Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281203 Renewal 01/20/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 receives checks from their rep payee that the provider agency is to deposit and keep an up-to-date financial log. The individual's 5/1/25 through 1/20/26 financial log frequently shows a negative balance. Many "deposits" are shown as withdrawals. From 7/7/25 through 11/4/25, there are no receipts for any spending that occurred. From 7/7/25 through 1/8/26, there was no accurate ledger kept, with all deposits/withdrawals for that 6-month time period added after 1/8/26. At the time of the 1/20/26 on-site inspection, there were 2 uncashed $25 checks from Individual #1's rep payee, there was no cash available at the home, and the ledger indicated the individual had a negative balance of funds.(2) Disbursements made to or for the individual. The individual's Financial Transaction Account and Ledger were audited in full. All funds were accounted for, and there were no discrepancies in the actual money held. The issue was identified as documentation and software use, not mismanagement of funds. The existing financial documentation record was closed, and a new Financial Transaction Account and Ledger were opened using the correct current balances to ensure accurate and ongoing recordkeeping. Therap technical support was consulted, and this course of action was advised as the most appropriate method to ensure accurate tracking of financial transactions moving forward. In addition, the Lead Program Specialist submitted an addendum to the individual's assessment documenting that, as part of learning budgeting and independent money management skills, the individual chooses to save checks and cash and deposit them when a predetermined savings goal is reached for a specific, planned purpose. 02/02/2026 Implemented
6400.64(a)At the time of the inspection, the toilet in the bathroom located off the spare bedroom had a brown substance in the toilet, a yellowish-brown drip mark on the toilet seat, and black hair on the toilet seat. The shower in this bathroom had black residue in the tub.Clean and sanitary conditions shall be maintained in the home. This bathroom has been cleaned. 01/22/2026 Implemented
6400.82(f)At the time of the inspection, there was no toilet paper available in the bathroom downstairs. In the bathroom off the spare bedroom there was no hand soap, toilet paper, or paper towels available.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 Residential Supervisor stocked the staff bathroom on site during the walk-through. 01/22/2026 Implemented
6400.104The fire letter sent for Individual #1 on 8/14/25 documents that their bedroom is on the third floor down the hall, on the right. The written diagrams provided are labeled entry floor, first floor, and second floor.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The language on the fire letter was aligned. 01/22/2026 Implemented
6400.106106-Furnace-(Repeat from 4/14/25 Inspection) A furnace inspection was completed on 6/13/24. At that inspection the following items were found to require immediate attention: UV light, condensate switch, and the surge protector. No additional work was completed. A furnace inspection was then completed on 5/30/25. It was recommended that a signature duct cleaning take place including cleaning the ducts, fogging and disinfecting for bacterial growth, and a UV light for better air quality. No additional work was completed.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. This maintenance was scheduled. 01/30/2026 Implemented
6400.112(h)The fire drill held on 4/11/25 did not document if everyone made it to the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Being as this fire drill was completed between 04/2025 and 1/2026, it cannot be completed or rectified. 01/30/2026 Implemented
6400.141(c)(7)Individual #1 had a well woman exam and pap smear on 2/14/24 and not again until 7/28/25. There was not a pap smear completed at the 7/28/25 well woman examination, and there is no deferment letter on file.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. This appointment was completed in a timeframe that was non-compliant. No correction can be made at this time. 01/30/2026 Implemented
6400.211(b)(3)Individual #1's demographic information does not include the name, address, and phone number for a person who can give consent for emergency medical treatment.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. It was added to the individual's IDF/face sheet that CHC staff is able to give consent for emergency medical treatment, if required. 01/30/2026 Implemented
6400.18(a)(5)Individual #1 was prescribed Aquaphor twice daily for 5 days for a rash on 10/29/25. This medication was never administered to Individual #1. This constitutes neglect -- failure to provide medication management. This was not reported in the department's incident management system.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 incidences of medication omission were entered into EIM. Due to the consecutive omission errors, a neglect EIM was entered and is being investigated by a Certified Investigator. Individual #1's designated person(s) were contacted. The provider was contacted and no further medical intervention was suggested. 01/30/2026 Implemented
6400.18(c)The individual and designated persons were not notified of the neglectful incident described in 6400.18a5.The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual.When the incidents were entered into EIM, the designated persons were notified. 01/22/2026 Implemented
