Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259309 Unannounced Monitoring 01/23/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)At 10:25AM, there was no screen in the window in the staff office. [Repeated Violation-10/7/24 and 11/21/24]Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens have been installed or repaired on all required windows and doors to ensure they are securely in place when opened. Any missing or damaged screens have been replaced to meet regulatory standards. 03/07/2025 Not Implemented
6400.112(a)At 10:26A, a fire drill schedule was posted in the staff office which displayed the date and time that the fire drills were to occur from August 14, 2024 through August 11, 2025. An unannounced fire drill shall be held at least once a month. The posted fire drill schedule has been removed from the staff office to ensure that all fire drills remain unannounced. Staff have been informed that fire drills must occur without prior notice to maintain compliance with ODP 6400 regulations. 03/07/2025 Not Implemented
6400.144Individual #1 is prescribed Ventolin HFA Aerosol with instructions to inhale 2 puffs by mouth every four hours as needed for wheezing. Individual #1 is also prescribed an Optichamber Diamond VHC with instructions to use as directed with inhaler. At 10:25AM, Individual #1 was at school and the Ventolin HFA Aerosol and the Optichamber Diamond VHC were in the home and not available to Individual #1. Staff interviews reveal that Individual #1 does not take the inhaler medications when she leaves the home. [Repeated Violation- 9/20/24]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 medical provider will be contacted to verify whether Individual #1's Ventolin HFA Aerosol and Optichamber Diamond VHC must be available at all times or only when symptoms arise. If it is determined that the medication must always be accessible, staff will be instructed to ensure that Individual #1¿s prescribed medication accompanies her whenever she leaves the home. A medication transport protocol has been implemented to verify that all necessary medications are readily available to the individual at all times. This may include having our new Program Specialist communicate with school officials to determine if the school nurse or administration can assist in holding and administering the medication as needed. 03/07/2025 Not Implemented
6400.32(d)At 11:57AM, there was a dry erase board in the dining room. On this board, it had handwritten notes to the staff about Individual #1 which stated "Complete sweet treat tracker daily, only 2 sweet treats per week. Blood sugar needs checked 2 hours prior to breakfast". There was also a Carbohydrate Counting diet on the wall with breakfast and lunch options posted in the dining room. Having specific diet posted in the staff office, limiting to twice weekly.An individual shall be treated with dignity and respect.The dry erase board in the dining room containing handwritten notes about Individual #1¿s dietary restrictions has been removed/erased. Additionally, the Carbohydrate Counting diet and meal options posted in the dining room have been taken down. To ensure that necessary dietary and medical information remains accessible to staff while maintaining the individual's dignity and privacy, a confidential binder has been created. This binder will store all dietary guidelines, medical tracking requirements, and related notes in a private area accessible only to staff. 03/07/2025 Implemented
6400.166(b)Clonidine Tab 0.1mg, Guanfacine Tab 2mg, Melatonin Tab 5mg, Olanzapine 20mg Tab, Prenatal 19 tab, and Topiramate 50mg tab prescribed to Individual #1 were not initialed as administered on 1/4/25 and 1/19/25 at 8:00PM. Clonidine 0.1mg tab, Topiramate 50mg tab, Vitamin D3 1000 IU, and Vyvanse Cap 50mg prescribed to Individual #1 were not initialed as administered on 1/8/25 and 1/9/25 at 8:00AM. Clonidine Tab 0.1mg, Sertraline 50mg tab, Topiramate 50mg tab, Vitamin D3 1000 IU, and Vyvanse 50mg Cap prescribed to Individual #1 were not initialed as administered on 1/17/25 and 1/23/25 at 8:00AM. Metformin 500mg ER Tab prescribed to Individual #1was not initialed as being administered on 1/17/25 and 1/19/25 at 5:00PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All missed medication administration initials have been reviewed, and staff involved have been re-trained on proper medication documentation procedures. The Medication Administration Record (MAR) has been updated to ensure all medications are recorded at the time they are administered. A review of all current MARs is being conducted to identify and correct any other potential documentation issues. 03/07/2025 Not Implemented
6400.166(d)Individual #1 is prescribed Sertraline Tab 50mg with instructions to take 1 and ½ tablets(75mg) by mouth every morning for depression/anxiety. Individual #1's January 2025 electronic medication record list administration times for this medication at 8:00AM and at bedtime (8:00PM). On 1/23/25, there was only a blister pack for Sertraline Tab 50mg at 8:00AM. Individual #1's electronic medication record and staff interviews indicate that Sertraline was administered to Individual #1 both at 8:00AM and 8:00PM throughout January 2025 including on 1/22/25. At 12:15PM, on 1/23/25, the pharmacy confirmed that the 8:00PM dosage of Sertraline for Individual #1 was discontinued on 4/16/24. [Repeated Violation- 9/20/24]The directions of the prescriber shall be followed.The medication administration error regarding Sertraline was immediately corrected upon confirmation from the pharmacy that the 8:00PM dose had been discontinued as of 4/16/24. Staff involved have been retrained on the importance of verifying current prescriptions and ensuring that all medication administration follows the prescriber's most recent orders. The Therap has been updated to reflect the correct dosing schedule, and the blister pack for the discontinued 8:00PM dose has been removed from the medication storage area. 03/07/2025 Implemented
6400.167(a)(1)Indiviudal #1's January 2025 electronic medication record indicated that Individual #1 was not administered Olanzapine 20mg Tab on 1/15/25 at 8:00PM. [Repeated Violation- 11/21/24]Medication errors include the following: Failure to administer a medication.The missed administration of Olanzapine 20mg Tab on 1/15/25 at 8:00PM has been reviewed, and staff responsible have been retrained on medication administration protocols. Therap, the electronic medication record system, has been checked for any additional discrepancies, and all staff have been reminded of the importance of following medication administration schedules as prescribed. 03/07/2025 Not Implemented
