| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00266583
|
Renewal
|
05/13/2025
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 5/13/2025 at approximately 10:15am, Chief Executive Officer #7 made licensing personnel aware of an open neglect investigation for Individual #1. Chief Executive Officer #7 explained that Direct Service Worker #4 arrived at the residence on 5/11/2025 at approximately 7:00am to begin their assigned shift. Upon arrival, Direct Service Worker #3 was not at the home and Individual #1 was unsupervised. The agency neglected to provide Individual #1 with needed supervision. Individual #1's physical examination completed 5/12/2025 indicated the individual was to start taking Montelukast 10mg tablet "Take 1 tablet by mouth every evening." Individual #1's physical examination completed 5/12/2025 indicated the individual was to continue taking the following medications: Albuterol 90mcg inhaler "Take 2 puffs every 6 hours as needed", Fluticasone Propion-Salmeterol 500-mcg "Take 1 puff 2 times a day, medical marijuana, Omeprazole 20mg "Take 1 capsule by mouth daily", and Polyethylene Glycol "Take 17g by mouth 2 times a day". On 5/14/2025 Program Specialist #6 stated Individual #1 does not take any medications other than pro re nata medical marijuana. [Repeated violation: 7/19/2024 et al, 8/13/2024 et al, 11/19/2024 et al] | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | CEO informed the agencies CI whom immediately corrected the late EIM. The agency CI input the EIM and investigated the allegations. |
06/07/2025
| Not Implemented |
| 6400.21(a) | Direct Service Worker #1, date of hire 1/10/2025, had an application for a Pennsylvania criminal history record check shall be submitted to the State Police on 1/3/2025. The criminal history record check indicated that Direct Service Worker #1 had a criminal record to include the following: Driving Under the Influence of Controlled Substance on 5/24/2019, Disorderly Conduct on 8/1/2019, Retail Theft on 12/27/2022, and Retail Theft on 3/13/2024. The agency did not document their review of Direct Service Worker #1's criminal history check and the agency's decision making process for hiring. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| CEO and admin team will develop a criminal history attestation form. This form will be completed with all criminal history checks even if the employees background is clear. |
06/07/2025
| Implemented |
| 6400.22(e)(3) | The financial management section of Individual #1's individual support plan, last updated on 4/9/2025, reads, "[Individual #1] needs support with budgeting and money management···[Individual #1] has very little real-world experience with money management and will need support to ensure [they have] proper money management skills." Interviews with Direct Service Worker #2 and Program Specialist #6 revealed that the agency does not assist the individual with money management, retain receipts for purchases made that exceed $15.00, or keep a financial ledger to track the individual's purchases. [Repeated violation: 11/19/2024 et al] | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | CEO submit an email request to the individuals SC supervisor to have these updates added to the individuals ISP. SC supervisor confirmed these updates will be added to the ISP. Program Director will be completing a new full assessment of the individual and emailing the SC any additional updates or discrepancies with the ISP and assessment. |
06/30/2025
| Implemented |
| 6400.63(a) | On 5/14/2025 at 10:39am, the hot water temperature at the kitchen sink measured 123.2°F. On 5/14/2025 at 10:42am, the hot water temperature at the basement level washtub measured 123.4°F. [Repeated violation: 5/23/2024 et al, 7/19/2024 et al, 8/13/2024 et al, 9/16/2024 et al, 1/24/2025 et al] | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Program director adjusted the hot water tank and checked the temperature to the temperature was not exceeding 120 degrees. |
06/07/2025
| Implemented |
| 6400.64(a) | On 5/14/2025 at 10:35am, trash to include a paper plate with food residue and 2 empty single-serve beverage bottles were observed on Individual #1's nightstand adjacent to the bedroom door. | Clean and sanitary conditions shall be maintained in the home. | CEO worked with the Program director and DSP staff to aid the individual in cleaning his room. All items of debris were removed and disposed of. |
06/07/2025
| Not Implemented |
| 6400.66 | On 5/14/2025 at 10:31am, the ceiling light fixture in the vacant bedroom was observed with only one operable bulb. The working bulb was very dim and did not provide sufficient lighting to the room. This was the only light fixture present in the vacant bedroom. [Repeated violation: 9/16/2024 et al, 11/19/2024 et al] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| CEO purchased light bulbs for the home and had all light bulbs replaced in the ceiling fixture. Program director completed an audit of the home and all light bulbs were replaced that were missing or not operable. |
06/07/2025
| Implemented |
| 6400.72(a) | On 5/14/2025 at 10:45am, the screens in the two operable windows, overlooking the front yard, in the living room did not provide a secure fit to prevent against the intrusion of pests. The screens in both windows were universal accordion-style screens that were not properly fit into the windows. [Repeated violation: 5/23/2024 et al, 11/19/2024 et al, 4/22/2025 et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | CEO contacted the maintenance team whom installed the screens to have them repaired/adjusted so there are no gaps in the screens. |
06/30/2025
| Not Implemented |
| 6400.72(b) | On 5/14/2025 at 10:32am, the screens in the two operable windows in the vacant bedroom were in disrepair. The screen in the window to the right of the closet, when facing the closet, was detached from the frame in the lower right corner. The detached portion of the screen measured approximately two inches high by four inches in length. The screen in the window directly across from the bedroom door was observed with a tear in the lower right corner that measured approximately two inches high by one-half inch wide. [Repeated violation: 7/19/2024 et al, 8/13/2024 et al, 11/19/2024 et al, 4/22/2025 et al] | Screens, windows and doors shall be in good repair. | CEO contacted the maintenance contractor to schedule the screens to be repaired and or replaced. |
06/30/2025
| Not Implemented |
| 6400.81(k)(6) | On 5/14/2025 at 10:36am, Individual #1's bedroom was observed without a mirror. When asked, Individual #1 stated that they did not have a mirror in their bedroom and that their mirror was located in the vacant bedroom across the hall. [Repeated violation: 11/19/2024 et al] | In bedrooms, each individual shall have the following: A mirror. | CEO will purchase a mirror for the individuals room. Each room of the home will have a mirror and dresser. |
06/30/2025
| Implemented |
| 6400.103 | The agency's Emergency Evacuation Procedures do not include a specific emergency shelter location. The agency's procedure for emergency evacuations states "In the event of an emergency the program coordinator will make arrangements for a hotel stay at a local hotel." | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Program Admin will update all the emergency evacuation forms to ensure they reflect the local hotel that will be used during emergency situations. |
06/30/2025
| Implemented |
| 6400.112(e) | During the last 12 months, no fire drills were conducted during sleeping hours. All fire drills conducted from 5/8/2024 through 4/16/2025 were held between the times of 8:20am and 5:42pm. [Repeated violation: 11/19/2024 et al] | A fire drill shall be held during sleeping hours at least every 6 months. | Program director will run a sleep fire drill during the the June fire drills. |
06/30/2025
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination completed 5/12/2025 did not include a review of the individual's previous medical history. This section was blank. [Repeated violation: 11/19/2024 et al] | The physical examination shall include: A review of previous medical history. | Program director is reaching out to the individuals PCP to get an updated physical. If one cannot be provided the program director will notify the PCP of the individuals previous medical history for review. |
06/07/2025
| Not Implemented |
| 6400.141(c)(12) | Individual #1's physical examination completed 5/12/2025 did not include physical limitation. This section was blank. | The physical examination shall include: Physical limitations of the individual. | Program director will be contacting the PCP to get an updated physical. |
06/30/2025
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 5/12/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program director will contact the PCP to request an updated physical. |
06/30/2025
| Not Implemented |