6400.18(g)There was not a certified investigation completed for the neglect incident described in 6400.18a5.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.A certified investigation is taking place as a result of the neglect/medication errors. 01/22/2026 Implemented
6400.18(b)(2)The medication errors described in 6400.167a1 and 6400.167a3were not reported in the department's incident management system.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 incidences of medication omission were entered into EIM. 01/22/2026 Implemented
6400.165(g)(Repeat from April 2024 and 4/15/25 Inspections) The Psych Med Review held on 12/15/25 did not indicate whether or not to continue medications as 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 12/15/2025 Quarterly Psychiatric Medication Review form was sent back to the providers office for correction. 01/29/2026 Implemented
6400.167(a)(1)(Repeated Violation -- 4/14/25) Individual #1 was prescribed Aquaphor twice daily for 5 days for a rash on 10/29/25. This medication was never administered to Individual #1. Individual #1 was prescribed Xylimelt tabs to be taken overnight on 1/14/26. As of the 1/20/26 inspection, this medication has not been administered to Individual #1.Medication errors include the following: Failure to administer a medication.When the incidents were entered into EIM, the designated persons were notified. Communication between the provider, pharmacy and Agency Nurse continues to ensure the order is actionable and the medication is received. 01/22/2026 Implemented
6400.167(a)(3)Individual #1 was administered their "placebo" birth control pills on 7/19/25 and 7/20/25 instead of the "active" pills that they were to be given. This constitutes a "wrong dose" medication error.Medication errors include the following: Administration of the wrong dose of medication.The EIM for the medication error was entered into EIM. 01/22/2026 Implemented
6400.213(1)(i)Individual #1's demographic information does not include the next of kin.Each individual's record must include the following information: Personal information, including: (v) Next of KinRB's next of kin was identified and the words 'next of kin' were added to their IDF (face sheet) 01/30/2026 Implemented
SIN-00263659 Renewal 04/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was not completed in the timeframe either between 10/23/24-1/23/25 and/or 10/11/24-1/11/25. The agency completed the self-inspection on 1/24/25.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. Since the timeframe for the submission of the 2024 self-assessment has passed, the agency can not correct this specific violation. The plan to maintain compliance outlines the plan for prevention and future compliance. 04/25/2025 Implemented
6400.15(c)The self-assessment completed on 1/24/25 did not contain a written summary of corrections. The agency only acknowledged what violations were found, but no plan of correction was completed.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The plan of correction that was submitted with the self-assessment deficient. The agency can not correct the previously submitted plan. The plan to maintain compliance outlines the plan for prevention and future compliance. 05/01/2025 Implemented
6400.67(a)(Repeat from July 2024 inspection) During the walk-through of the home on 4/16/25 the first wooden step off the wooden deck in the back of the home was beginning to rot causing the wood to feel spongy when stepped on.Floors, walls, ceilings and other surfaces shall be in good repair. During the time of the inspection, Director of Operations submitted an internal maintenance work order. The issue was then submitted to the leasing agency for the property. At the time of submission of this plan, CHC is awaiting scheduling and repair of the effected deck step. 05/15/2025 Implemented
SIN-00247672 Unannounced Monitoring 07/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection, there was a strong odor of urine due to the toilet being used and not flushed.Clean and sanitary conditions shall be maintained in the home. The home is vacant currently. A cleaning was scheduled for the program prior to accepting any placements. 07/29/2024 Implemented
6400.67(a)At the time of the inspection, the blinds in the bedroom at the front of the house were broken.Floors, walls, ceilings and other surfaces shall be in good repair. The Director of Programming purchased the blinds, the staff and cleaning crew will install the new blinds. 07/29/2024 Implemented
6400.67(b)At the time of the inspection, there was a golf size amount of lint in the dryer, the appliance was not in use at the time. Floors, walls, ceilings and other surfaces shall be free of hazards.The dryer vent was cleaned out. 07/29/2024 Implemented
6400.73(a)At the time of the inspection, both the handrails on the rear deck stairs were loose and easily moved. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The Director of Operations will contact and schedule with the agency maintenance contractor to secure the deck handrails. 07/29/2024 Implemented