SIN-00256067 Unannounced Monitoring 11/21/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1 is not accessed to safely use and avoid poisonous materials. Interviews revealed that poisonous materials are to be locked in the home. The following cleaning supplies with instructions to contact a physician or poison control if ingested were unlocked and accessible under the kitchen sink: 16 fluid ounce bottle of Spic and Span advanced clean, 32 fluid ounce bottle of Solutions all-purpose cleaner, 32 fluid ounce Great Value lemon scent multi-purpose cleaner, 64 fluid ounce bottled of LA's totally awesome lemon scent bleach, 17.5 ounce can of Raid ant and roach spray, and 29 fluid ounce can of Glidden Interior paint plus primer.Poisonous materials shall be kept locked or made inaccessible to individuals. All cleaning supplies and potentially hazardous materials currently accessible under the kitchen sink, including Spic and Span advanced clean, Solutions all-purpose cleaner, Great Value multi-purpose cleaner, LA's Totally Awesome bleach, Raid ant and roach spray, and Glidden Interior paint plus primer, will be removed and secured in a locked storage cabinet by DSP staff. Devon Baskin, the Director of Compliance and Residential, will inspect the lock on the cabinet to confirm it provides adequate security and functionality. The Site Coordinator responsible for the home will verify that no hazardous materials remain accessible in any part of the home. Additionally, a comprehensive safety audit of all other storage areas will be conducted to ensure compliance with safety protocols. Staff will receive training on the proper handling and storage of poisonous materials, emphasizing the risks associated with exposure and ingestion. This training will include a practical demonstration of securing hazardous materials and a detailed review of related safety policies. Staff will sign an acknowledgment form upon completion of the training to confirm their understanding and commitment to compliance. Furthermore, a revised policy mandating that all poisonous materials be locked or made inaccessible will be distributed to all staff and incorporated into the employee handbook. 01/03/2025 Implemented
6400.64(a)At 10:31AM, the inside of the microwave in the kitchen was charred, delaminating, and rusting. The inside of the microwave door was coated in what appeared to be in grease. At 10:32AM, the inside of the air fryer was coated in food remnants and what appeared to be grease. At 10:35AM, the inside of the oven had an inordinate amount of dark stained areas from what appeared to be burned on food spills.Clean and sanitary conditions shall be maintained in the home. The microwave in the kitchen was replaced due to its charred, delaminating, and rusting interior. Additionally, staff will clean the interior of the air fryer and remove all food remnants and grease to restore it to a sanitary condition. The oven will also be thoroughly cleaned to remove the dark-stained areas and burned-on food spills, ensuring it meets the required cleanliness standards. Staff responsible for cleaning and maintaining kitchen appliances will be instructed on proper cleaning techniques and provided with a checklist to ensure all appliances are inspected and cleaned regularly. Devon Baskin, the Director of Compliance and Residential, will conduct a follow-up inspection to confirm that all corrective actions have been completed. A written record of the inspection will be maintained for documentation purposes. 01/03/2025 Implemented
6400.67(a)At 10:40AM, the kitchen wall, next to the door, had a crack from the ceiling to the floor. At 10:47AM, the ceiling tile in the dining room had dark brown spots that appeared to be from water leaking from the bathroom on the second floor of the home. At 10:54AM, the dining room wall had a crack from the ceiling to the floor. At 11:21AM, there is a doorknob shaped hole in the wall directly behind the door in the bathroom on the second floor of the home.Floors, walls, ceilings and other surfaces shall be in good repair. To address the violation, immediate corrective actions will be undertaken to ensure that all floors, walls, ceilings, and other surfaces in the home are in good repair. For the kitchen, the crack running from the ceiling to the floor will be repaired by the maintenance team. The team will fill, sand, and repaint the crack to restore the wall to its original condition. In the dining room, the ceiling tile with dark brown spots indicating water damage will be replaced. Additionally, the maintenance team will inspect and address any leaks or contributing factors to prevent further water damage. The dining room wall crack, extending from the ceiling to the floor, will also be repaired by filling, sanding, and repainting the affected area. For the bathroom, the doorknob-shaped hole in the wall will be patched using a durable repair method, and a protective doorstop will be installed behind the door to prevent recurrence. All repairs will be documented with receipts for verification. Devon Baskin, the Director of Compliance and Residential, will inspect all repaired areas to confirm they meet compliance standards. 01/03/2025 Not Implemented
6400.72(a)At 10:28AM, the air conditioner unit in the dining room window was not fully sealed at the bottom creating a half inch gap between the windowsill and the unit.Windows, including windows in doors, shall be securely screened when windows or doors are open. Immediate corrective actions will be taken to ensure the dining room window air conditioner unit is securely sealed and compliant with regulations. The half-inch gap between the windowsill and the air conditioner unit will be sealed using a durable weatherproof material, such as foam insulation or caulking, to eliminate the gap and prevent any potential safety or environmental concerns. The maintenance team will complete this repair within two weeks and inspect the seal to ensure it is secure and provides complete coverage. Additionally, the maintenance team will inspect all windows in the home, including those with air conditioner units, to confirm they are securely screened and free of any gaps. Any identified issues will be promptly corrected following the same repair methods. 01/03/2025 Implemented
