Medication Error, Omission the incident was discovered 3/1/2023 and reported 3/14/2023. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. |
03/20/2023
| Not Implemented |
| 6400.18(i) | Incident #9182206 for Individual #1 for Sexual Abuse, Other final section was due 2/25/2023. As of 3/16/2023 at 4:24pm the final section has not been completed and an extension was not filed. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. |
03/20/2023
| Not Implemented |
| 6400.163(g) | on 3/17/2023 located in an unlocked kitchen cupboard was a 4.1-ounce container of Miralax powder. Individual #1 is not prescribed Miralax powder and is unable to self-administer medication. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The CEO, Program Specialist and House Lead assessed the entire home including all cabinets in the kitchen bathrooms basements to ensure no medications are left out. The medication found was left in the home by the previous owner and all previous owners items were assessed and removed from the home. |
03/27/2023
| Not Implemented |
| 6400.163(h) | On 3/17/2023 a 4.1-ounce container of Miralax powder was located in an unlocked kitchen cupboard. Upon notification, the Chief Executive Officer poured the Miralax Powder down the kitchen sink drain. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The CEO, Program Specialist and House Lead assessed the entire home including all cabinets in the kitchen bathrooms basements to ensure no medications are left out. The medication found was left in the home by the previous owner and all previous owners items were assessed and removed from the home. |
03/27/2023
| Implemented |
| 6400.186 | At 12:40 PM on 3/17/2023, Individual #1 was on the ground floor alone. The Program Specialist and a Direct Service Worker were on the top floor, in the office located at the back of the home. Individual #1's ISP last updated 1/31/23, states "IF [Individual #1] IS HAVING A BEHAVIOR STAFF MUST HAVE EYES ON SUPERVISION THROUGHOUT THE ENTIRETY TO THE BEHAVIOR TO SUPPORT [Individual #1's] HEALTH AND SAFETY." Individual #1 was on the ground floor yelling and slamming items due to licensing staff having to dispose of expired foods. | The home shall implement the individual plan, including revisions. | The CEO, Program Specialist and House lead did not consider this a behavior for the individual. The individual acts in this way regularly. This is normal behavior for this individual and there actual behaviors are more sever. The Program Specialist and House Lead have been educated that during an onsite inspection a staff member will remain with the individual at all times to ensure health and safety of the individual is met. |
03/27/2023
| Not Implemented |
|
|
|
SIN-00219164
|
Unannounced Monitoring
|
02/14/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Chief Executive Officer #1 has failed to implement policies and procedures to ensure the home is following safe smoking procedures, ensure food is safe for consumption, the inside and outside of the home is clean and well maintained and hazard free. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The agency CEO reviewed and revised the safe smoking policy and procedure. The CEO trained the program specialist and DSP staff as well as the individual on the safe smoking policy and procedures as well as the designated areas allowed for smoking. |
03/07/2023
| Not Implemented |
| 6400.43(b)(4) | Chief Executive Officer #1 has failed to ensure compliance with the 6400 regulations to include compliance with regulations relating to providing a safe and well maintained home that is accordance with following and implementing Individual #1's ISP. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | The CEO has trained the Program Specialist and DSP staff on 3/2/32 on how to read and ISP and how to implement the ISP within the individuals home. The individuals ISP was reviewed thoroughly and all staff stated were trained on all areas of need within the ISP. |
03/02/2023
| Not Implemented |
| 6400.62(a) | Individual #1 is not assessed to safely use and avoid poisonous materials. On 2/14/2023, at approximately 11:40AM, throughout the home there was the following unlocked and accessible poisonous materials. In the bedroom adjacent to the balcony on the second floor, there was a bottle of carpet cleaner with instructions to "consult physician if incase of eye contact if irritation persists." In the garage, there were bottles of insect killer and Round-up, plant killer. On and under the sink in the bathroom in the basement of the home, there were two bottles of Lysol All-purpose cleaner and one bottle of Clorox bathroom cleaner with instructions to include "call poison Control Center or doctor for treatment advice" and a precautionary statement to include "hazards to Humans." In the laundry area there was a bottle of Clorox Disinfecting Bleach with precautionary hazards to include "hazards to humans" and to contact poison control or doctor. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The CEO hired a moving company on 2/27/23 to remove all unused poisonous materials from the home. All remaining poisonous materials have been locked in the cabinet in the Kitchen and Basement. The CEO trained the Program specialist and DSP staff on the individuals ISP and the regulations surrounding the storage of poisonous materials on 3/2/23. |