| 6400.142(e) | Individual #1's dental examination completed 8/22/2024 documented the need for additional fillings under sedation. The agency had no documentation to verify that Individual #1 had completed the recommended follow-ups or that these follow-ups had been scheduled. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Program Director will find a new dental provider and schedule the follow up dental appointment. |
06/30/2025
| Not Implemented |
| 6400.181(a) | Individual #1's assessment, completed 2/04/2025, states he can have more than 120 minutes of unsupervised time in the community. Individual #1's individual support plan, last updated 5/09/2025 states that the individual "needs partial physical assistance in interacting with community members and support to communicate effectively. He is regularly redirected from inappropriate topics, such as masturbation. Individual #1 needs partial physical assistance in protecting self from exploitation. He is easily manipulated and gives away money and then will share that he did not agree". Individual #1's assessment completed 2/04/2025, states he is independent managing his own money. Individual #1's individual support plan, last updated 5/09/2025, states the individual "needs partial physical assistance in protecting self from exploitation, and he is easily manipulated. Individual #1 easily gives away money and then will share that he did not agree. He needs support with budgeting and money management. Individual #1 also knows the value of money. He has very little real-world experience with money management and will need support to ensure he has proper money management skills". Individual #1's assessment completed 2/04/2025, states "Individual #1 has the ability to acquire all adl skills however chooses not to attempt those abilities. Individual #1 relies on staff to do everything for him and needs assistance keeping routines and schedules to be productive in his day". The assessment also documents the individual is independent in the following areas: household chores, medical care, safety, hygiene, clothing, and general health and nutrition. Individual #1's individual support plan, last updated 5/09/2025, states the individual may need verbal reminders on when to shower or brush his teeth. Individual #1 needs verbal and gesture prompting for bathing and taking care of personal hygiene and grooming needs. [Repeated violation: 11/19/2024 et al] | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program director will complete a full reassessment of the individual. Program director will notify the SC via email any discrepancies and updated found during this reassessment. |
06/30/2025
| Not Implemented |
| 6400.181(d) | Program Specialist/Incident Manager #5 did not sign or date Individual #1's assessment that was completed on 2/4/2025. Program Specialist/Incident Manager #5's name and date was typed into the body of the assessment on Microsoft Excel which is not a secure system. It could not be confirmed that Program Specialist/Incident Manager #5 is the one that signed their name on Individual #1's assessment. | The program specialist shall sign and date the assessment. | Program director will be completing a full reassessment of the individual and sign off on the assessment with a wet hand signature. |
06/30/2025
| Not Implemented |
| 6400.214(b) | On 5/14/2025 at 10:15am, Individual #1's psychological evaluation was not present on-site in the residential home. According to Individual #1's support plan last updated 5/9/2025, Individual #1 had a psychological evaluation completed on 12/8/2018. [Repeated violation: 9/16/2024 et al, 1/24/2025 et al, 4/22/2024 et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Program director will make a copy of the phycological evaluation and place the copy in the individuals binder within the home. Program director will also place a copy of the evaluation in therap for the staff to access. |
06/30/2025
| Not Implemented |
| 6400.18(a)(5) | On 5/13/2025 at approximately 10:15am, Chief Executive Officer #7 made licensing personnel aware of an open neglect investigation for Individual #1. Chief Executive Officer #7 explained that Direct Service Worker #4 arrived at the residence on 5/11/2025 at approximately 7:00am to begin their assigned shift. Upon arrival, Direct Service Worker #3 was not at the home and Individual #1 was unsupervised. The corresponding incident, EIM #9621270, was not entering into the Department's information management system until 5/14/2025 at 2:00pm. [Repeated violation: 9/16/2024 et al] | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| CEO informed the agencies CI whom immediately corrected the late EIM. The agency CI input the EIM and investigated the allegations. |
06/07/2025
| Implemented |
| 6400.46(a) | Direct Service Worker #3, date of hire 2/12/2025, participated in fire safety training on 1/23/2025. This training was not conducted by a fire safety expert. Direct Service Worker #1, date of hire 1/10/2025, participated in fire safety training on 12/31/2024. This training was not conducted by a fire safety expert. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | CEO will contract and or purchase a certified fire safety trainer/program and implement the certified training into the orientation and annual training program. |
06/30/2025
| Implemented |
| 6400.46(b) | Direct Service Worker #2, date of hire 9/10/2023, participated in fire safety training on 8/28/2024. This training was not conducted by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | CEO will contract and or purchase a certified fire safety trainer/program and implement the certified training into the orientation and annual training program. |
06/30/2025
| Implemented |
| 6400.46(d) | Direct Service Worker #1, date of hire 1/10/2025, completed First Aid and CPR training online through the National Health and Safety Association on 1/2/2025. This training did not include an in-person component to learn proper form to perform life-saving techniques. Direct Service Worker #2, date of hire 9/10/2023, completed First Aid and CPR training online through the National Health and Safety Association on 4/11/2024. This training did not include an in-person component to learn proper form to perform life-saving techniques. Direct Service Worker #3, date of hire 2/12/2025, completed First Aid and CPR training online through the National Health and Safety Association on 4/5/2025. This training did not include an in-person component to learn proper form to perform life-saving techniques. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | CEO has contracted with a Certified CPR professional whom completes in person on site trainings. All staff will be retrained on CPR and first aid. |
06/30/2025
| Implemented |
| 6400.50(a) | Direct Service Worker #1, date of hire 1/10/2025, participated in trainings on Person-Centered Practices, Community Integration, Individual Choice, and Supporting Individuals to Develop and Maintain Relationships from 12/31/2024 through 1/9/2025. The orientation training record does not include the training sources, content, and length of the training. Direct Service Worker #3, date of hire 2/12/2025, participated in trainings on Person-Centered Practices, Community Integration, Individual Choice, and Supporting Individuals to Develop and Maintain Relationships from 1/21/2025 through 1/23/2025. The orientation training record does not include the training sources, content, and length of the training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | CEO will be completing a full review of the agencies training program to ensure all training regulatory requirements a being met. All new training sign offs will be developed that indicated the exact date and length of time for each training. |
06/30/2025
| Implemented |
| 6400.52(a)(1) | Direct Service Worker #2, date of hire 9/10/2023, only participated in 17 hours of training during the 9/10/2023-9/9/2024 training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | CEO will be completing a full review of the agencies training program to ensure all training regulatory requirements a being met. All new training sign offs will be developed that indicated the exact date and length of time for each training. |
06/30/2025
| Not Implemented |
| 6400.52(c)(4) | Direct Service Worker #2, date of hire 9/10/2023, did not participate in training to encompass recognizing and reporting incidents during the 9/10/2023-9/9/2024 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | CEO will be completing a full review of the agencies training program to ensure all training regulatory requirements a being met. All new training sign offs will be developed that indicated the exact date and length of time for each training. |
06/30/2025
| Not Implemented |
