Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00291264 Renewal 06/04/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)On 6/5/2026, the fire extinguisher located in the kitchen of the apartment was last inspected and approved by a fire safety expert in May of 2025. This exceeds the annual requirement. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The Fire extinguisher was taken to ABC Fire Extinguisher Inc at 4641 Peoples Road Pgh Pa 15237 to be serviced on 6/9/2026 06/09/2026 Implemented
6400.141(a)Individual #1 had a physical examination completed on 01/08/25, and then again on 01/30/26. This exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The annual physical examination was completed at the primary care physician's earliest availability. Next year's appointment was scheduled to meet compliance. 06/13/2026 Implemented
6400.141(c)(3)Individual #1 does not have documentation of immunizations required by the Center for Disease Control, to include the Tetanus and Diphtheria vaccine.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. A letter from the primary care physician stating that the individual should not receive vaccinations due to medical contradictions is placed in medical file with the annual physical. 07/08/2026 Implemented
6400.141(c)(11)Individual #1's physical examination completed on 01/30/26 did not address their medication regimen, stating on the form to see the printed list, but there was no list attached to the form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The printed listed was printed and attached to the physical examination that was completed on 1/30/2026. 06/08/2026 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness, and their medication review completed on 03/02/26 did not include the following information: the necessary dosage of medication that is prescribed.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 Residential Coordinator will create a Medication List that includes the following: the individual's name, a list of medications, the dosage, the route, time the medication is to be given, and the reason these medications are to be given. This form will be attached to all psych review forms, in which the individuals will have at least every 3 months. This will be reviewed by the Program Specialist to ensure accuracy for all medication lists and the Program Specialist will review all Psych review forms to ensure the form is fully completed and accurate. 07/23/2026 Implemented
SIN-00268464 Renewal 06/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65At 1:24 PM on 6/11/25, there was no mechanical exhaust fan or an operable window for ventilation in the full bathroom located in the apartment's bedroom hallway. At 1:26 PM on 6/11/25, there was no mechanical exhaust fan or an operable window for ventilation in the full ensuite bathroom located in Individual' #1's bedroom.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Vents are located on top of roof in the entire apartment building the bathrooms. A letter was requested from the property manager to explain how the exhaust fan works. 06/28/2025 Implemented
6400.82(f)At 1:23 PM on 6/11/25, there was no trash receptacle in the full bathroom located in the apartment's bedroom hallway.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. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. A trashcan was purchased and placed at site. 06/28/2025 Implemented
6400.106This home had furnace inspections and cleanings completed by a professional furnace cleaning company on 5/10/23, and then again on 6/3/24 to 6/6/24.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Residential Coordinator has created a tracking sheet of the cleaning inspections annual due date. 06/28/2025 Implemented
6400.112(d)According to the written fire drill record submitted from 7/2/24 to 5/10/25, the drill conducted on 4/16/25, documented an evacuation time of 2 minutes, 50 seconds. This home does not have an extended evacuation time approved by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. A fire drill conducted in May 2025 exceeded safe evacuation time (over 2 1/2 minutes), indicating an extended evacuation time. All Staff involved will be trained on the importance of following the designated route and evacuation timing. 2. 2. Systemic Preventive Measures: The Fire Drill Documentation Form was updated to include: Time started and ended Route used Number of individuals evacuated Comments on barriers/delays Staff will be re-trained by 6/30/2025 regarding fire drill procedures, use of alternate routes, and evacuation speed expectations. 06/28/2025 Implemented
6400.113(a)Individual #1 was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home on 9/24/23, and then again on 10/25/24. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. An audit was conducted of all individuals annual general fire safety training including evacuation procedures, responsibilities during fire drills and the designated meeting place, ensuring the trainings were completed. 07/01/2025 Implemented
6400.141(c)(4)Individual #1 had a hearing screening performed on their current physical examination, completed 1/8/25, but not on their previous physical examination, conducted 1/3/24. Individual #1's content of records did not include any other hearing examinations that had been completed between 1/3/24 and 1/8/25. [Repeat Violation- 7/9/24 et al]The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual was immediately scheduled for both hearing and vison screenings upon identification of oversight. Screenings are scheduled as follows hearing exam 7/8/2025 at 10AM at UPMC Shadyside and Vision scheduled for 7/21/2025 at 8:30am at Blind and vison rehab services. 07/01/2025 Implemented