03/02/2023
| Not Implemented |
| 6400.64(a) | On 2/14/2023, from 10:00AM to 1:00PM, throughout the home to include but not limited to; in the garage, on the balcony, in the basement, in the vacant bedroom, on the second-floor landing, in the basement closet, in the furnace room, there were large trash bags containing a variety of items to include but not limited clothing, linens and garbage. On 12/14/2023, at 11:26AM, there was evidence of a spilled liquid leaving a variety of sizes of droplets of a brownish red substance on the shelves and bottom of the refrigerator in the kitchen of the home. | Clean and sanitary conditions shall be maintained in the home. | The CEO has trained the Program Specialist and DSP staff on the agencies expectation of a clean and sanitary environment. He also trained them on the regulations surrounding these requirements on 3/2/23. DSP staff cleaned and sanitized the identified areas of the home as well as any additionally identified areas of insanitation. |
03/02/2023
| Implemented |
| 6400.64(c) | On 2/14/2023, from 10:00AM to 1:00PM, throughout the home to include but not limited to in the garage, on the balcony, in the basement, in the vacant bedroom, on the second-floor landing, in the basement closet, in the furnace room, there were large trash bags containing a variety of items to include but not limited clothing, linens and garbage. There were electronic items including a television on the ground between the two outside trash receptacles on the side of the home. There were two unused bedframes including head and foot boards in the vacant bedroom next to the staff office. The garage had a multitude of what appeared to be unused items to include but not limited to a variety of shoes not belonging to the individual, children's bikes, an unused door, lattice, pieces of cardboard and Styrofoam, a propane tank, and a furniture kit. | Trash shall be removed from the premises at least once per week. | The CEO hired a moving/cleaning/maintenance company to remove all trash and debris from the home on 2/27/23. All items not belonging to the individual have been removed from the home and all the poisonous materials have been removed and locked. The CEO trained the Program Specialist and House Manager on the agencys requirements for the homes condition. They were trained on how to report any maintenance issues that need completed that include but not limited to the removal of any unwanted items. |
03/02/2023
| Implemented |
| 6400.67(a) | On 2/14/2023, at 11:21AM, the top and middle panels of the wooden cabinet door to the left of the fireplace in the living room of the home were separated leaving gaps and exposing the unfinished wood. | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO hired a maintenance man to repair the wooden door in the living room on 2/27/23. The door was nailed and glued to ensure everything was in good working condition. The CEO trained the Program Specialist and DSP staff on the procedures to report maintenance request. To ensure all furniture and items broken are reported immediately. |
03/02/2023
| Implemented |
| 6400.71 | On 2/14/2023 at 12:33PM, the telephone on the floor in the living room of the home did not have the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center. | 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 CEO has trained the Program Specialist and DSP staff on the regulation and requirements for the home's emergency contact including the emergency numbers needed to be attached to the home phone. DSP staff Phyllis has placed the emergency numbers on the back on the phone with adhesive. |
03/02/2023
| Implemented |