| 6400.165(c) | Individual #1's physical examination completed 5/12/2025 indicated the individual was to start taking Montelukast 10mg tablet "Take 1 tablet by mouth every evening." Individual #1's physical examination completed 5/12/2025 indicated the individual was to continue taking the following medications: Albuterol 90mcg inhaler "Take 2 puffs every 6 hours as needed", Fluticasone Propion-Salmeterol 500-mcg "Take 1 puff 2 times a day, medical marijuana, Omeprazole 20mg "Take 1 capsule by mouth daily", and Polyethylene Glycol "Take 17g by mouth 2 times a day". On 5/14/2025 Program Specialist #6 stated Individual #1 does not take any medications other than pro re nata medical marijuana. The agency is not ensuring Individual #1's medications are administered as prescribed. [Repeated violation: 7/19/2024 et al, 8/13/2024 et al, 9/16/2024 et al] | A prescription medication shall be administered as prescribed. | Program Director contact the PCP and received copies of all scripts. Program director got all scripts filled and into the individuals home and stored properly. |
06/30/2025
| Implemented |
| 6400.213(1)(i) | (ii) On 5/14/2025 at 10:15am, Individual #1's record did not contain personal information to include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | Program director will review the individuals record and update the demographic form to indicate and personal identifying marks. |
06/30/2025
| Not Implemented |
|
|
|
SIN-00262574
|
Unannounced Monitoring
|
03/07/2025
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 3/7/2025 at 12:00pm, the interior of the oven door was observed with a thick brown film and burnt food particles built up on the glass. On 3/7/2025 at 12:08pm, the following trash was observed throughout Individual #1's bedroom: a paper plate with unidentified food substance on top of the dresser, two empty single-serve macaroni and cheese cups with a plastic spoon protruding from the cups on the nightstand below Individual #1's television, an empty water bottle on the night stand below Individual #1's television, an empty water bottle on the floor by Individual #1's nightstand, and empty Faygo pop bottle on Individual #1's dresser, and open bag of potato chips inside of a McDonald's food bag on the floor near Individual #1's bedroom door, various pieces of food wrappers strewn across Individual #1's bedroom floor, an empty bottle of Louisiana hot sauce on the night stand below Individual #1's television. On 3/7/2025 at approximately 3:10pm, a plastic food container with unidentified food residue was observed on the nightstand below Individual #1's television. On 3/7/2025 at 12:16am, a black substance, that appeared to be mold or mildew, was observed on the inside of the washing machine lid and around the bleach dispenser on the washing machine. | Clean and sanitary conditions shall be maintained in the home. | Ceo immediately cleaned the oven to make sure it was free of thick build up and food particles. |
04/04/2025
| Not Implemented |
| 6400.70 | On 3/7/2025 at 12:02pm, the corded telephone in the staff office was unplugged. No other operable telephone was observed in the home. [Repeated violation: 5/23/2024 et al] | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Ceo immediately had the dsp on shift plug the phone in. |
04/04/2025
| Not Implemented |
| 6400.76(a) | On 3/7/2025 at 12:20pm, the grill on the back patio, to the left outside of the basement door, was observed with built up food and, what appeared to be, rust on the grill grates. [Repeated violation: 11/19/2024 et al] | Furniture and equipment shall be nonhazardous, clean and sturdy. | Ceo immediately had dsp and staff remove the grill grates and ordered new ones. |
04/04/2025
| Not Implemented |
| 6400.114(b) | On 3/7/2025 at 12:07pm, a metal tray with cigarette and marijuana ashes and butts was observed on top of Individual #1's dresser. Individual #1 was utilizing this metal tray in lieu of an ashtray. Per the agency's smoking safety procedures, "At the sites where individuals have chosen to smoke and specific locations are designated, the following guidelines will be observed and monitored by staff: an ashtray will be used at all times." [Repeated violation: 8/13/2024 et al and 9/16/2024 et al] | Written smoking safety procedures shall be followed. | Ceo immediately removed the unsafe ashtray and purchased and replaced it with a proper ashtray. |
04/04/2025
| Not Implemented |
| 6400.171 | On 3/7/2025 at 11:57am, a pot of, what appeared to be, used cooking oil was observed in a medium pot on top of the stove. The oil was uncovered, undated, unlabeled, and unstrained. According to the FDA, if cooking oil is being saved for reuse, it is recommended to strain the oil, store it in an airtight and light-proof container, and refrigerate. On 3/7/2025 at 11:59am, a 14-ounce box of Minute Rice was observed open to contamination in the pantry cupboard across from the refrigerator. [Repeated violation: 4/9/2024 et al, 8/13/2024 et al, and 9/16/2024 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| Ceo immediately confirmed with the client that the oil could be disposed of and was disposed of. |
04/04/2025
| Not Implemented |
| 6400.32(g) | On 3/3/2024, an anonymous report was made via phone stating that Individual #1 was being denied the opportunity to participate in overnight visits with family and friends. According to conversations with Chief Executive Officer #1 on 3/7/2025 at approximately 1:45pm, Individual #1's request to participate in overnight visits with family and friends during the week of 3/2/2025 were denied due to their supervision needs and their ability to only be unattended in the community for a maximum of four hours per day. | An individual has the right to control the individual's own schedule and activities. | Ceo immediately informed the individual, management team and staff of the individuals ability to stay overnight with family and friends. Ceo informed the same people how to track and monitor overnight stays and visits. |
04/04/2025
| Not Implemented |
|
|
|
SIN-00259370
|
Unannounced Monitoring
|
01/24/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 1/24/2025 at 12:07pm, the hot water temperature in the main floor full bathroom sink measured 130.2°F. [Repeated violation: 5/23/2024 et al, 8/13/2024 et al, and 9/16/2024 et al] | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Hot water tank gage was adjusted and checked with a temp of 115 degrees. |
02/14/2025
| Implemented |
| 6400.68(b) | On 1/24/2025 at 12:08pm, the hot water temperature in the main floor full bathroom bathtub measured 126.6°F. [Repeated violation: 5/23/2024 et al, 8/13/2024 et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water tank gage was adjusted and checked with a temp of 115 degrees. |
02/14/2025
| Implemented |
| 6400.80(a) | On 1/24/2025 at 11:19am, the exterior walkway leading from the street to the front door of the home was observed with a thick layer snow that had been packed down due to walking on top of the snow. The snow posed a potential slipping hazard. [Repeated violation: 8/13/2024 et al] | Outside walkways shall be free from ice, snow, obstructions and other hazards. | CEO had maintenance go to the home and clear the walkway. Maintenance man also applied salt after removing the snow. |
02/14/2025
| Implemented |
| 6400.214(b) | On 1/24/2025 at approximately 11:35am, Individual #1's dental examination that was on-site in the residential home was completed on 6/18/2024. Individual #1's most recent dental examination was completed on 8/22/2024. [Repeated violation: 4/9/2024 et al, 9/16/2024 et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Program Director is reviewing the client file to ensure all appointment documentation is located in the client file. Any missing documents the Program Director will reach out to the clients doctors for copies of all required paperwork. |
03/31/2025
| Implemented |
|
|
|
SIN-00256536
|
Renewal
|
11/19/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Enterprise Incident Management incident #9496296 stated that Chief Executive Officer #1 allegedly told individual #1 that he "needs to find a new home' and to "save his BS for someone else." The incident report indicated that there was video evidence preserving a record of the text messages exchanged between Individual #1 and Chief Executive Officer #1; however, Program Specialist #3 did not collect this evidence when completing the certified investigation. Program Specialist #3 indicated that the investigation was inconclusive; however, individual #1's testimony, as summarized by Program Specialist #3 stated that Chief Executive Officer #1 called Individual #1 "snapping at him." According to Enterprise Incident management incident #9496294, Chief Executive Officer #1 allegedly told Individual #1, "NEW RULE, NO MORE GUESTS AT THE HOUSE! YOU WANT TO MEET WITH YOUR FRIENDS AND FAMILY IT HAS TO BE OUTSIDE THE HOUSE." Chief Executive Officer #1's witness statement, as summarized by Program Specialist #3, states "It had been explained to Kris numerous times before that he was not following the rules and if it continued, he would need to find a new place to live." Individual #1 has the right to receive scheduled and unscheduled visitors at any time and agency rules cannot infringe upon this right.