6400.142(d)Individual #1 had dental examinations completed on the following dates: 4/2/24; 8/14/24; 11/14/24; 1/20/25; and 5/14/25. However, none of these examinations documented that a teeth cleaning or the checking of gums or dentures was performed.The dental examination shall include teeth cleaning or checking gums and dentures. The program specialist contacted the dental provider advance dental solutions and obtained updated documentation clarifying whether a dental exam or cleaning was completed. The updated documentation has been filed in the individuals' records. 07/02/2025 Implemented
6400.144On Individual #1's current physical examination, completed 1/8/25, the physician checked "Yes" for vision in reference to the field entitled, "Further Recommendation by A Specialist." However, the agency did not provide documentation showing that Individual #1 had completed a follow-up appointment with a vision specialist or that such an appointment had been scheduled. [Repeat Violation- 7/9/24 et al]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. The individual was immediately scheduled for a vison screening with a specialist upon identification of oversight. Vision screening scheduled for 7/21/2025 at 8:30am at Blind and vison rehab services. 07/02/2025 Implemented
6400.151(a)Direct Service Provider #1's date-of-hire is 9/20/24. They had a physical examination completed on 10/2/24. In addition, Direct Service Provider #1 had a tuberculin skin test via Mantoux method planted on 10/5/24 and read with negative results on 10/7/24. 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. A review of all current employee files was conducted to ensure tb compliance for all staff. 06/13/2025 Implemented
6400.181(e)(11)Individual #1's current assessment, completed on 9/9/24, did not include an applicable psychological evaluation, as the corresponding field indicated that such an evaluation had been completed on 9/4/24, and read, "See attached." However, Individual #1's content of records did not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. The file was reviewed to determine if a psychological evaluation was applicable. There was no Psychological eval completed 9/24/24 however it was a psych appointment completed on this date. And this field should have been documented as N/A. This field has been revised and sent to the team and individual on 7/3/2025. 07/03/2025 Implemented
6400.51(b)(1)Direct Service Provider #1's date-of-hire is 9/20/24. Their orientation training, conducted from 9/23/24 to 9/27/24, did not include completion of the following required content areas: individual choice and supporting individuals to develop and maintain relationships. [Repeat Violation- 7/9/24 et al]The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The identified staff who received incomplete orientation were immediately scheduled for a supplemental training session covering the missing topics. Supplemental training will be completed by 7/4/2025 and training certificates will site the source of training and training records will be updated accordingly. 06/27/2025 Implemented
6400.51(b)(5)Direct Service Provider #1's date-of-hire is 9/20/24. Their orientation training, conducted from 9/23/24 to 9/27/24, did not include completion of job-related knowledge and skills encompassing individual-specific reviews on the implementation of individual service plans and on the safe and appropriate use of behavior support plans.The orientation must encompass the following areas: Job-related knowledge and skills.We have updated the orientation checklist to include job-specific training topics based on role responsibilities (Direct Support Professional, Residential Manager, Program Specialist, Medication Administrator). Include training scenarios and competency checks to confirm staff understanding of their specific duties. 07/02/2025 Implemented
6400.182(c)Individual #1's Service Plan, last updated 5/30/25, contained the following discrepancies between their current assessment, completed on 9/9/24, in the following health and safety skill domains: regarding fire safety evacuation, Individual #1's Service Plan, last updated 5/30/25, stated that "[Individual #1] knows to evacuate in the event of a fire." In contrast, Individual #1's assessment, completed on 9/9/24, informed that "[Individual #1] requires verbal prompting to evacuate" in the event of a fire; and regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 5/30/25, explained that "[Individual #1] knows about heat source safety" and "has heat source safety skills." However, Individual #1's assessment, completed on 9/9/24, indicated "No" for Individual #1 being able to identify heat sources and a "Score of 4," meaning that "[Individual #1] requires verbal prompting to avoid hazardous areas." [Repeat Violation- 7/9/24 et al]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.A review of the individual's current status and support needs were conducted and request to have the ISP updated to reflect the individual requires verbal prompting to avoid hazardous areas. The request was sent 7/2/2025. 07/02/2025 Implemented
SIN-00247803 Renewal 07/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71On April 10, 2024, the house phone was located in the living room with no emergency numbers posted near the phone.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. On July 13, 2024, The CEO Educated the Residential Coordinator on the importance of Emergency Telephone numbers being posted by every site phone. 08/06/2024 Implemented
6400.181(d)Individual #1's assessment was completed on 12/1/23; however, the assessment was not dated or signed by the program specialist.The program specialist shall sign and date the assessment. On July 16, 2024, The CEO Educated the Program Specialist on , II aspects of the individual assessments (admission and annually) being completed fully and sent to the planning team with in the 6400 regulation requirements. This will ensure that the individuals' needs are being met and the planning team is sent i his information to be able to plan for any revisions needed. 08/07/2024 Implemented