SIN-00240854 Unannounced Monitoring 03/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)At the time of the inspection, a window in the upstairs bedroom (facing the front of the home) was damaged with a baseball size indent/spider web cracking in it. Screens, windows and doors shall be in good repair. The Director of Operations has coordinated with a contractor for immediate repair. The contractor visited the site on 3/21/2024 to assess the damage and repair options and placed an order for glass/window replacement. The provider anticipates the repair to be complete no later than 04/20/2024. 04/20/2024 Implemented
6400.80(b)At the time of the inspection, a spindle from the deck railing was lying on the deck with a nail sticking out of it. The bottom portion of the deck railing where the spindle connects was not attached to the deck at all. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The Director of Operations scheduled a priority appointment with the agency contractor. The contractor visited the program site on 03/21/2024 to assess the damages and plan repairs. The work was started and will be completed in a timely manner. 04/01/2024 Implemented
SIN-00236633 Unannounced Monitoring 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)All of the fire drills completed from July 2023 through November 2023 used the front door exit to evacuate the property.Alternate exit routes shall be used during fire drills. The provider cannot remedy past fire drills. The form for recording fire drills has been updated and a fire drill will be conducted between 1/15-1/20 with a member of the administrative team to serve as training for program staff to exhibit thorough, accurate completion. 02/08/2024 Implemented
6400.112(h)(Repeat from Inspection Completed 7/25/23) The fire drills completed on 7/10/23 and 8/21/23 indicated that everyone met at the designated meeting place of "the living room." Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The provider cannot remedy past fire drills. The form for recording fire drills has been updated and a fire drill will be conducted between 1/15-1/20 with a member of the administrative team to serve as training for program staff to exhibit thorough, accurate completion. 01/20/2024 Implemented
6400.141(c)(14)(Repeat from Inspection held on 7/25/23) Individual #1's most recent physical completed on 11/13/23 does not identify information pertinent to treat/diagnose in the event of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The RSS for Individual #1 will request clarification from the PCP and will attach the clarification to the current physical. Prior to obtaining the information, Individual #1 left the care of Maxcare and this was unable to be completed. 02/01/2024 Implemented
6400.141(c)(15)(Repeat from Inspection held 7/25/23) Individual #1's most recent physical completed on 11/13/23 does not provide instructions about Individual #1's dietary needs. The physical documents that Individual #1 has needs around their "diet and weight loss." However, the physical does not identify what the needs are.The physical examination shall include:Special instructions for the individual's diet. The RSS for Individual #1 will request clarification from the PCP and will attach the clarification to the current physical. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. 02/01/2024 Implemented
6400.144(Repeat from Inspection held on 7/25/23) Individual #1 is diagnosed with Constipation and is prescribed PRN medication to treat constipation. A bowel movement protocol was developed on 9/5/23. The protocol does not clearly define when staff should administer the PRN medications for constipation. In addition, staff are to be tracking the individual's bowel movements. Tracking is not occurring. As of 8/2/23, Individual #1 was to drink 64 ounces of fluid a day. This is not being tracked.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 RSS will contact the PCP for clarification of the constipation PRNs. The Provider's RN will review and revise the constipation/bowel movement protocol for Individual #1. The plan will be reviewed by the PCP and staff will receive training on the steps of the plan as well as data recording for the PRN and plan. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. The RSS will review data daily and the agency RN will review data collection monthly. The agency RN will be available to staff for questions and support. The individual is no longer in the care of MaxCare and will not be returning to their care. Therefore, the bowel tracking, and fluid tracking will not be occurring for this individual. 02/08/2024 Implemented
6400.181(c)The most recent assessment completed on 11/9/23 was not documented as being based on instruments, interviews, notes, or observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The assessment will be updated to include verbiage to support the assessment was completed based on assessment instruments, interviews, progress notes and observations. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. 02/01/2024 Implemented
6400.181(d)(Repeat from 7/25/23) Individual #1's most recent assessment completed on 11/9/23 was signed and dated by the director of compliance, Staff #3. Staff #3 does not meet the requirements to serve as a Program Specialist.The program specialist shall sign and date the assessment. The provider submitted an exception request for Staff #3 to act as a program specialist. Until that request is approved, another staff with acceptable qualifications will acts as a program specialist. 02/01/2024 Implemented