According to Enterprise Incident Management incident #9496296, Individual #1 was evaluated for an injury to his finger on 10/4/2024. The incident states that Individual #1 had the injury assessed and was prescribed medications for treatment. Chief Executive Officer #1 instructed Individual #1 to pick up his medications at the pharmacy and to put them in his closet. According to Individual #1's ISP, last updated 10/21/2024, Individual #1 needs verbal/gestural prompting to take medications. Additionally, Individual #1's assessment, lasted updated 5/8/2024, states that medication management is not a foreseeable outcome. The agency failed to provide Individual #1 with medication management. [Repeated violation 8/13/2024 et al] | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | CEO has been educated on proper forms of communication with the clients. |
12/20/2024
| Not Implemented |
| 6400.22(e)(3) | The financial management section of Individual #1's individual support plan, last updated on 10/21/2024, reads, "[Individual #1] needs support with budgeting and money management. He has very little real-world experience with money management and will need support to ensure he has proper money management skills." Interviews with agency staff revealed that the agency does not assist him with money management, retain receipts for purchases made that exceed $15.00, or keep a financial ledger to track the individual's purchases. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | CEO and PS will hold a meeting to discuss the individuals financial needs and independence. CEO and PS will ensure ISP and agency assessment reflect the same information. |
12/20/2024
| Not Implemented |
| 6400.64(a) | On 11/20/2024 at 10:12am, the microwave was observed with food splatters and grease built up on the inside walls of the appliance. On 11/20/2024 at the inside walls and doors of the oven were observed with built up food and grease particles. On 11/20/2024 at 10:35am, and inordinate amount of dirt, debris, hair, and cobwebs were observed on the floors, walls, and windowsills throughout the basement and garage. On 11/20/2024 at 10:36am, the washtub, located to the left of the washing machine in the basement of the home was observed with a thick grey sludge in the basin. On 11/20/2024 at 10:45am, the couch in the basement of the home was observed with dirt and debris n the seat cushions. On 11/20/2024 at 10:46am, the basement stairs were observed with dirt, hair, and debris built-up in the corners and along the edges of the stair treads. | Clean and sanitary conditions shall be maintained in the home. | CEO has disposed of previous microwave and purchased a new microwave for the client. |
12/20/2024
| Not Implemented |
| 6400.64(b) | On 11/20/2024 at 10:35am, dead bugs and spider's egg nests were observed suspended in cobwebs throughout the basement and garage. [Repeated violation: 9/16/2024 et al] | There may not be evidence of infestation of insects or rodents in the home. | CEO has scheduled a deep cleaning on the home which will included cleaning of the cob webs in the basement. |
12/20/2024
| Not Implemented |
| 6400.64(f) | On 11/20/2024 at 10:39am, one plastic Gatorade bottle and two plastic water bottles were observed on the ground outside of Individual #1's bedrooms window. [Repeated violation: 4/9/2024 et al, 8/13/2024 et al, and 9/16/2024 et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | CEO removed the water bottles and disposed of them. |
12/20/2024
| Not Implemented |
| 6400.67(b) | On 11/20/2024 at 10:43am, four bolts were observed protruding approximately one inch out of the wall near the rear basement exit. | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO has scheduled maintenance to repair the exposed bolts. |
12/20/2024
| Not Implemented |
| 6400.72(a) | On 11/20/2024 at 10:42am, the glass block window in the basement was observed with louvered glass in the middle that could be opened to provide ventilation. The was no secure screen present over the louvered glass. [Repeated violation: 5/23/2024 et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | CEO has scheduled maintenance to repair the window and screen. |
12/20/2024
| Not Implemented |
| 6400.72(b) | On 11/202/204 at 10:18am, the screen in individual #1's bedroom window that is adjacent to the bedroom closet was observed with the screen detached from the frame in the bottom right corner. The portion of the screen that was no longer secured to the frame measured approximately three inches high by two inches in length. [Repeated violation: 4/9/2024 et al and 8/13/2024 et al] | Screens, windows and doors shall be in good repair. | CEO has scheduled maintenance for the repair of the screen in the individuals bedroom window. |
12/20/2024
| Not Implemented |
| 6400.76(a) | On 11/2024 at 10:12am, the microwave was observed with, what appeared to be, rust throughout the inside of the appliance. Additionally, the inner face of the appliance, located behind the microwave door appeared to be delaminating. On 11/20/2024 at 10:45am, a mattress was observed in the basement with a hole in top measuring approximately three inches long by one inch high. On 11/20/2024 at 10:41am, the grill located outside near the rear basement exit was observed with rusted grates. | Furniture and equipment shall be nonhazardous, clean and sturdy. | CEO has disposed of the microwave and purchased a new one. |
12/20/2024
| Not Implemented |
| 6400.82(f) | On 11/20/2024 at 10:15am, the main level hallway bathroom was observed without individual clean paper or cloth towels. [Repeated violation: 4/9/2024 et al] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | CEO has placed paper towels in the bathroom while towel holder is being fixed. |
12/20/2024
| Not Implemented |
| 6400.112(c) | The fire drill logs for the drills occurring from 12/1/2023 through 11/5/2024 did not include a space for staff to document problems that were encountered during the fire drills. [Repeated violation: 4/9/2024, et al] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | CEO has updated the fire drill log to give staff an area to document problems encountered during the drill. |
12/20/2024
| Not Implemented |
| 6400.112(e) | The fire drill logs for the drills occurring from 12/1/2023 through 11/5/2024 did not indicate if the individual was awake or sleeping at the time of the fire drill. The fire drill logs did not include documentation that any drills were conducted during normal sleeping hours. [Repeated violation: 4/9/2024, et al] | A fire drill shall be held during sleeping hours at least every 6 months. | CEO has updated the fire drill logs to give staff an area to document if the drill was conducted during awake or sleep hours. |
12/20/2024
| Not Implemented |
| 6400.112(f) | The front door of the home was utilized for the exit route for all drills occurring from 12/1/2023 through 11/5/2024. [Repeated violation: 4/9/2024, et al] | Alternate exit routes shall be used during fire drills. | CEO has had PS schedule fire drill for the year and indicate which exit route is to be used. |
12/20/2024
| Not Implemented |
| 6400.141(c)(1) | Individual #1's annual physical examination, completed on 5/13/2024, did not include a review of the individual's previous medical history. | The physical examination shall include: A review of previous medical history. | PS has sent the individuals medical history to the doctor for review. |
12/20/2024
| Implemented |
| 6400.142(c) | Individual #1 had a dental examination completed on 8/22/2024; however, the documentation from this visit did not include procedures completed. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | PS has reached out to the dental office to obtain the dental report. |
12/20/2024
| Implemented |
| 6400.181(a) | Individual #1's annual assessment, completed on 5/8/2024, states that the individual is unable to self-administer medications and self-administration is not a foreseeable outcome. This assessment also states that the individual is unable to manage their own funds and is unable to responsibly carry their money. Interviews with agency staff revealed that Individual #1 self-administers their own medication and manages their own money independently. Individual #1's assessment has not been updated to accurately reflect their current abilities with self-administration and financial independence. [Repeated violation 4/9/2024 et al] | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | PS has scheduled a meeting to discuss the individuals ability to self administer his medications. ISP and assessment will be updated pending the results of the meeting |
12/20/2024
| Not Implemented |
| 6400.212(b) | Program Specialist #3 completed individual #1's annual assessment on 5/8/2024 and disseminated a copy to the individual plan team on 5/18/2024. Program Specialist #3 had previously written another entry on the date line to indicate when the assessment was disseminated to the team; however, the initial entry was scribbled out and no longer legible. [Repeated violation: 8/13/2024 et al] | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| CEO has educated the PS on the proper way to edit a date on a client release form. ALL edits will include a single line through with an initial and date. |
12/20/2024
| Not Implemented |
| 6400.18(i) | Enterprise Incident Management incident #9496296 had a due date of 11/3/2024 for the Provider Administrative Review section. The Provider Administrative Review Section was submitted by the agency on 11/4/2024 at 1:51pm. No extensions were filed for this incident.