6400.76(a)At 10:48AM, the four dining room chairs had loose legs, that wobbled back and forth approximately an inch in all directions. Furniture and equipment shall be nonhazardous, clean and sturdy. Immediate corrective actions will be taken to ensure all furniture is safe, clean, and sturdy. The four dining room chairs with loose legs will be removed from use immediately to prevent any potential hazards. The maintenance team will assess and attempt to repair the chairs by tightening and securing the legs to eliminate the wobbling. If the chairs cannot be adequately repaired to meet safety and sturdiness standards, they will be replaced with new chairs that comply with the regulation. These actions will be completed within this month December 2024. If the chairs are repaired and not replaced then once repairs are finalized, the Site Coordinator will inspect the chairs to confirm they are nonhazardous and sturdy before they are returned to use. Devon Baskin, the Director of Compliance and Residential, will review the completed maintenance actions to ensure they align with regulatory standards and compliance expectations. 01/03/2025 Implemented
6400.101At 10:10AM, there was a eye hook latch on the inside door to the basement, posing an obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Immediate action will be taken to ensure that all stairways, halls, doorways, passageways, and exits remain unobstructed. The eye hook latch on the inside door to the basement, which poses an obstructed egress, will be removed promptly by the maintenance team. This action will be completed by the end of the month December 2024. The door will be inspected by the maintenance team to ensure it functions properly without the latch and allows for unobstructed access and egress at all times. Once the latch has been removed, Devon Baskin, the Director of Compliance and Residential, will conduct an inspection of all doors, stairways, and exits in the home to confirm there are no other obstructions or potential hazards. 01/03/2025 Implemented
6400.171At 10:35AM, there was an unsealed, open cardboard leftover food box containing food in the refrigerator in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. The unsealed, open cardboard leftover food box in the refrigerator was immediately removed and discarded to eliminate the risk of contamination. Staff will inspect the refrigerator daily to ensure all remaining food items are properly sealed and stored in appropriate containers. Staff will be retrained on food storage practices, specifically focusing on the requirement that all food must be stored in sealed, contamination-resistant containers. This training will include clear instructions on identifying improperly stored items and taking corrective actions promptly. The Site Coordinator will complete a follow-up inspection to confirm that proper food storage practices have been implemented and are being maintained. 01/03/2025 Not Implemented
6400.181(a)Individual #1's most recent annual assessment was completed on 8/21/23. 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. Immediate action will be taken to ensure compliance with annual assessment requirements. Individual #1's updated annual assessment has been scheduled and will be completed by the end of the month to ensure their needs, adaptive behavior, and level of skills are thoroughly evaluated. The previous Director of Programs and Program Specialist are no longer with the organization. A new Program Specialist has been hired and is actively working to bring all outstanding tasks, including overdue and incomplete assessments, up to date. She is ensuring that all regulatory requirements are met and that records are thoroughly reviewed and updated. Devon Baskin, the Director of Compliance and Residential, will review the updated assessments and processes to confirm compliance with regulatory standards and provide support for the Program Specialist as needed. 01/03/2025 Not Implemented
6400.166(b)Individual #1 was prescribed Prednisone 20mg with instructions to take 2 tablets by mouth every day for 4 days. This mediation was to end on 11/1/24 at 9:00AM. This medication was not initialed as administered on 11/1/24.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Immediate steps will be taken to ensure that all medications are accurately documented in the medication administration record (MAR) at the time they are administered. Specifically, the omission of initials for the administration of Prednisone 20mg on 11/1/24 at 9:00 AM will be investigated by the Program Specialist to determine the cause of the error. The responsible staff member will be retrained on the proper procedures for recording medication administration in the MAR. The medication record will be updated to include a clear notation of whether the dose was administered or missed, along with an explanation if applicable. the Director of Compliance and Residential, will review the corrective actions to ensure they align with regulatory standards. 01/03/2025 Not Implemented
6400.167(a)(1)Individual #1 is prescribed Melatonin Tab 5mg with instructions to take 1 tablet by mouth every night at bedtime for sleep. On 11/21/24, this medication was not present in the home. An empty blister pack for this medication was most recently dated 11/18/24 for the last pill. Individual #1's medication administration record was initialed as administered for this medication on 11/19/24 and 11/20/24 at 8:00PM.Medication errors include the following: Failure to administer a medication.Corrective actions will be implemented to ensure proper medication administration and documentation. An investigation will be conducted to determine the reason for the discrepancy in the administration and documentation of Melatonin Tab 5mg on 11/19/24 and 11/20/24. This investigation will include reviewing the medication administration record (MAR) and interviewing the staff involved to identify any errors in administration or documentation. All staff responsible for medication administration will be retrained on proper procedures for documenting medications in the MAR at the time of administration. The importance of cross-checking the MAR and verifying that medications are administered as prescribed will be emphasized. The MAR will also be reviewed by the Site Coordinator/Program Specialist to ensure that it accurately reflects medication administration records. Staff will receive clear instructions on the policy and procedures for verifying medication availability and accurately documenting all medications administered. The Site Coordinator/Program Specialist will conduct a follow-up review to confirm compliance with the corrective actions and the accuracy of MAR documentation. 01/03/2025 Not Implemented