6400.182(c)Individual #1's Individual Service Plan, last updated 7/1/24, indicates s/he is safe to be around poisonous materials; however, the assessment, dated 12/1/23 indicates s/he is unsafe to use or avoid poisonous materials.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On July 11, 2024, The CEO reeducated the Program specialist on the development, annual update and revisions of individuals plans. 08/06/2024 Implemented
SIN-00228520 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment, completed on 7/11/23, was not conducted either within 3-6 months of the current license's expiration date or within 6-9 months following the last annual inspection by the Department.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Self assessment shall be completed 3-6 months prior to expiration date of agency COC. 08/21/2023 Implemented
6400.68(b)On 7/19/23, the hot water temperature of the bathtub in the bathroom located in the bedroom hallway measured 124.3°F at 12:19 PM. [Repeated Violation---11/9/21, 10/4/22, et al] Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water temp shall not exceed 120 degrees 08/21/2023 Implemented
6400.112(a)According to the written fire drill record submitted from November 2022 to July 2023, only one drill, which was held on 7/11/23, was conducted during sleeping hours. An unannounced fire drill shall be held at least once a month. An unannounced fire drill shall be held at least once a month 08/21/2023 Implemented
6400.141(c)(11)Individual #1's physical examination completed on 7/18/23 did not include an assessment of their health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals. This section was left blank. [Repeated Violation---10/4/22, et al]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. Physical exam shall include health maintenance needs and the need for blood work 08/21/2023 Implemented
6400.141(c)(15)Individual #1's physical examination completed on 7/18/23 did not include special instructions for their diet. This section was left blank.The physical examination shall include:Special instructions for the individual's diet. Physical exam shall include individual diet 08/21/2023 Implemented
6400.181(a)Individual #1's admission date is 9/9/22. Their record did not include completion of an initial 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. Each individual shall have initial assessment within one year prior to or 60 calendar days after admission to the residential home. 08/21/2023 Implemented
6400.15(b)The agency used the Self-Inspection and Declaration Tool to measure and record compliance at the home on 7/11/23 instead of the Department's Licensing Inspection Instrument.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency shall use the dept of licensing inspection instrument of the community homes for individual with IDD 08/21/2023 Implemented
6400.18(a)(3)EIM Incident #: 9155538 for a behavioral health crisis involving a facility-based response was discovered on 1/20/23 at 6:15 PM and reported on 1/22/23 at 3:50 PM.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: Inpatient admission to a hospital. The home shall report the following incidents within 24 hours of discovery by a staff person. 08/21/2023 Implemented
6400.18(a)(8)EIM Incident #: 9229497 involving law enforcement activity was discovered on 6/8/23 at 10:45 AM and reported on 6/9/23 at 1:32 PM.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: Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual. The home shall report the following incidents within 24 hours of discovery by a staff person. 08/21/2023 Implemented
6400.165(g)Individual #1 is prescribed psychotropic medication. They had a 3-month medication review completed on 1/19/23 that did not identify the medication reviewed, the reason for it being prescribed, the need to continue taking it, and the necessary dosage. [Repeated Violation---10/4/22, 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.If a med is prescribed to treat symptoms of psych illness there shall be a review by a licensed physician every 3 months that includes the reason for prescribing the med. 08/21/2023 Implemented
6400.166(a)(4)On 7/19/23, Individual #1's prescribed pro re nata medication, Acetaminophen Tab. 325 MG---Take 1 tablet by mouth every four hours as needed for right leg pain---was found at the home. However, this medication was not named on their July 2023 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The MAR shall include the name of medication 08/21/2023 Implemented
6400.166(a)(9)On 7/19/23, Individual #1's prescribed pro re nata medication, Acetaminophen Tab. 325 MG---Take 1 tablet by mouth every four hours as needed for right leg pain---was found at the home. However, the frequency of administering this medication was not recorded on their July 2023 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.A MAR shall have the frequency of administration. 08/21/2023 Implemented
6400.166(a)(11)On 7/19/23, Individual #1's prescribed pro re nata medication, Acetaminophen Tab. 325 MG---Take 1 tablet by mouth every four hours as needed for right leg pain---was found at the home. However, the purpose or diagnosis for this medication was not recorded on their July 2023 Medication Administration Record.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.A Mar shall be kept with diagnosis including PRN . 08/21/2023 Implemented
6400.166(b)On 7/19/23, the pill pack for Individual #1's prescribed pro re nata medication, Ibuprofen Tab. 600 MG, was observed with a dispensed tablet blister and the date of 7/2/23 written beside it. However, initials of the person conducting and recording administration of the above medication on 7/2/23 were not found on Individual #1's July 2023 Medication Administration Record.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The information in subsection a12 and 13 shall be recorded in the MAR at the time medication is adminstered. 08/21/2023 Implemented