Enterprise Incident Management incident #9496294 had a due date of 11/11/2024 for the Provider Certified Investigation, Provider Administrative Review, and Incident Final Section. These sections were submitted by the agency on 11/12/2024. No extensions were filed for this incident. [Repeated violation: 4/9/2024 et al and 9/16/2024 et al] | 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. | PS has taken the IM management training in the myodp portal to reeducate himself on the guidelines and deadline regarding incident management. |
12/20/2024
| Not Implemented |
| 6400.24 | On 11/19/2024, licensing personnel requested to review the witness statements that were collected for the Certified Investigations that were conducted for Enterprise Incident Management incident #9496294 and # 9496296. Chief Executive Officer #1 stated to licensing personnel that Program Specialist #3 reported that the new Certified Investigator training no longer requires witness statements to be collected as part of an investigative interview. No witness statements were provided for review for either incident. According to page 30 of Incident Management Bulletin 00-21-02, "If an investigation is required or desired for an incident, each entity investigating must follow the Department's standardized investigation process as outlined in the most current ODP CI manual." Page 58 of the current Certified Investigator Manual, last updated 8/13/2024, indicates that all witness testimony must be preserved in written format, witness statements should be signed and reviewed by the witness and CI for accuracy, and the witness statement should be written in a narrative format by the witness. Individual #1's assessment, last updated 5/8/2024, indicates that he is able to read and write; therefore, he would have the ability to complete a witness statement. According to pages 15 and 16 of the CI Manual, a CI not obtaining witness statements for interviews would be considered a Process Deviation. Such deviations must be described in detail in the CI report. No such detail was included in the CI reports. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | CEO has developed a witness statement form for all agency CI's to utilize during investigations. |
12/20/2024
| Implemented |
| 6400.32(l) | According to Enterprise Incident management incident #9496294, Chief Executive Officer #1 allegedly told Individual #1, "NEW RULE, NO MORE GUESTS AT THE HOUSE! YOU WANT TO MEET WITH YOUR FRIENDS AND FAMILY IT HAS TO BE OUTSIDE THE HOUSE." Chief Executive Officer #1's witness statement, as summarized by Program Specialist #3, states "It had been explained to Kris numerous times before that he was not following the rules and if it continued, he would need to find a new place to live." Individual #1 has the right to receive scheduled and unscheduled visitors at any time and agency rules cannot infringe upon this right. | An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time. | PS has scheduled a meeting to discuss the individuals visitors and if restrictions need to be put in place. The HRT will meet and approve and new RPPs. |
12/20/2024
| Not Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1 did not complete training to include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the January 15, 2023, through January 14, 2024, training year. Direct Service Worker #2 did not complete training to include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the February 6, 2023, through February 5, 2024 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | CEO has completed the additional mydop abuse training and certificated are kept on file. |
12/20/2024
| Implemented |
| 6400.182(c) | Individual #1's annual assessment, completed on 5/8/2024, states that the individual can be unattended for 120 minutes plus. The individual plan that was last updated on 10/21/2024 states that the individual can be unattended for 28 hours per week. Individual #1's annual assessment, completed on 5/8/2024, states that the individual can swim independently. Individual #1's individual support plan, last updated on 10/21/2024, reads, "[Individual #1] did not report if he knew how to swim or not." No documentation was provided to demonstrate that the agency had notified the individual's supports coordinator of these discrepancies. [Repeated violation: 4/9/2024 et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | PS has scheduled a team meeting to discuss and clarify the individuals alone time and how it is to be utilized. |
12/20/2024
| Implemented |
| 6400.186 | The financial management section of Individual #1's individual support plan, last updated on 10/21/2024, reads, "[Individual #1] needs support with budgeting and money management. He has very little real-world experience with money management and will need support to ensure he has proper money management skills." Interviews with agency staff revealed that Individual #1 manages his spending money independently. The agency is not implementing individual #1's support plan as written as the agency does not assist him with money management or keep a financial ledger to track the individual's purchases.
According to Enterprise Incident Management incident #9496296, Individual #1 was evaluated for an injury to his finger on 10/4/2024. The incident states that Individual #1 had the injury assessed and was prescribed medications for treatment. Chief Executive Officer #1 instructed Individual #1 to pick up his medications at the pharmacy and to put them in his closet. Interviews with agency staff also confirmed that Individual #1 self-administered these prescribed medications. According to Individual #1's ISP, last updated 10/21/2024, Individual #1 needs verbal/gestural prompting to take medications. Additionally, Individual #1's assessment, lasted updated 5/8/2024, states that medication management is not a foreseeable outcome. The agency failed to provide Individual #1 assistance in administering his prescribed medications. [Repeated violation 8/13/2024 et al] | The home shall implement the individual plan, including revisions. | PS has scheduled a team meeting to discuss and document the individuals financial management abilities. |
12/20/2024
| Not Implemented |
|
|
|
SIN-00251663
|
Unannounced Monitoring
|
09/12/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | On 9/12/2024 at 12:15pm, Individual #1's bedroom door was observed with a key lock on the outside. According to Chief Executive Officer #1, Individual #1 was present in the home when the doorknob was changed and individual #1 witnessed where the staff key was hidden. Chief Executive Officer #1 stated that Individual #1 stole the staff key and refused to give it back on 9/6/2024. During the inspection on 9/12/2024, Chief Executive Officer was given the option to take necessary action to provide licensing access to the individual's bedroom. Chief Executive Officer did not order provide access to the Department. [Repeat violation: 8/13/2024 et al] | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | CEO spoke with the staff and individual and was able to get the individual to give the master key he had stolen. CEO made multiple copies of the master key to the individuals bedroom. |
09/23/2024
| Implemented |
| 6400.64(a) | On 9/12/2024 at 11:53am, the oven was observed with built-up food particles on the interior walls, door, and racks. On 9/12/2024 at 12:01pm, the main level full bathroom was observed with dirt, debris, and hair on the floor, baseboards, and toilet base. Additionally, the bathtub and surround were observed with built-up dirt and soap scum. On 9/12/2024 at 12:06pm, significant dirt and cobwebs were observed throughout the basement in the corners, on the floor, and underneath the basement steps. On 9/12/2024 at 12:15pm, the furnace vent in the main floor bedroom hall, directly across from the basement door, was observed with a significant amount of dirt and debris on the vent slats. [Repeat violation: 9/25/2023, 11/9/2023, 4/9/2024 et al, and 8/13/2024 et al] | Clean and sanitary conditions shall be maintained in the home. | CEO has scheduled the stove to be cleaned. CEO will inspect the cleanliness of the stove upon completion. |
09/27/2024
| Implemented |
| 6400.64(f) | On 9/12/2024 at 11:49am, trash to include food wrappers and mail were observed in the bushes to the right of the front stoop. [Repeat violation: 4/9/2024 et al and 8/13/2024 et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | CEO has picked up all debris and trash from inside the bushed of the home. |
09/23/2024
| Implemented |
| 6400.65 | On 9/12/2024 at 12:02pm, the vent in the main floor full bathroom was plugged with dirt and debris and could not provide sufficient air flow and ventilation. The mechanical vent is the only form of ventilation in this bathroom. [Repeat violation: 4/9/2024 et al] | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Upon inspection of the vent it was noticed that the vent was not full of debris. The vent protective white coat has worn away and appears to be full of debris. CEO has scheduled maintenance to replace the vent cover for this part of the homes ventilation system. |
09/27/2024
| Implemented |
| 6400.67(b) | On 9/12/2024 at 12:04pm, the washtub in the basement had overflowed onto the basement floor creating a slipping hazard. Upon further inspection, it was evident that the washtub had been plugged with, what appeared to be dryer lint. When the washer was turned on, it emptied into the washtub and overflowed onto the basement floor. On 9/12/2024 at 12:16pm, a wire that appeared to be an old cable wire was observed protruding from the floor to the left of the closet in the spare bedroom. [Repeat violation: 9/25/2023, 4/9/2024 et al, and 8/13/2024 et al] | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO removed the debris from the wash tub in the basement during the inspection. The drain worked properly after the lint was removed. |