SIN-00253943 Unannounced Monitoring 10/07/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:18AM, a sticky, black substance was in the egg holder compartment in the door of the refrigerator in the kitchen of the home. At 10:22AM, there was a cloudy, liquid on the top shelf and inside the drawer in the refrigerator in the kitchen of the home. At 10:25AM, there were food crumbs and splatter throughout the plate and walls and the top was rusting and peeling inside the microwave in the kitchen of the home. At 10:33AM, there was an inordinate amount of black spots that appeared to be mold and/or mildew inside the air slats in the window air conditioning unit in Individual #1's bedroom.Clean and sanitary conditions shall be maintained in the home. We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. 12/16/2024 Not Implemented
6400.71At 10:39AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were not on or by the telephone on the bed side table next to the bed in Individual #1's bedroom.[Repeated violation 7/23/2024 et al.]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. To address the absence of emergency contact numbers, a list of telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center will be placed next to or on each telephone, including the bedside table in Individual #1's bedroom. Residential Site Supervisors will ensure that these numbers are clearly displayed and securely attached by each phone to prevent future removal or misplacement. 12/16/2024 Implemented
6400.73(a)At 11:55AM, there was no railing on the four exterior stairs between the basement and the backyard of the home. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. 12/16/2024 Not Implemented
6400.80(b)At 11:55AM, there was a black, plastic drainpipe coming from underneath the outside stairs and across a step to the landing where it was held with a large rock; posing a tripping hazard from the rear of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. 12/16/2024 Not Implemented
6400.105At 11:53AM, there was approximately three inches of lint inside the lint trap of the dryer in the basement of the home.[Repeated violation 7/23/2024 et al.]Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. 12/16/2024 Not Implemented
6400.171At 10:22AM, an undated, plastic container of used oil was on top of the microwave in the kitchen of the home. At 10:21AM, a gallon of 2% milk with a sell-by of 9/19/2024, a package of shredded mild cheddar cheese with an expiration date of 9/30/2024, an unsealed, partially used container of sliced cheddar cheese, an unsealed, partially used foil package of cream cheese and a partially used container of sour cream without the lid secured and dried, sour cream around the edges, were in the refrigerator in the kitchen of the home.[Repeated violation 7/23/2024 et al.]Food shall be protected from contamination while being stored, prepared, transported and served. To address improper food storage practices, all expired and improperly stored items in the refrigerator, freezer, and kitchen area were immediately discarded. Staff have been reminded of food storage protocols, including checking expiration dates and ensuring food is wrapped and protected from contamination. Additionally, a food safety flyer has been created and will be posted in the kitchen as a reminder of proper storage practices. Residential Site Supervisors will monitor food storage during their weekly inspections to ensure compliance. 12/16/2024 Not Implemented
6400.214(b)At 10:15AM, the current copies of Individual #1's assessment, Individual plan, physical examination and dental 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 current copies of Individual #1¿s assessment, individual plan, physical examination, and dental examination will be obtained and immediately placed in the home. These documents will be stored securely in the staff office to ensure accessibility and compliance. 12/16/2024 Not Implemented
6400.216(a)At 10:29AM, a Cross-System Crisis Prevention and Intervention Plan containing Individual #1's personal and confidential information was unlocked and unattended on top of a basket on a furniture stand in the dining room of the home. An individual's records shall be kept locked when unattended. All personal records will be stored in a locked filing cabinet within the staff office. Staff will receive training on the importance of securing records immediately after use. 12/16/2024 Not Implemented
6400.32(r)(3)Individual #1 has not been provided the assistive technology to lock and unlock her bedroom door without assistance. Individual #1 does not have a designated device to lock and unlock her bedroom door that is equipped with a thumb turn lock on the doorknob.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.To ensure Individual #1 can independently lock and unlock her bedroom door, the current pinhole lock will be replaced with an accessible locking mechanism that meets her needs for privacy and independence. Maintenance staff have been instructed to install an appropriate assistive lock device that does not require staff assistance. This replacement will be completed promptly, and staff will verify the functionality of the new lock. 12/16/2024 Not Implemented
6400.32(r)(5)Direct service workers providing services to Individual #1 do not have designated device to lock and unlock Individual #1's bedroom that is equipped with a thumb turn lock on the doorknob.[Repeated violation 7/23/2024 et al.]Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.To ensure that Individual #1 can independently lock and unlock her bedroom door, the current pinhole lock will be replaced with an accessible locking mechanism that meets her needs for privacy and independence. Maintenance staff have been assigned to install an assistive lock device that Individual #1 can operate without assistance, and staff will verify the functionality of this new lock upon installation. Additionally, each direct service worker providing services to Individual #1 will be equipped with a designated entry device to unlock her door as needed. The device will be kept on hand at all times by Direct Support Professionals assigned to Individual #1¿s care to ensure immediate access in the event of an emergency. 12/16/2024 Not Implemented