6400.182(b)Individual #1's admission date is 9/9/22. Their record did not include documentation of an individual plan having ever been developed since admission, as an initial assessment for Individual #1 has not been completed.The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home.THe individual plan shall be developed based on assessment within 90 days of submission 08/21/2023 Implemented
SIN-00226585 Unannounced Monitoring 06/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)On 6/23/23, the one-level apartment's only fire extinguisher located in the kitchen was last inspected and approved by a fire safety expert in April 2022. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. House Supervisor will take fire extinguisher to fire safety expert to be inspected by July 1. 06/26/2023 Implemented
6400.166(a)(11)On 6/23/23, the purpose or diagnosis for the following prescribed medications were not recorded on Individual #1's June 2023 Medication Administration Record: Divalproex Sod. ER 500 MG; Sertraline HCL 100 MG Tab.; Metoprolol Tartrate 25 MG Tab.; Carbamazepine ER 100 MG Tab.; Xarelto 20 MG Tab.; Olanzapine 20 MG Tab.; and Folic Acid 1 MG Tab.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.All management was re-trained on 6/27 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the diagnosis is listed accurately on the MAR. 06/27/2023 Implemented
SIN-00212929 Renewal 10/04/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)On 10/5/22, the full bathroom located in the bedroom hallway was observed at 11:07 AM as having very low hot and cold-water pressure at the shower.A home shall have hot and cold running water under pressure. The Provider has asked maintenance and the property manager to adjust water pressure in the apt complex. 10/25/2022 Implemented
6400.70On 10/5/22 at 11:05 AM, it was discovered that the phone located in the living room does not have access to an outside line, as the phone can only receive incoming calls and cannot complete outgoing calls. The home's only other phone connected to an outside line is kept locked in the staff office. Currently, Individual #1 does not have a restrictive procedure plan limiting their phone usage.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The provider does not have a restrictive procedure plan in place for individual #1 therefore the ISP shall be implemented as written. 10/25/2022 Not Implemented
6400.112(c)The fire drill written record for the drill conducted on 6/27/22 did not include the time it took to evacuate the home. [Repeat violation 11/9/21 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. The COO has updated the fire drill form to include the time to evacuate the home. 10/25/2022 Implemented
6400.141(c)(1)Individual #1's physical examination completed on 8/30/22 did not include a physician's review of their previous medical history.The physical examination shall include: A review of previous medical history. As a result of violation 141c The Provider has implemented a new form for physical examinations for all clients. The new form includes previous medical history. 10/25/2022 Implemented
6400.214(b)On 10/5/22 at 11:02 AM, it was found that the following records for individual #1 were not located on site: their most recent dental exams and dental hygiene plans. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The provider has placed records including but not limited to physical and dental exams for all individuals in the residential home. 10/25/2022 Not Implemented
6400.32(n)Individual #1's phone access has been restricted, as it was observed on 10/5/22 at 11:05 AM that the phone located in the living room can only receive incoming calls and cannot complete outgoing calls. The home's only other phone is non-restricted but is kept locked in the staff office. Currently, Individual #1 does not have a restrictive procedure plan limiting their phone usage.An individual has the right to unrestricted and private access to telecommunications.The provider does not have a restrictive procedure plan in place for individual #1 therefore the ISP shall be implemented as written. 10/25/2022 Not Implemented
6400.34(a)Individual #1 was informed and explained their rights on 9/9/22. The rights document did not include the following: 6400.32c···the right to be free from exploitation and abandonment; 6400.32n···the right to unrestricted and private access to telecommunications; 6400.32r2···the right to limiting access to their bedroom except in a life-safety emergency or with their expressed permission; and 6400.32s···the right to having a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The Provider has updated the individual rights form and reviewed with all clients. 10/25/2022 Implemented
SIN-00196388 Renewal 11/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's most recent physical examination, dated 8/26/2021, does not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. It has been determined that individual #1 annual physical was not completely filled out by the physician. In order to prevent this citation from reoccurring the house/lead supervisor and program specialist will ensure that during the individuals appt all medical forms will be filled out in it's entirety prior to the individual leaving the doctors office. The supervisor will update the check list to specify the required areas to be completed on an individuals physical documentation. 12/05/2021 Implemented