09/23/2024
| Implemented |
| 6400.68(a) | On 9/12/2024 at 12:03pm, the hot water temperature in the main floor bathroom measured 79.7°F when tested at the sink. Upon further inspection, it was discovered that the hot water tank had been set to vacation mode. | A home shall have hot and cold running water under pressure. | CEO adjusted the water temperature during inspection and the water temperature increased upon the following temp check. |
09/16/2024
| Implemented |
| 6400.76(a) | On 9/12/2024 at 11:58am, the upper kitchen cabinet door to the right of the refrigerator was observed with a loose hinge. The loose hinge was causing the door to slam shut. [Repeat violation: 9/25/2023 and 4/9/2024 et al] | Furniture and equipment shall be nonhazardous, clean and sturdy. | CEO has scheduled maintenance to repair the door to ensure it opens and closes properly. |
09/27/2024
| Implemented |
| 6400.114(b) | On 9/12/2024 at 12:00pm, the remains of a marijuana joint were observed on the bathroom floor near the toilet paper holder. The agency's safe smoking policy states "Hot or lit cigarettes/cigars/pipes will never be left unattended. Each will be extinguished/ emptied in the ashtray before proceeding to another activity." The policy is not being followed as written. [Repeat violation: 9/25/2023 and 8/13/2024 et al] | Written smoking safety procedures shall be followed. | CEO removed the remains of the marijuana use from the bathroom and placed them in the garbage. |
09/23/2024
| Implemented |
| 6400.171 | On 9/12/2024 at 11:56am, an open 19-ounce bottle of Burman's Memphis style barbeque sauce with instructions to refrigerate after opening was observed in the upper pantry cupboard to the right of the refrigerator. [Repeat violation: 9/25/2023, 4/9/2024 et al, and 8/13/2024 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| CEO removed the sauce and disposed of the it on site. |
09/23/2024
| Implemented |
| 6400.214(b) | On 9/12/2024 at 12:18pm, the most current copies of the following records for Individual #1 were not available at the residential home: physical examination, dental examination, dental hygiene plan, psychological evaluation, and personal information to include the individual's height, weight, hair color, eye color and identifying marks. [Repeat violation: 4/9/2024 et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| CEO had removed client file from the home for ISP meeting and audit. CEO put the file back into the individuals home for everyone to have access to. |
09/23/2024
| Implemented |
| 6400.32(r)(5) | On 9/12/2024 at 12:15pm, Individual #1's bedroom door was observed with a key lock on the outside. Agency staff that provide supports to individual #1 did not have a key to lock or unlock the individual's bedroom door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | CEO spoke with the staff and individual and was able to get the individual to give the master key he had stolen. CEO made multiple copies of the master key to the individuals bedroom. |
09/23/2024
| Implemented |
|
|
|
SIN-00249890
|
Unannounced Monitoring
|
08/13/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 8/13/2024 at 1:05pm, the water temperature at the bathroom sink measured 132.2°F [Repeat violation: 5/23/2024 et al]. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | CEO will check temp gage during weekly house checks |
09/27/2024
| Not Implemented |
| 6400.64(a) | On 8/13/2024 at 1:26pm, various pieces of trash to include a compact disc, plastic food wrappers, sale advertisements, a broken door, cardboard boxes, and plastic shopping bags were observed on the floor in the garage. On 8/13/2024 at 1:27pm, spider's webs and cobwebs were observed throughout the basement and garage. The webs were very thick in the corners of the basement and hanging from the basement and garage ceilings. Dead bugs and debris were observed suspended from various spider's webs and cobwebs in the basement and garage. On 8/13/2024 at 1:29pm, the basement steps were observed with dust, dirt, and debris built up on the outer sides of the stair treads [Repeat violation: 9/25/2023, 11/9/2023, and 4/9/2024 et al]. | Clean and sanitary conditions shall be maintained in the home. | CEO Scheduled maintenance to complete remove the trash and debris from the home. |
09/23/2024
| Not Implemented |
| 6400.64(f) | On 8/13/2024 at 1:22pm, various pieces of trash to include dog training pads, chicken wire, food wrappers, plastic water bottles, disposable plates, plastic zip-top bags, and plastic utensils. were observed strewn throughout the backyard. The trash was not in a garbage bag or placed in a lidded receptacle [Repeat violation: 4/9/2024 et al]. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | CEO picked up all trash and debris from the backyard. |
09/23/2024
| Not Implemented |
| 6400.67(a) | On 8/13/2024 at 1:12pm, the register cover on the furnace vent in Individual #1's bedroom, located directly below the window that faces the front yard, was not on the covering the vent. The cover was laying on the floor in Individual #1's bedroom, directly to the left of the vent. On 8/13/2024 at 1:20pm, approximately 1.5 inches of standing water was observed in the washtub. The washtub appeared to be clogged with dirty rag towels and socks [Repeat violation: 9/25/2023, 11/9/2023, and 4/9/2024 et al]. | Floors, walls, ceilings and other surfaces shall be in good repair. | CEO scheduled maintenance to complete a repair of the individuals bedroom vent cover. |
09/23/2024
| Implemented |
| 6400.67(b) | On 8/13/2024 at 1:09pm, the door frame on the hall side of Individual #1's bedroom door was broken on the lower left side. The piece of the frame that had broken left a sharp corner. The broken frame also exposed 1 nail on the left side near the floor, and 1 screw on the left side of the door frame. On 8/13/2024 at 1:26pm, a set of jumper cables was observed on the floor in the basement. The cables had not been properly wrapped or stored and were creating a potential tripping hazard [Repeat violation: 9/25/2023 and 4/9/2024 et al]. | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO scheduled maintenance to repair the door frame around the individuals room. |
09/23/2024
| Not Implemented |
| 6400.68(b) | On 8/13/2024 at 1:06pm, the water temperature in the bathtub measured 129.9°F [Repeat violation: 5/23/2024 et al]. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | CEO has adjusted the temp gage to ensure the water temperature is meets regulations. |
09/23/2024
| Implemented |
| 6400.72(b) | On 8/13/2024 at 1:09pm, the door frame on the hall side of Individual #1's bedroom door was broken. On the lower left side of the door frame, a portion of the frame was missing and, on the top corners of the door frame, there were one-half inch gaps where the frame pieces should join together. On 8/13/2024 at 1:13pm, the screen in Individual #1's bedroom window, closest to the closet, was observed with the lower right-hand corner no longer attached to the frame. The screen was not attached approximately three inches on the side of the frame and two inches on the bottom of the frame [Repeat violation: 4/9/2024 et al]. | Screens, windows and doors shall be in good repair. | CEO has scheduled maintenance to complete the repairs to the individuals door. |
09/23/2024
| Implemented |
| 6400.80(b) | On 8/13/2024 at 1:18pm, The exterior balcony, located outside of the dining room was observed with chipped and peeling paint on the floorboards and railing. On 8/13/2024 at 1:23pm, two pieces of rebar were observed protruding approximately 8-inches from the ground in the back yard [Repeat violation: 9/25/2023, 11/9/2023, and 5/23/2024 et al]. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | CEO has scheduled the home to have the balcony painted. |
09/27/2024
| Not Implemented |
| 6400.84(a) | On 8/13/2024 at 1:28pm, two dirty rag towels were observed on the floor in the basement, in the corner to the left of the washing machine. It appeared that the rags towels had been placed on top of the garbage can; however, the garbage can was observed tipped on its side and the towels were lying next to the top of the can. | Bed linens, towels, washcloths and individual clothing shall be laundered at least weekly. | CEO had the home cleaned and all debris removed and stored properly. |
09/23/2024
| Implemented |
| 6400.114(b) | On 8/13/2024 at 1:12pm, ashes from Individual #1's medical marijuana were observed on Individual #1s bedroom windowsills. The agency's smoking safety procedure states "At the sites where individuals have chosen to smoke and specific locations are designated, the following guidelines will be observed and monitored by staff: An ashtray will be used at all times" [Repeat violation: 9/25/2023]. | Written smoking safety procedures shall be followed. | CEO had the ashes and marijuana debris removed and cleaned from the home |
09/23/2024
| Not Implemented |
| 6400.171 | On 8/13/2024 one half-gallon container of milk with a best by date of 7/31/2024 and a one-gallon container of milk with a best by date of 8/5/2024 were observed in the refrigerator in the kitchen [Repeat violation: 9/25/2023, and 4/9/2024 et al]. | Food shall be protected from contamination while being stored, prepared, transported and served.