6400.181(e)(9)(Repeat from 7/25/23) Individual #1's most recent assessment completed on 11/9/23 indicates their hearing is within normal limits. However, Individual #1's most current ISP and their medical records document that Individual #1 has limited hearing in their left ear.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The assessment will be updated to include a more thorough description of the individual's hearing. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. 02/01/2024 Implemented
6400.181(e)(11)(Repeat from 7/25/23) Individual #1's most recent assessment completed on 11/9/23 does not indicate if the individual has had a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. Information will be added to the assessment regarding the individual's psychological evaluations as applicable. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. 02/01/2024 Implemented
6400.214(b)(Repeated Violation -- 7/25/23) At the time of the 12/19/23 physical site inspection, the Individual Support Plan available in the home for Individual #1 was dated 9/6/23. There was an update completed on 12/5/23. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The provider will print, file and train on the most updated version of the ISP. 02/01/2024 Implemented
6400.44(c)(3)Staff #3 does not meet the criteria to serve as a Program Specialist. Their Associate's degree is not from an accredited college or university.A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism.The provider submitted an exception request for Staff #3 to act as a program specialist. Until that request is approved, another staff with acceptable qualifications will act as a program specialist. 02/01/2024 Implemented
6400.51(b)(1)(Repeat from Inspection completed 7/25/23) No documentation was provided verifying that Staff #1 or Staff #2 completed training on Community Integration offered by ODP.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.All current staff will complete the myODP website training listed as acceptable under the Orientation guidelines for community integration by 2/1/24, though the training was provided to all staff hired prior to 07/2023, as listed on their program orientation. 02/01/2024 Implemented
6400.165(f)(Repeat from 7/25/23) Individual #1 takes medication to treat a psychiatric disorder. At the time of the inspection, an acceptable SEEN plan had not been developed for Individual #1. The SEEN plan does not document the desired and undesired outcomes. It does not identify acceptable alternatives.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.The PS and agency RN will work with the prescribing provider to create an acceptable SEEN plan in accordance with the regulations, then the PS will appropriately train staff on said plan, to include data collection. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. 02/01/2024 Implemented
6400.165(g)(Repeat from 7/25/23) The quarterly psych med review held on 11/1/23 did not clarify whether Individual #1 was to continue taking their psychiatric medications. The quarterly Psych Med Review held on 9/1/23 did not list the reason that the psychiatric medications were prescribed to Individual #1.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 form used for quarterly psychotropic medication review has been updated. The prescriber will be contacted for clarification of information missing from previous appointments and they will be saved with the incomplete forms. The PS will be re-trained on the regulations regarding psychotropic medication management. 02/01/2024 Implemented
6400.166(a)(4)Individual #1 was prescribed Tylenol as needed for headaches on 10/4/23. This medication is not listed on the MAR along with all of the required information.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The provider will change pharmacies to a pharmacy knowledgeable on the regulation requirements for medication administration and records. The RSS will request updated PRN forms and prescriptions for all currently prescribed medications and confirm they are accurately listed on the MAR. Program staff will undergo training on the process for accurately recording PRN medication administration. 02/01/2024 Implemented
6400.167(a)(1)Individual #1 did not receive their Gavilax, Lybalvi, or Clonidine on 10/1/23. They did not receive their Symbicort, Lybalvi, or Clonidine on 11/19/23, 12/9/23, or 12/16/23. On 10/23/23, Individual #1 was taken to the Emergency Room and diagnosed with Scabies. They were prescribed Permethrin topical cream. This medication was not administered.Medication errors include the following: Failure to administer a medication.The individual was out of program for the dates in question, but it was not documented appropriately on the MARs. The MARs will be reviewed and updated. 02/01/2024 Implemented
6400.169(a)(Repeat from 7/25/23) Staff #4 and Staff #5 administered the Victoza injection to Individual #1. Staff #4 and Staff #5 did not receive the additional required training on subcutaneous injections.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).A record existed of staff receiving training to administer injection medication, but since the previous medication administration trainer has separated from the agency, it was not available for submission during this unannounced visit. At this time, there are no injection medications being administered. Should there be another need for this training, all program staff would be trained by a certified medication administration trainer and/or agency RN. 02/01/2024 Implemented