| 6400.72(b) | On 2/14/2023, at 11:42AM, the bifold door to the closet in the basement of the home was detached from the track, leaning, and resting on the floor rendering the door inoperable. On 12/14/2023, at 11:42AM, the bifold door to the bathroom in the basement of the home was detached from the track, leaning, and resting on the floor rendering the door inoperable. On 12/14/2023, at 12:59PM, the door to individual #1's bedroom had a section of wood approximately 10 inches by 2 inches that was broke from the door exposing the inner locking mechanism and the splintering wood. | Screens, windows and doors shall be in good repair. | The CEO hired a maintenance company to come and repair the bifold doors in the basement. The maintenance company will be installing new doors on 3/15/23. The CEO has trained the Program Specialist and DSP staff on the requirements for the homes furniture and physical site operations including but not limited to screens windows and doors. All other doors have been assessed and are in good working condition. |
03/02/2023
| Implemented |
| 6400.76(c) | On 2/14/2023, at 11:45AM, the couch in the basement of the home did not have sitting cushions. | Furniture shall be comfortable and home-like. | The CEO located the cushions for the couch in the basement office and all cushions have been replaced and furniture is in good working condition. The CEO has trained the program specialist and DSP staff on 3/2/32 on the requirements of the home furniture and what is considered acceptable and in good repair. |
03/02/2023
| Implemented |
| 6400.80(b) | On 2/24/2023 at 11:13AM, the floor of the second story balcony, there were several large piles of dried leaves, intermixed with a multitude of cigarette butts, and other various items including a coke can and cigarette boxes and a partially fully large black garbage bag. On top of the small, rusty outdoor table on the balcony there was an ash tray overflowing with approximately 50 cigarette butts, another coke can, a plastic water bottle, a plastic cup and loose cigarette butts. The outdoor gas grill on the balcony had one door that was broke completely off and leaning against the base of the grill. At 11:15AM, the approximately eight feet long, top section of the aluminum drainpipe from the gutter at the back of the home, was detached and laying across the yard at the base of the other section of drainpipe. At 11:15AM, In the back of the home there was discarded plastic shelving. At 12:43PM the outside dryer vent contained an inordinate amount of dryer lint that extended approximately 8 inches into the yard debris including dried leaves and other various plants. At 12:41PM, In the front yard of the home just off the front porch, there was a multitude of cigarette butts. At 12:42PM, on the right side of the home the lower section, approximately two feet long, of the drainpipe was detached and on the ground near the down spout. At 12:42PM, there were electronic items including a television on the ground between the two outside trash receptacles on the side of the home. At 11:45AM, the stairway exit from the basement to the backyard of the home, had discarded items including a multitude of cigarette butts, a red solo cup, and scraps of paper and dried leaves posing a slipping and tripping hazard. In addition, the top two stairs had antiskid material that was delaminating, bunching, and protruding from the steps posing a tripping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The CEO has trained the Program Specialist and DSP staff on 3/2/23 on the regulation and agency requirements for the homes grounds. The DSP staff Phyllis cleaned the debris on the balcony, back steps, front porch and surrounding the home on 2/25/23. All debris and material was bagged and taken to the trash. |
03/02/2023
| Implemented |
| 6400.81(k)(3) | On 2/14/2023, at 10:00AM, Individual #1's bed did not have linens including sheets and blankets. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | The CEO held a training on 3/2/23 with the Program Specialist and DSP staff to discuss the regulations surrounding the individuals bedding and condition of bedroom furniture. The individuals bedding has been replaced and the bed is fully covered with sheets, blankets and pillows. |
03/02/2023
| Implemented |
| 6400.101 | On 2/14/2023 at 12:40PM, the door knob, of the door leading to the garage of the home had, "child proof" plastic cover posing an obstructed egress through the garage to the man door exit in the rear of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The CEO has trained the Program Specialist, House Manager and DSP staff on what is considered a restrictive to the individual means of egress throughout the home. All restrictive measures have been removed from the individuals home and the individual has a restrictions within the home. |
03/04/2023
| Not Implemented |