| CEO had the home food audited and all expired food removed from the home. |
09/23/2024
| Not Implemented |
| 6400.216(a) | On 8/13/2024, licensing personnel exited the home at approximately 1:32pm. House manager #1 was leaving the home at the same time and stated to licensing personnel that the front door could be left open. Licensing staff were under the impression that House Manager #1 was going to get something from her vehicle and would be coming back to the home momentarily. Licensing personnel observed House Manager #1 enter the agency car and leave the premises. The house manager did not lock the home and failed to lock the staff office leaving Individual #1's records unsecured in the home. | An individual's records shall be kept locked when unattended.
| CEO removed the house manager role from the employee. |
09/23/2024
| Implemented |
| 6400.32(r)(1) | On 8/13/2024 at 1:10pm, Individual #1's bedroom door was observed with a privacy doorknob. The door could easily be unlocked with an item such as a coin or a screwdriver. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | CEO scheduled maintenance to replace the door knob in the individuals bedroom. |
09/23/2024
| Implemented |
|
|
|
SIN-00249528
|
Unannounced Monitoring
|
07/19/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(h) | On 7/19/2024 at approximately 10:30am, while completing an unannounced monitoring at another one of the agency's licensed homes, Individual #2 informed licensing personnel that many of the direct services workers providing services in their home, discuss information relating to Individual #1 in their presence. Although, specific direct service workers were not named, Individual #2 was able to provide details relating to EIM Incident #9270501. | An individual has the right to privacy of person and possessions. | CEO couched and counseled the individual to ensure they were not in distress. CEO spoke with all staff and explained that conversation about other clients and incidents within other homes/programs are not to be discussed around the client. |
08/20/2024
| Implemented |
|
|
|
SIN-00246099
|
Unannounced Monitoring
|
05/23/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(4) | Chief Executive Officer #1 has not exercised responsibility for the administration and general management of the home, including compliance with this chapter. On 5/23/2024 at approximately 12:45pm, licensing observed what appeared to be an approximately six-month old Pitbull puppy in a dog crate in the spare bedroom of the home. Upon entering the room, the licensing representatives were overwhelmed by the strong odor of urine and feces. The wooden floors throughout the room were slimy and were covered in a yellow film that appeared to be dried dog urine. The puppy was inside the crate with two empty bowls that, according to Chief Executive Officer #1, were the dog's food and water bowls. Inside the crate, there was also a dirty bedsheet that had been soiled with dog urine and feces. There was approximately one-half inch of dried feces that the puppy was standing in. The crate liner was not inside the crate but was being used as a tray for two additional empty food bowls located outside of the crate in the back left corner of the room. When licensing observed the four empty bowls in the room, Chief Executive Officer #1 was asked if the puppy had been given food or water yet that day or if the puppy had been taken outside to relieve himself. Chief Executive Officer's response was that individual #1 had just woken up and showered, "so probably not". Licensing also inquired if there was a schedule for individual #1 to follow in regard to feeding and watering and taking the animal outside. Chief Executive Officer #1 stated that there was not. Chief Executive Officer #1 had not ensured that staff were providing the necessary assistance to individual #1 to properly care for the animal or to properly clean the home in the event that the animal relieved himself inside of the home and individual #1 was unable to successfully complete these tasks independently. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | CEO worked with the individual on understanding why the dog was not being cared for properly. The CEO and the individual came to an agreement to give the dog to a family friend of the individuals. The CEO drove the dog and the individual to drop off the animal to his new home. |
06/17/2024
| Implemented |
| 6400.63(a) | On 5/23/2024 at approximately 12:50pm, the water temperature at the bathroom sink measured 124.3°F. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | CEO adjusted the water temperature and checked it to ensure it was correct. |
06/25/2024
| Implemented |
| 6400.68(b) | On 5/23/2024 at approximately 12:51pm, the water temperature at the bathtub measured 123.4°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | CEO adjusted the water temp gage and checked the temp to ensure it was correct. |
06/25/2024
| Implemented |
| 6400.70 | On 5/23/2024 at approximately 12:36pm, the cordless phone located on the kitchen counter was observed to be broken with the back cover partially detached from the handset and with no operable outside line. No operable phone could be produced for licensing. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| CEO located the other phone in the house after the inspection. The extra phone was in the clients bedroom. CEO hooked that phone up in the staff office. |
06/25/2024
| Implemented |
| 6400.72(a) | On 5/23/2024 at approximately 12:38pm, the open sliding back door located in the dining room was observed with a magnetic latching screen. The screen had been placed over the entire door opening; however, it was no longer attached to the frame at the upper right and left corners, and it was not providing a tight seal against the penetration of insects. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | CEO contacted the maintenance manager and scheduled a full site inspection of the home. The Maintenace manager will be repairing the screen after his inspection. |
06/25/2024
| Implemented |
| 6400.80(b) | On 5/23/2024 at approximately 12:15pm, the front side of the riser on the front step leading up to the landing at the front door of the home was observed with crumbling concrete that was protruding onto the concrete walkway, creating a tripping hazard for staff and individuals. On 5/23/2024 at approximately 12:38pm, the rear balcony, outside of the dining room, was observed with chipping and peeling paint on the handrail and deck boards. Additionally, the deck boards were observed with a brown, squishy substance that was making the deck slippery. According Chief Executive Officer #1, the squishy brown substance was likely old dog food that had been rained on and partially dissolved. Chief Executive Officer #1 stated that individual #1 will dump a bag of dog food on the rear balcony and place the puppy outside to gorge himself. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | CEO removed the debri from around the front porch to ensure there was no tripping hazard. The CEO contacted the landlord and submit a maintenance request. Maintenance is scheduled to come on 6/21/24. |
06/25/2024
| Implemented |
| 6400.82(e) | On 5/23/2024 at approximately 12:51pm, the bathtub was observed with no non-slip mat or non-slip surface. | Bathtubs and showers shall have a nonslip surface or mat. | CEO purchased a new non slip mat and placed it in the shower. |
06/20/2024
| Implemented |
| 6400.181(c) | Individual #1's assessment, completed on 5/8/2024 by Program Specialist #2, has sections to include individual's functional strengths, individual's preferences, individual's likes, individual's dislikes, individual's interests, acquisition of functional skills, and recommendations that have been copied verbatim from the individual's ISP that were last updated 2/27/2024. The assessment was not based on the results of assessment instruments, interviews, progress notes and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | CEO has personally updated the assessment to reflect the accurate description of the individuals functioning needs. |
06/25/2024
| Implemented |
|
|
|
SIN-00242667
|