6400.166(a)(10)Individual #1 is prescribed Vyvanse with instructions to, "Take one capsule by mouth every morning for ADHD." The administration time listed on Individual #1's October 2024 Medication Administration Record is 6:30PM.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.All staff will be retrained on proper medication administration and the accurate use of the Therap system for documentation. The training will emphasize the importance of correctly recording administration times to match the prescribed instructions. The Medication Administration Record (MAR) for Individual #1 will be immediately corrected to reflect the accurate morning administration time. 12/16/2024 Not Implemented
6400.166(b)At 10:15AM, Individual #1's prescribed medication, Clonidine, was not initialed as administered at 8:00AM on 10/2/2024, 10/4/2024 and 10/7/2024.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All staff will be retrained on the correct procedures for medication administration, emphasizing the importance of immediate documentation in the medication administration record (MAR) at the time of administration. The training will include detailed guidance on using the Therap system to ensure accurate and timely recording. The Director of Residential Facilities and Compliance and Program Specialists will oversee the training and provide ongoing support. 12/16/2024 Not Implemented
SIN-00252204 Unannounced Monitoring 09/20/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16In the home supervision section of Individual #1's individual plan, last updated 6/27/2024, reads, "[Individual #1] requires 24-hour supervision...[Individual #1] requires constant supervision. Her safety is at risk and she is an elopement risk." On 9/10/24, Individual #1 was left unsupervised in the home while Direct Service Worker #1 was in a car parked on the street in front of the home. The police approached the vehicle and found Direct Service Worker #1 smoking Marijuana with an unknown male. The police searched the car and Marijuana blunts, zip lock bags with green leafy substance and cash were found. In addition, a 9mm semi-automatic pistol was found in the purse of Direct Service Worker #1. Surveillance cameras show that Direct Service Worker #1 left Individual #1 unattended for 90 minutes. During that time, Individual #1 came out of the home requesting toilet paper. [Repeated Violation- 7/23/24 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.To address the violation, Direct Service Worker #1 was immediately terminated upon discovery of the incident. The incident was reported to the necessary authorities, and an internal investigation was conducted to identify any systemic failures. A mandatory team meeting, led by the Residential Site Supervisor on September 25, reviewed Individual #1's Individual Plan (IP), stressing the necessity of constant supervision due to her elopement risk. Staff were reminded of the severe consequences of non-compliance with supervision requirements. Beginning October 8, mandatory training sessions for all direct care staff were launched by the Training Specialist, focusing on client supervision, elopement risk management, and a reiteration of the agency's zero-tolerance policy for substance use. 12/16/2024 Not Implemented
6400.43(b)(4)Chief Executive Officer #2 has failed to ensure the administration and general management of the agency including compliance with 55 Pa. Code Chapter 6400. Chief Executive Officer #2 has failed to ensure adequate and competent staffing leading to the lack of supervision and implementation of the individuals' individual plans resulting in neglect of individuals. Chief Executive Officer #2 has failed to ensure homes are clean, hazard free, and have required supplies. Chief Executive Officer #2 has failed to ensure timely reporting, investigation, and closure of reportable incidents.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. To address the violation concerning the Chief Executive Officer¿s (CEO) responsibilities, immediate corrective actions have been initiated. The CEO will ensure full compliance with 55 Pa. Code Chapter 6400 by implementing robust oversight mechanisms across all operational aspects of the agency. A comprehensive review of current staffing will be conducted by the New Director of Residential Facilities & Compliance to assess competency levels and ensure adequate supervision. This includes mandatory training for all staff on the implementation of individual plans and the importance of maintaining constant supervision to prevent neglect. Additionally, a thorough evaluation of each home will be conducted to ensure cleanliness, hazard-free environments, and the availability of required supplies. 12/02/2024 Not Implemented
6400.73(a)On 9/20/2024 at 12:08PM, the four steps, at the basement egress in the rear of the home, did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. 12/02/2024 Implemented
6400.82(f)On 9/20/2024 at 11:50am, the second-floor full bathroom did not contain toilet paper.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. To address this issue, toilet paper was immediately restocked in the second-floor bathroom. Staff were reminded of the importance of maintaining all necessary bathroom supplies. A bathroom supply checklist has been implemented to ensure daily restocking of toilet paper and other essential items. 12/02/2024 Implemented
6400.171On 9/20/2024 at 11:54AM, a saucepan filled approximately one-quarter of the way with what appeared to be, used cooking oil was on the stove. The cooking oil had not been strained, transferred to an airtight container, or refrigerated per the FDA's safe-storage recommendations.Food shall be protected from contamination while being stored, prepared, transported and served. To address improper food storage practices, all expired and improperly stored items in the refrigerator, freezer, and kitchen area were immediately discarded. Staff have been reminded of food storage protocols, including checking expiration dates and ensuring food is wrapped and protected from contamination. Additionally, a food safety flyer has been created and will be posted in the kitchen as a reminder of proper storage practices. Residential Site Supervisors will monitor food storage during their weekly inspections to ensure compliance. 12/02/2024 Not Implemented