| 6400.105 | On 2/14/2023, at 11:46AM, there were at least two large plastic bins and three large black plastic garbage bags containing what appeared to be clothing and linens that were abutting the furnace in the small room with the furnace and the hot water heater in the basement of the home. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The CEO hired a moving company on 2/27/23 to remove all debris and items that are not of the individuals from the home. During this time the moving company removed all items surrounding the furnace. The CEO trained the Program Specialist, House Manager, and DSP staff on the regulations and requirements surrounding the storage of flammable items near the fireplace on 3/4/23 |
03/04/2023
| Implemented |
| 6400.108(b) | On 2/14/2023 at 11:21AM, the fire place in the living room of the home contained an inordiante of amount of ashes that were approximately 3 to 4 inches thick. | Wood and coal burning stoves, including chimneys and flues, shall be cleaned at least every year if used more frequently than once per week during the winter season. Written documentation of the cleaning shall be kept. | The CEO hired a moving/cleaning company to come to the home on 2/27/23. During this time the fireplace ashes were removed and disposed of. The agency has locked the fireplace so it cannot be used. The Program Specialist, House Manager and DSP staff were trained on the homes use of the fireplace and that it will not be utilized for any purpose. |
03/04/2023
| Implemented |
| 6400.171 | On 2/14/2023 at approximately 11:30 AM, there was prepackaged white meat chicken salad wedge sandwich with a "sell by" date of 2/1/2023, a prepackaged Italian style wrap with a "sell by" date of 1/31/22023, a partially used 9 oz. package of honey ham with a "best if used" by date of January 20, 2023, a partially used 9 oz. package of turkey breast luncheon meat with a "best if used" by date of January 9, 2023, and a thawed 2.08lb package of ground 85/15 family pack with a "sell by" date of January 28, 2023 in the refrigerator in the kitchen of home. In addition, the cupboards in the kitchen contained the following partially used, unsealed, opened bag of flour, bag of sugar and cocoa puff cereal. Also, there was a container of Salt free Dash seasoning blend that had a best by 9/27/2020. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The CEO trained the Program Specialist, House Manager and DSP staff on the regulations surrounding the proper storage of food. Staff were trained on agency requirements for checking the expiration dates and disposing of expired food weekly. |
03/04/2023
| Not Implemented |
| 6400.214(b) | On 2/14/2023 at 10:00AM, Individual #1's current ISP and physical examination were not at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The CEO has reached out the previous agency to obtain a copy of the individuals ISP but have not heard back from that organization. The Program Specialist had scheduled the individual for a annual visit with her PCP on 3/23/23 @ 1pm where she will received her annual physical and TB. Once that appointment his held a copy of her physical will be placed in her file.
The previous Program Specialist had obtained a copy of her physical and would not return the client file when her employment was terminated. The agency policy now is that no client information to permitted to be taken our of the individuals home or office. |
03/04/2023
| Not Implemented |
| 6400.32(d) | On the cabinet door in the kitchen of the home a handwritten sign read, "We are no longer giving [Individual #1] any pop cans. The box of coke she has have [sic] to be opened and pourd [sic] into a cup." Individual #1's Individual Plan, updated 1/31/2023 reads, "she enjoys helping to prepare meals by measuring and mixing ingredients and reading basic rescipes. | An individual shall be treated with dignity and respect. | The CEO trained the Program Specialist House Manager and DSP staff on the proper way to communicate the individuals programming and safety concerns without infringing on the integrity of the individual. The staff were trained on how to communicate and implement safety concerns of the individual in a respectful manner. Agency protocol is that staff do not make any changes to the homes environment without management approval this includes posting messages related to the individuals care. |
03/04/2023
| Implemented |
| 6400.51(b)(4) | The orientation for Program Specialist #2 did not include recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | The CEO has reviewed the documentation submitted for the program specialist as well as the agencies orientation training program. The orientation does include training on recognizing and reporting incidents. The Program Specialist was initially trained on 1/5/23 on the agencies policy and procedures as well as the bulletins pertaining to recognizing and reporting incidents. The Program Specialist orientation training documentations does reflect this training.