6400.181(a)Individual #1, date of admission 2/16/2021, had an initial assessment completed on 5/30/2021. 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 CEO has created a new assessment and will train the program specialist and/or designated person how to fill out the assessment form. The program specialist will ensure that all assessments moving forward will be completed in a timely manner within 1 year prior to or 60 calendar days after admission to the residential home. 12/05/2021 Implemented
6400.181(d)Individual 1's assessment, dated 5/30/2021, was not dated by the program specialist.The program specialist shall sign and date the assessment. Program specialist didn't sign annual assessment Program Specialist signed annual assessment on 11/1/21 12/05/2021 Implemented
6400.181(e)(1)Individual #1's assessment, completed 5/30/2021, does not include functional strengths, needs and preferences of the individual. [Repeat Violation, 12/15/2020] The assessment must include the following information: Functional strengths, needs and preferences of the individual. The CEO has created a new assessment to address the strengths, needs and preference of the individual. The CEO will train the program specialist and/or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment forms. The new form will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.181(e)(10)Individual #1's assessment, completed 11/1/2021, does not include information regarding a Lifetime Medical History.The assessment must include the following information: A lifetime medical history. The CEO has created a new assessment to address the lifetime medical history of the individual. The CEO will train the program specialist and/or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment forms. The new form will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.181(e)(12)Individual 1's assessment, completed 5/30/2021, does not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The CEO has created a new assessment to address the recommendations for specific areas of training, programming and services of the individual. The CEO will train the program specialist and/or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment forms. The new form will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.181(e)(13)(i)Individual 1's assessment, completed 5/30/2021, does not include individual's progress over the last 365 calendar days and current level in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The CEO has created a new assessment to address the individuals progress over the last 365 calendar days and current level in health. The CEO will train the program specialist and/or designated person on how to fill out the assessment. The program specialist is updating all assessment on the new assessment forms. The new forms will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.181(e)(13)(vi)Individual #1's assessment, completed 5/30/2021, does not include information regarding the individual's current level in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The CEO has created a a new assessment to address the individuals current level in recreation. The CEO will train the program specialist or designated person on how to fill out the assessment form. The program specialist is updating all assessments on the new assessment form. The new assessment forms will be used for all initial assessments and annually thereafter. 12/05/2021 Implemented
6400.52(c)(1)Chief Executive Officer #1's training for training year from 11/1/2020 to 10/31/2021 did not encompass Individual Choice and Supporting Individuals to Develop and Maintain Relationships. Program Specialist #2's training for training year from 11/1/2020 to 10/31/2021 did not encompass Individual Choice and Supporting Individuals to Develop and Maintain Relationships. [Repeat Violation, 12/15/2020]The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The current annual training curriculum has been reviewed and revised to ensure that all required annual training topics are included in the annual training provided to all employees. Moving forward the CEO will be responsible to ensure that all employees will receive training in the updated training curriculum. The Program specialist and supervisor will ensure that new employees receive the training and annually thereafter. 12/05/2021 Implemented
6400.182(c)Individual #1's Individual plan, last updated 4/28/2021 states that Individual #1, "Has a lack of sensitivity to hot water. At her home staff set the temperature of the water for her... Respondents reported that Individual #1 needs to have support around heat sources··· Respondents reported that Individual #1 has a high tolerance for pain and needs support to know when something is hot." Individual #1's assessment, completed 5/30/2021, assesses Individual #1 at a Level 4, "Independent: Individual initiates and performs the behavior without a word, gesture, or touch" for "Knowledge of danger from heat sources and ability to sense and move away quickly from heat sources that exceed 120 degrees F and are not insulated."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Individual #1 had moved to the home, the assessor did not request the SC update the plan to reflect the residential supervision levels. The CEO has made revisions to the initial and annual assessments so necessary information is clearly defined. All adjustments to the assessment template will be made by the program specialist on or before 12/10/2021. All assessments will be reviewed by the CEO to ensure quality and compliance in 2021 and forward. 12/05/2021 Implemented
6400.213(1)(i)Individual #1's record does not include information about identifying marks. [Repeat Violation, 12/15/2020]Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Identifying marks of individual #1 was updated on the record by house manager. Staff were reminded that all areas of the record must be filled out in it's entirety during admission. 12/05/2021 Implemented