6400.214(b)On 9/20/2024, the most current copy of the following records for Individual #1 at the home were: assessment, completed 8/21/2023, dental examination, completed 1/19/2023, and physical examination completed, 6/2/2023. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The current copies of Individual's assessment, individual plan, physical examination, and dental examination will be obtained and immediately placed in the home. These documents will be stored securely in the staff office to ensure accessibility and compliance. 12/16/2024 Not Implemented
6400.18(a)(5)The agency became aware of an allegation of neglect on 9/11/24. Incident #9486456 for the allegation was not reported in Enterprise Incident Management, the Department's incident management system until 9/18/24. The agency became aware of an allegation of neglect on 9/11/24. Incident #9486351for the allegation was not reported in Enterprise Incident Management, the Department's incident management system until 9/18/24.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. To address the violation of delayed reporting of neglect allegations, the agency has implemented immediate corrective measures. All staff will undergo mandatory re-training on the requirements of timely reporting as stipulated in 55 Pa. Code Chapter 6400. This training will emphasize the critical importance of reporting any incidents of neglect through the Enterprise Incident Management (EIM) system within 24 hours of discovery. The New Director of Residential Facilities & Compliance and Program's Department will now oversee the incident reporting process to ensure strict adherence to these timelines. 12/16/2024 Not Implemented
6400.45(e)In the home supervision section of Individual #1's individual plan, last updated 6/27/2024, reads, "[Individual #1] requires 24-hour supervision... [Individual #1] requires constant supervision. Her safety is at risk, and she is an elopement risk." On 9/10/24, Individual #1 was left unsupervised in the home while Direct Service Worker #1 was in a car parked on the street in front of the home. Surveillance cameras show that Direct Service Worker #1 left Individual #1 unattended for 90 minutes. Interviews reveal, Individual #1 was unsupported in the home intermittently for up to 5 hours.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.To address the violation of leaving Individual #1 unsupervised, immediate corrective actions have been implemented. Direct Service Worker #1 was terminated upon discovery of the incident. A mandatory staff meeting was held by the Residential Site Supervisor to review Individual #1¿s Individual Plan (IP), emphasizing the critical need for 24-hour supervision due to her elopement risk. Staff were reminded of the serious consequences of failing to adhere to supervision requirements. Additionally, the New Director of Residential Facilities & Compliance will oversee the implementation of enhanced supervision protocols. 12/16/2024 Not Implemented
6400.186In the home supervision section of Individual #1's individual plan, last updated 6/27/2024, reads, "[Individual #1] requires 24-hour supervision... [Individual #1] requires constant supervision. Her safety is at risk, and she is an elopement risk." On 9/10/24, Individual #1 was left unsupervised in the home while Direct Service Worker #1 was in a car parked on the street in front of the home. Surveillance cameras show that Direct Service Worker #1 left Individual #1 unattended for 90 minutes. Interviews reveal, Individual #1 was unsupported in the home intermittently for up to 5 hours.The home shall implement the individual plan, including revisions.To address the violation of leaving Individual #1 unsupervised, immediate corrective actions have been implemented. Direct Service Worker #1 was terminated upon discovery of the incident. A mandatory staff meeting was held by the Residential Site Supervisor to review Individual #1¿s Individual Plan (IP), emphasizing the critical need for 24-hour supervision due to her elopement risk. Staff were reminded of the serious consequences of failing to adhere to supervision requirements. Additionally, the New Director of Residential Facilities & Compliance will oversee the implementation of enhanced supervision protocols. 12/16/2024 Not Implemented
SIN-00248517 Renewal 07/23/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 6/23/2024. The certificate of compliance expired on 6/18/2024. In addition, page 17 of the self-assessment was not completed.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. COO has scheduled the next self-assessment for the week of October 1, 2024. 10/03/2024 Not Implemented
6400.64(a)On 7/24/2024 at 11:10AM, the windowsills in Individual #1's bedroom had a thick layer of dirt and debris. On 7/24/2024 at 11:20AM, the mechanical vent in the second-floor full bathroom was clogged with a thick layer of dirt and debris. On 7/24/2024 at 11:21AM, the baseboards and carpeting in the second-floor hallway had a thick layer of dirt and debris. The carpeting in the second-floor hallway had what appeared to be small pieces of toilet paper strewn across the floor. On 7/24/2024 at 11:55AM, the baseboards and windowsill in the living room, dining room, and kitchen had a thick layer of dirt and debris. On 7/24/2024 at 12:04pm, the basement steps had an inordinate amount of dirt, debris, and dead bugs on the stair treads.Clean and sanitary conditions shall be maintained in the home. Staff cleaned windowsills, mechanical vent, and baseboards 7/24/24. Maintenance deep cleaned the site 8/16/24. 08/16/2024 Not Implemented
6400.67(a)On 7/24/2024 at 12:03PM, the floor near the rear basement exit had wet muddy film that was slippery under foot.Floors, walls, ceilings and other surfaces shall be in good repair. 7/24/24 staff cleaned flood in basement. Maintenance deep cleaned the site 8/16/24. 08/16/2024 Not Implemented
6400.71On 7/24/2024 at 11:10AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in Individual #1's bedroom. On 7/24/2024 at 11:54AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home.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. 7/24/24 Site Supervisor placed telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center. 08/26/2024 Implemented