The Program Specialist was retrained on these specific items on 3/4/23. |
03/04/2023
| Implemented |
| 6400.186 | Individual #1's Individual Plan, last updated 1/31/2023, reads "Individual #1 has deficient awareness of safety precautions. She prefers a clean and clutter-free living environment. The home had a multitude of areas that were cluttered including but not limited to one bedroom which had unused bedframes and various items including stuffed animals, linens, and clothing. Due to the excessive amount of items in this room, entry could not be gained into the room. The basement of the home had bags of clothing items and children's toys not belonging to Individual #1. The garage of the home was cluttered with items not belonging to Individual #1 to the where there was just a narrow walking path from the door of the home to the door of the garage at the back of the home. Individual #1's Individual Plan, last updated 1/31/2023, reads "[Individual #1] has a long history of self-injurious behaviors···. She will use any item she can find, for example she recently cut arm using a pop tab." On the cabinet door in the kitchen of the home a handwritten sign read, "We are no longer giving [Individual #1] any pop cans. The box of coke she has have [sic] to be opened and pourd [sic] into a cup." On 12/14/2023, at 11:13AM, two coke cans were available to Individual #1 on the balcony of the home. Individual #1's Individual Plan, last updated 1/31/2023, reads In the Safety precautions section; "cleaning supplies are kept locked for her safety." On 12/14/2023, from 10:00AM to 1:00PM, there were unlocked cleaning products in the bedrooms, bathrooms, and laundry area of the home. | The home shall implement the individual plan, including revisions. | The CEO hired a moving company that came and removed all waste and debris from the home on 2/27/23. The CEO has trained the Program Specialist House Manager and DSP staff on the individuals ISP related to but limited to the individuals identified safety concerns surrounding pop cans and other items that she can harm herself with. All sharp items have been disposed of or locked away. The CEO trained the Program Specialist, House Manager, and DSP staff on the regulations surrounding poisonous materials. Everyone was trained on the agencies policy as well as where the locked areas of the home are where these materials can be stored |
03/04/2023
| Not Implemented |
| 6400.188(b) | The agency is not providing Individual #1 opportunities and support for participation in community life, including volunteer or civic-minded opportunities and membership in National or local organizations. | The home shall provide opportunities and support to the individual for participation in community life, including volunteer or civic-minded opportunities and membership in National or local organizations. | The CEO, Program Specialist and Supports Coordinator are working with outside agencies to enroll the individual in a new CPS program. During this time the DSP staff will offer Individual #1 daily options to enter/attend community events. The DSP staff will utilize community social media pages to identify community options for the individual. The Program Specialist and DSP staff will develop a weekly calendar with options for the individual to choose from to attend in the community. |
03/04/2023
| Not Implemented |
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SIN-00217026
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Unannounced Monitoring
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01/05/2023
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Non Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(2) | The mattress and box springs of Individual #1's bed were placed directly on the floor of the bedroom. There was no solid foundation. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | The individual was sleeping on the side of the bed sitting up as if she was in a chair. The individual was observed sliding off the bed so CEO of the agency decided to remove the bedframe so the bed was not sitting so high off the ground. Then when the individual was sleeping sitting up as if in a chair her feet where on the floor and she was not sliding off the bed. The box spring and mattress were stable and on solid ground.
The bed frame has been reinstalled and the CEO is working with individual's SC to get everything input into her plan that she can have a bed that sits directly on the floor. |
01/12/2023
| Implemented |
| 6400.214(a) | Individual #1's record at the home did not include the following information: sex, admission date, birthdate, Social Security number, race, height, weight, color of hair, color of eyes, identifying marks, primary language, religious affiliation, next of kin, and a current dated photograph. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | SWAP POC is to update the client files with the required information. SWAP currently holds all this information in the there electronic system Therap. during onsite inspection this information was not printed out and included with the clients first day admission paperwork that was presented to the inspector.