SIN-00233068 Unannounced Monitoring 10/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.167(a)(1)Individual #1 did not receive their 8pm doses of Lybalvi or Clonidine on 10/1/23.Medication errors include the following: Failure to administer a medication.Through review of the paper MAR on location at this program, it was discovered that 8pm medications were administered. There was a connectivity issue with Therap, the software this agency uses for medication administration records. To remedy issues revolving around potential Therap outages and miscommunication of staff, the agency has implemented a "Therap Contingency Policy" that requires use of a paper MAR and retroactive updating of the digital MAR by a member of the administrative team. The Director of Compliance will create and implement the Medication Administration Contingency Policy. Staff will all receive training by 10.27.2023 and will utilize the process to ensure timely documentation of all medication administrations. All program staff will review the 15-steps of Medication Administration by 10.31.2023. 10/24/2023 Implemented
SIN-00228100 Renewal 07/25/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the 07/26/23 physical site inspection, the third-floor common bathroom had dirt accumulation in the HVAC (Heating Ventilation and Cooling) system vent and the handle used to flush the toilet was broken and not functional.Floors, walls, ceilings and other surfaces shall be in good repair. HVAC Vent was cleaned during the inspection on 7/26/23 upon notation of this violation by the Program Specialist. The toilet handle has been fixed effective 8/7/23 by MaxCare HCBS personnel (See Attachment 23) 08/07/2023 Implemented
6400.103The emergency relocation site for Individual #1 lists "nearest hotel" not a specific site that will be available in an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Emergency Evacuation Procedures Plan has been updated as of 8/7/23 for each individual receiving residential services through the agency (See Attachment 8). The Program Specialist will review the plans with the individuals and train all staff on the plans by 8/31/23. 08/31/2023 Not Implemented
6400.104The 07/10/23 letter to the fire department does not list the exact location of the bedroom of the Individual in the home that requires assistance evacuating in the event of an actual fire.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The letter to the fire department has been updated to reflect the specific needs of each individual in order to safely evacuate the home (See Attachment 25). The floor plan that is attached to the notification indicates the exact bedroom location of each individual. Copies were mailed to the associated fire departments 8/7/23. 08/31/2023 Implemented
6400.106The home had the furnace inspection completed 04/28/22 and not again until 07/08/23, outside of the annual timeframe.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 Director will complete an excel sheet that will track the service, preferred vendor, recent service date, next due date, that will be shared with the administrator, CEO and Program Specialist by 8/31/2023. A Compliance calendar was created and shared with all administrative personnel for the agency. Each required service appointment has been entered to provide advanced notice to schedule the service appointment. 08/31/2023 Implemented
6400.111(f)The fire extinguishers in the home are all labeled as being inspected in July of 2023, but the exact date of inspection is not noted. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Summit Fire & Security inspected the fire extinguishers at this location on 7/18/23 (See Attachment 26). Moving forward, a form has been created to document the fire extinguishers inspection to include the date, exact location of the site, number of extinguishers inspected, signature of technician, etc. (See Attachment 27) 08/31/2023 Implemented
6400.112(a)There is no record of a successful fire drill being conducted the month of June 2023 or April 2023 or March 2023 or February 2023 or January 2023 or December and November of 2022 for either Individual #2 or #3 . An unannounced fire drill shall be held at least once a month. The individuals were not successfully participating in the fire drills partly due to difficulty exiting the house. As such, to resolve this, the individuals were relocated into a new home on 7/8/23 and have been able to complete two successful fire drills. The Residential Site Supervisor, Program Specialist and direct care staff will be retrained on the need to repeat unsuccessful drills no later than 72 hours after the initial attempt. 08/31/2023 Implemented
6400.112(c)The 06/21/23, 03/28/23 and 03/14/23 fire drill records do not include the time it took to attempt to evacuate the home.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 Director and Program Specialist will retrain all staff on how to conduct fire drills and how to complete the forms by 8/31/23. A sample fire drill form has been completed and will be available in the Fire Safety binder at each residential location for reference. 08/31/2023 Implemented
6400.112(d)Individual #2 was not able to successfully evacuate the home during a fire drill in either June or May of 2023. Only one attempt at a successful fire drill was made each month. 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. Fire Safety Policy has been updated (See Attachment 28) to reflect proper procedures to take place if a drill is unsuccessful. The Director and Staff will be required to repeat the drill within 72 hours to assess the individual(s) abilities to safely evacuate the premise during drills. Follow up to a repetitive failed drills will result in consultation with the local fire department as well as the individual's team and medical providers. 08/31/2023 Implemented