6400.72(a)On 7/24/2024 at 11:11AM, the window air conditioner unit in Individual #1's bedroom was not securely sealed to prevent from infestation. On 7/24/2024 at 11:45AM, the window air conditioner unit in the second-floor staff office was not securely sealed to prevent from infestation. On 7/24/2024 at 11:56AM, the window air conditioner unit in the dining room was not securely sealed to prevent from infestation.Windows, including windows in doors, shall be securely screened when windows or doors are open. 8/16/24 Maintenance secured AC window units. 08/16/2024 Not Implemented
6400.72(b)On 7/24/2024 at 11:14AM, the two windows in Individual #1's bedroom were equipped with metal extension rods that could prevent the windows from opening. Screens, windows and doors shall be in good repair. 7/29/24 Maintenance removed the metal extensions rods. 07/29/2024 Not Implemented
6400.80(a)On 7/24/2024 at 12:00PM, a plastic downspout extension pipe was across the sidewalk at the side of the home, posing a tripping and falling hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. 7/29/24 Maintenance addressed the plastic downspout extension pipe so that it does not pose a tripping or falling hazard. 07/29/2024 Not Implemented
6400.101On 7/24/2024 at 11:09AM, Individual #1's bedroom had clothing, shoes, bags, and other belongings on the floor on the right side of the bed, at the bottom of the bed, and in front of the closet obstructing egress from Individual #1's bedroom in the case of an emergency.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 7/24/24 Staff assisted the individual with cleaning room so that it is not obstructing egress in case of an emergency. 08/26/2024 Not Implemented
6400.112(e)The most recent fire drill completed during sleeping hours was held on 8/4/2023.A fire drill shall be held during sleeping hours at least every 6 months. COO created a fire drill schedule for management team and team leads 7/24/24. August 14, 2024 fire drill was completed during sleeping hours. 08/14/2024 Not Implemented
6400.114(b)On 7/24/2024 at 12:03PM, approximately eight cigarette butts were on the ground underneath the rear exterior steps. The agency's policy for safe smoking procedures states that "staff are to properly dispose of all cigarette butts in a receptacle with a lid."Written smoking safety procedures shall be followed.7/24/24 Staff removed cigarette butts from ground. 08/05/2024 Not Implemented
6400.141(a)Individual #1 had an annual physical examination completed on 6/2/2023 and then again on 7/24/2024.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Scheduling PCP appointments a year out is no longer an option, as a result Program Director and program specialist have added appointments in click up app which will notify department to remind staff about appointments. 08/26/2024 Not Implemented
6400.141(c)(1)Individual #3's physical examination, completed 7/18/24, did not include a review of previous medical history.The physical examination shall include: A review of previous medical history. 8/7/24 Program Director requested previous medical history 08/05/2024 Not Implemented
6400.141(c)(7)Individual #1, date of admission 7/10/2023, has not had a gynecological examination. [Repeated Violation-8/7/23, et al]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. The program director obtained a document that states the gynecological exam is not required until 21. However, the document was not accepted. 8/5/24 The program specialist scheduled another exam to get another document to explain this in more depth. 08/05/2024 Not Implemented
6400.141(c)(11)Individual #3's physical examination, completed 7/18/24, did not include an assessment of the individual's health maintenance needs, and the need for bloodwork at recommended intervals. These sections were left blank.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. 7/29/24 The program department has requested this information from the PCP. However, the program department will pre-fill forms for the PCP to sign and ensure information is accurate. 08/05/2024 Implemented
6400.141(c)(14)Individual #3's physical examination completed 7/18/24, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. 7/29/24 The program department has requested this information from the PCP. However, the program department will pre-fill forms for the PCP to sign and ensure information is accurate. 08/05/2024 Implemented
6400.142(g)Individual #1's most recent dental hygiene plan was completed on 1/19/2023.A dental hygiene plan shall be rewritten at least annually. The program director updated the dental hygiene plan for the individual 8/9/24. 08/09/2024 Implemented
6400.151(a)Direct Service Worker #1's most recent physical examination was completed on 4/12/2022. Direct Service Worker #1 continued working directly with individuals until 6/21/2024.Chief Operating Officer Designee #1, date of hire 4/28/23, had an initial physical examination completed on 7/26/23. 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. 8/23/24 The staff member has been terminated.7/24/24 COO instructed to have physical completed by 7/26/25. 08/23/2024 Not Implemented
6400.181(e)(4)Individual #3's assessment, completed 12/10/23, indicates Individual #1 has 1:1, staffing to Individual ratio, supervision in the home; however, another section of the assessment indicates Individual #3 has unsupervised time at home. The assessment must include the following information: The individual's need for supervision. The individual has transitioned to another agency as of 7/22/24. 8/26/24 Program Director and program specialist are reviewing all assessment to determine any discrepancies. 08/26/2024 Implemented
6400.181(e)(10)Individual #1's assessment, completed 8/21/2023 did not include a lifetime medical history. Individual #3's assessment, completed 12/10/23, did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The individual has transitioned to another agency as of 7/22/24. 8/26/24 Program Director and program specialist are reviewing all assessment to determine any discrepancies. 08/26/2024 Implemented
6400.181(e)(11)Individual #1's assessment, completed 8/21/2023, did not include a psychological evaluation. Individual #3's assessment, completed 12/10/23, did not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. The individual has transitioned to another agency as of 7/22/24. 8/26/24 Program Director and program specialist are reviewing all assessment to determine any discrepancies. 08/26/2024 Implemented