In the future SWAP CEO and Program Specialist will have all documentation printed and placed in the individuals paper file which is stored in the office as well as clients home. SWAPs CEO and Program Specialist have been trained on the regulations surrounding client files. |
01/12/2023
| Implemented |
| 6400.214(b) | Individual #1's record at the home did not include the following documents: incident reports relating to the individual, physical examinations. dental examinations, dental hygiene plans and copies of psychological evaluations. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| SWAP POC is to update the client files with the required information. SWAP currently holds all this information in the there electronic system Therap. during onsite inspection this information was not printed out and included with the clients first day admission paperwork that was presented to the inspector.
In the future SWAP CEO and Program Specialist will have all documentation printed and placed in the individuals paper file which is stored in the office as well as clients home. SWAPs CEO and Program Specialist have been trained on the regulations surrounding client files. |
01/12/2023
| Not Implemented |
| 6400.186 | Individual #1's ISP, last updated 12/12/22, states "[Individual #1] NEEDS STAFF TO KEEP them IN EYESIGHT AT ALL TIMES, EXCEPT FOR WHEN [Individual #1] IS UTILIZING THE BATHROOM OR PREPARING MEDICATIONS (EARSHOT)". Upon arrival at the home, Individual #1 was alone, sleeping in the ground floor living room. Staff were located in a room at the back of the house, on the 2nd floor of the home. Two separate times, Individual #1 was outside smoking alone, on the front porch of the home, while staff remained in the room on the 2nd floor, at the back of the home. | The home shall implement the individual plan, including revisions. | SWAP POC to correct this violation is as follows. During individual's ISP meeting on 1/10/23 the supervision needs were discussed. The team agreed that the staff did not need to have individual in line of site any longer. Individual's plan has been updated to state that she needs to be in audio range and that when outside smoking staff need to make checks on her every 30 minutes. |
01/12/2023
| Not Implemented |
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SIN-00215223
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Unannounced Monitoring
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11/22/2022
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The stairway leading from the kitchen to the basement of the home was not lighted. There was a motion light at the foot of the stairs that was not operative. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| SWAP house managers will be trained on the requirements for adequate lighting in the homes House managers will check the lighting of each home prior to opening a new site. Specific attention will be paid to hallways and stairwells.
This home has had a new light installed on the basement stairwell. The new light provides adequate lighting for the steps. |
11/30/2022
| Implemented |
| 6400.68(b) | The hot water temperature measured 122.7 degrees Fahrenheit at 11:20 AM, at the bathtub, in the bathroom by the bedrooms on the top floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | SWAP house manager and direct care staff have been trained on the regulations surrounding the water temperature in the homes. CEO trained the management team on 11/29/22 has adjusted the temperature thermostat on the hot water tank. House Manager has placed a sign on the hot water tank to direct all staff to not touch nor adjust the hot water tank temperature.
When licensing any new site house managers will check the hot water temperature to ensure it does not exceed 120 degrees. House managers will also place signs on the hot water tanks that direct all employees to not adjust the thermostat. |
11/29/2022
| Implemented |
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SIN-00210918
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New Provider Agency
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09/06/2022
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | The home has three stories including the basement. The home does not have interconnected smoke detectors on each floor. | 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. | SWAP CEO James O'Rourke has purchased 3 INTERCONNECTED smoke detectors. CEO removed the previous non-compliant smoke detectors and replaced them with the new INTERCONNECTED smoke detectors. CEO has updated the physical site check list to reflect the regulation covering interconnected smoke detectors. This will ensure when compliance checks are completed, and new sites are opened this regulation will be followed. I have attached pictured of the new INTERCONNECTED smoke detectors. They look the same as the previous smoke detectors so the pictures I have attached are of them still in the packaging. If you look closely at the packaging, you can see where it states they are INTERCONNECTED |
09/06/2022
| Implemented |
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