6400.112(h)Individual #2 was not able to successfully evacuate the home to the designated meeting place during a fire drill in either June or May 2023. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The Director and Program Specialist will retrain all support staff by 8/31/23 on the designated meeting location for each residential site. Fire Safety Policy has been updated to reflect proper procedures to take place if a drill is unsuccessful. Staff will be required to repeat the drill within 72 hours to assess the individual(s) abilities to safely evacuate the premise during drills. 08/31/2023 Implemented
6400.113(a)There is no record of Individual #1 receiving Fire Safety Training prior to or on the day of admission to the home, 07/10/23. There is record of Individual #1 receiving Fire Safety training on 07/13/23. There is no record of Individual #2 receiving Fire Safety Training prior to or on the day of admission, Individual #2 was trained on 11/18/22 and had a Date of Admission of 10/26/22. 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. A Fire Safety Training was completed for Individuals #1 and #2 on 7/10/23 (See Attachment 8B). This was still late and as such, a New Admission Checklist has been created to ensure all required trainings are completed during admission, including the Fire Safety Training (See Attachment 8). The Residential Site Supervisor will be trained on the checklist as well as what is required to be completed prior to an individual moving into a home. 08/31/2023 Implemented
6400.141(a)Individual #1's Date of Admission (DOA) is 07/10/23; there's a record of a Physical Exam being completed on 04/23/23 which does not include all of the required elements to be considered an accurate and complete Annual Physical.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The agency Annual Physical form has been updated to meet the regulatory requirements (See Attachment 29). All new admissions will be required to have this form completed prior to admission. The Director and/or Program Specialist will review to ensure compliance. If the information presented is not compliant, the Program Specialist will work with the individual's team to have the form corrected by the healthcare provider. Admission into the residential program will be postponed until the document is satisfactory. 08/31/2023 Implemented
6400.18(b)(2)Staff person #2 documented a note in Staff person #1's record that it was discussed with them that they were late in administering medications to the individual on 2/11/23, and the staff must adhere to ODP's medication administration policies and practices. The home entered an incident report for failure to administer the medications to Individual #1 on 2/11/23. However, the home didn't report the medication errors to the Department until 2/15/23, more than 72 hours after the event.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 Director will ensure that the Program Specialist, agency nurse, and all support staff are retrained on the Incident Management and Reporting bulletin by 8/31/23. The Program Specialist is reviewing EIM records and entering all unreported medication error incidents accordingly. This is expected to be completed by 8/9/23. The agency has contracted with Therap Services. The E-MAR system is scheduled to roll out 9/1/2023. Staff will be trained on the use of the E-MAR system on August 25, 2023. 08/31/2023 Implemented
6400.165(f)There is no record of a Social Emotional Environmental Need (SEEN) plan in the record for Individual #1 who currently has a diagnosed psychiatric illness that is being treated.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.A SEEN Plan was created for individual #1 on 8/5/23 (See Attachment 30). The SEEN Plan has been entered into Therap; all staff will be trained by the Program Specialist on the SEEN Plan by 8/31/23, as well as how to document noted concerns in relation to the plan. 08/31/2023 Implemented
6400.166(a)(11)At the time of the 07/26/23 physical site inspection, the Medication Administration Record (MAR) did not include a purpose or diagnosis for each prescription medication at the home (Symbacort, Lybalvi, Clonadine). Corrected on site.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 and agency nurse are following up with the individuals' prescribers to obtain the reason/diagnosis for all medications and contact the pharmacy to ensure that the MARs are updated correctly by 8/31/2023. 08/31/2023 Implemented
6400.213(1)(i)The following are violations for 55 Pa Code. § 6400.213.1.ii, iv, and v. The regulations and their violation descriptions were not available in the Certified Licensing System at the time of entry: 6400.213.1.ii - Individual #1 record does not include any current Identifying Marks. 6400.213.1.iv - Individual #1 record does not include the religious affiliation. 6400.213.1.v. - Individual #1 record does not include next of kin.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual's face sheet has been updated to include the missing information as of 8/5/23. The Program Specialist will review FACE sheets for all individuals to ensure that the required information is present by 8/31/23. 08/31/2023 Implemented
SIN-00242093 Renewal 04/03/2024 Compliant - Finalized