6400.18(a)(4)The agency became aware of an allegation of sexual abuse on 6/16/24. Enterprise Incident Management Incident #9435148 for the allegation sexual abuse was not reported in Enterprise Incident Management, the Department's information management system until 6/18/2024.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. COO had all staff meeting and discussed importance and procedure for incident reporting. COO created second Team August 16, 2024 to assist with EIM completion and maintenance. 08/16/2024 Not Implemented
6400.18(i)Enterprise Incident Management, Incident #9349217 for an allegation of a violation of individual rights had a due date of 5/30/24. As of 7/30/24, the incident has not been finalized or an extension has not been requested.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.Incident 9349217 finalized 8/14/24. 08/14/2024 Not Implemented
6400.46(b)On 7/24/2024 at 12:03PM, approximately eight cigarette butts were on the ground underneath the rear exterior steps. The agency's policy, Smoking Safety Procedure states that "STAFF or visitors are to properly dispose of all cigarette butts in a receptacle with a lid."Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).8/5/24 HR staff reviewed smoking policy and procedure. 08/05/2024 Not Implemented
6400.163(h)On 7/23/2024 at 12:52pm, the following discontinued and/or expired medications prescribed to Individual #2 had not been disposed of per the agency's medication disposal policy and were unlocked and accessible in the Agency's office: a blister pack Melatonin 3mg tablets, a bottle of Ibuprofen 400mg tablets, a bottle of Clonidine HCL 0.2mg tablets, a bottle of Buspirone HCL 10mg tablets, a blister pack of Clonidine 0.2mg tablets, and a blister pack of Ibuprofen 200mg tablets. On 7/23/2024 at 12:52pm, the following discontinued and/or expired medications prescribed to Individual #3 had not been disposed of per the agency's medication disposal policy and were unlocked and accessible in the Agency's office: four blister packs of Divalproex DR 500mg tablets, five blister packs of Oxcarbazepine 600mg tablets, six blister packs of Clonidine 0.1mg tablets, and two blister packs of Melatonin 5mg tablets.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.7/24/24 Training specialist removed the discontinued/expired medication and followed disposal protocol for these medications. 08/26/2024 Not Implemented
6400.165(g)Individual #1, date of admission 7/10/23, had an initial psychiatric medication review completed on 2/6/24. [Repeat violation: 8/7/2023 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.The individual has had a review of medication every 3 months as required. This is how the agency is able to renew prescriptions. The psychiatrist has not completed the documentation to show medication reviews have been completed. 7/24/24 Program Director and Program Specialist have been contacting the psychiatrist to obtain information needed for medication review documentation. 08/05/2024 Not Implemented
6400.166(b)Clonidine 0.1mg tablet with instructions to take ½ tablet (0.05mg) by mouth three times a day for hypertension prescribed to Individual #1 was listed twice on Individual #1's July 2024 medication administration record. On 7/24/2024 at 7:00PM, Direct Service Worker #2 initialed that two doses of Clonidine were administered to Individual #1.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.7/29/24 Program director, program specialist, training specialist and COO reviewed the MAR on therap and ensured there were no duplicate medications on the MAR to prevent potential documentation error. 07/29/2024 Implemented
6400.182(c)Individual #3's assessment, completed 12/10/23 reads, "Yes," [Individual #3] can exit under 2.5 minutes." Individual #3's individual plan, last updated 7/3/24 reads, "the concern is that [Individual #3] would not be paying enough attention to notice if there was a fire and that could place him in danger." Individual #3's assessment, completed 12/10/23 indicates, Individual #3 cannot swim. Individual #3's individual plan last updated 7/3/24 indicates, Individual #3 can swim with supervision.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.7/24/24 The individual has moved to another agency. However, the program specialist will update the individual's assessment during the next annual assessment review to ensure the assessment has no discrepancies. 08/27/2024 Implemented
6400.194(d)The agency is restricting Individual #3's telephone use by locking the telephone in the staff office and listening in on Individual #3's telephone conversations. The Agency does not have a record of human rights team meetings.A record of the human rights team meetings shall be kept.The agency submitted Human Rights meeting with pre-inspection document. 08/23/2024 Implemented
6400.195(a)The agency is restricting Individual #3's telephone use by locking the telephone in the staff office and listening in on Individual #3's telephone conversations. Individual #1's individual plan does not address behavior supports that were reviewed and approved by the human rights team prior to the use of Individual #1's restrictive procedure.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.Individual 1 does not have an RPP. Individual 3 has an RPP and it has been reviewed by HRC. Individual 3 has moved to another agency as of 8/22/24. 08/16/2024 Implemented
SIN-00229167 Renewal 08/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1, date of admission 7-10-23, does not have documentation of a gynecological examination, including a breast examination and Pap test. Individual #1 is 18 years of age or older.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. We have made Indiviudal an appointment to see their gynecologist which is on 9/26/23. At this appointment, we will get the doctor's recommendation in writing for the pap smear for our records. [Additional information provided by the agency via email on 10/24/23: Training on the regulation has occurred, but no date or documentation was provided. Monthly reviews of the appointment tracker by the Program Specialist and Director will be maintained. DPOC by HDKP, HSLS, on 11/1/2023]. 09/08/2023 Implemented
SIN-00210785 Renewal 08/30/2022 Compliant - Finalized
SIN-00190320 Unannounced Monitoring 07/15/2021 Compliant - Finalized
SIN-00179079 Renewal 10/20/2020 Compliant - Finalized
SIN-00159825 Initial review 07/22/2019 Compliant - Finalized