Renewal
|
04/09/2024
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | On 4/10/2024 at 10:36am a black kitchen trash can was observed on the back patio outside of the rear basement exit. The trashcan was overflowing with trash and the lid could not close to prevent from penetration of insects and rodents. Additionally, trash to include, what appeared to be puppy training pads, disposable plastic gloves, and paper plates were strewn throughout the back yard. [Repeat violation: 5/23/2023] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | CEO immediately removed all trash from the back patio and the back yard. CEO trained the Program Specialist House Manager and DSP staff on the quality of cleanliness throughout the home. Also trained them on the regulations that on the disposal of trash daily. |
05/01/2024
| Not Implemented |
| 6400.65 | On 4/10/2024 at 10:26am, the vent on the bathroom ceiling was observed packed with significant dirt and debris not allowing for proper airflow. This ceiling vent is the only form of ventilation in the bathroom. On 4/10/2024 at 10:29am, the furnace vents located in the staff office and in the main floor hallway across from the basement door were observed packed with dirt and debris, not allowing for proper airflow. [Repeat violation: 6/29/2023] | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| CEO has scheduled a maintenance/ cleaning service for the home. During which time all vents will be cleaned and or replaced. |
05/01/2024
| Not Implemented |
| 6400.112(c) | For all fire drills completed from 4/10/2023 through 3/20/2024, the fire drill record did not include the time the fire drills were conducted nor did it include whether or not problems were encountered during the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | CEO reviewed the regulations for required documentation of fire drill records. CEO developed a new fire drill record which indicates all the required areas of documentation for fire drills. CEO trained the program specialist House Manager and DSP staff on how to use this new documentation. CEO removed all previous fire drill logs from the home. |
05/01/2024
| Not Implemented |
| 6400.112(e) | For all fire drills completed from 4/10/2023 through 3/20/2024, the fire drill record did not indicate which drills, if any, were held during sleeping hours. | A fire drill shall be held during sleeping hours at least every 6 months. | CEO reviewed the regulations for required documentation of fire drill records. CEO developed a new fire drill record which indicates all the required areas of documentation for fire drills. CEO trained the program specialist House Manager and DSP staff on how to use this new documentation. CEO removed all previous fire drill logs from the home. |
05/01/2024
| Implemented |
| 6400.143(a) | Individual #1's annual dental examination and cleaning was scheduled for 9/14/2023. Individual #1 refused to attend this appointment. The individual's refusal to attend the dental examination was documented; however, continued attempts to train the individual about the need for dental care was not provided. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | CEO has developed a training and documentation form for individuals refusal of treatment. Training consists of explaining the importance of attending all scheduled treatment sessions. CEO has trained the program specialist and House manager on the use of this form and when it is required. The form will be attached to the individuals consultation form and stored in the individuals file |
05/01/2024
| Implemented |
| 6400.145(1) | The emergency medical plan for individual #1 does not include the hospital or source of healthcare to be used in the event of an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | CEO will discuss with the individual there preference for emergency medical treatment facility. CEO will updated the emergency binder in the home with the individuals preference. CEO will train the Program Specialist, House Manager and DSP staff on this new information. |
05/01/2024
| Implemented |
| 6400.171 | On 4/10/2024 at 10:30am, a 16 ounce package of Bar S beef jumbo franks that had expired on 2/28/2024 was observed in the refrigerator. [Repeat violation: 5/23/2023, 6/29/2023, 7/25/2023, and 9/25/2023] | Food shall be protected from contamination while being stored, prepared, transported and served.
| CEO disposed of all expired and unlabeled food. CEO purchased new labels and additional storage containers for the food within the home. |
05/01/2024
| Not Implemented |
| 6400.181(a) | Individual #1's annual assessment completed 2/13/2024 states that the individual cannot use knives safely and correctly and that the individual has no knowledge and understanding of heat sources. Individual #1's most current plan, last updated 2/27/2024, states that "[Individual #1] does not need protection from knives...or heat sources." Individual #1's annual assessment completed 2/13/2024 states that the individual cannot safely use or avoid poisonous materials. Individual #1's most current plan, last updated 2/27/2024, states that "[Individual #1] understands the dangers of poisons items. [Individual #1] knows how to safely use familiar cleaning chemicals and items." Individual #1's annual assessment completed 2/13/2024 states that the individual can be unsupervised in the residential home for up to 10 minutes and cannot be unsupervised in the community. Individual #1's most current plan, last updated 2/27/2024, states that Individual #1 can be alone for up to 28 hours per week in the home and community. According to Chief Executive Officer #2, Individual #1's current plan is accurate and individual #1 has been assessed incorrectly. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment completed on 2/13/2024 did not include the strengths, needs, and preferences of the individual. This section was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Not Implemented |
| 6400.181(e)(2) | Individual #1's assessment completed on 2/13/2024 did not include the likes, dislikes, and interests of the individual. This section was left blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Not Implemented |
| 6400.181(e)(3)(i) | Individual #1's assessment completed on 2/13/2024 did not include the current level of performance and progress in the acquisition of functional skills. This section was left blank. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's assessment completed on 2/13/2024 did not include the current level of performance and progress in communication. This section was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment completed on 2/13/2024 did not include the current level of performance and progress in personal adjustment. This section was left blank. | The individual's current level of performance and progress in the following areas: Personal adjustment. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's assessment completed on 2/13/2024 did not include the current level of performance and progress in personal needs without assistance from others. This section was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 2/13/2024 did not include recommendations for specific areas of training, programming and services. This section was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. |
05/01/2024
| Not Implemented |
| 6400.214(b) | Individual #1's current plan in HCSIS was last updated on 2/27/2024. On 4/9/2024 at approximately 11:10am, the most current plan that was available in the residential home was last updated on 9/25/2023. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Program Specialist has uploaded the clients most recent ISP in the Electonic file system Therap. |
04/18/2024
| Not Implemented |
| 6400.18(i) | Incident #9351769 had a due date of 3/9/2024 for the Incident Final Section. The Incident Final Section was entered into the Department's Enterprise Incident Management System on 3/12/2024 at 1:23:07 PM. Incident #9351769 had a due date of 3/9/2024 for the Provider Certified Investigator Report. The Provider Certified Investigator Report was entered into the Department's Enterprise Incident Management System on 3/12/2024 at 1:22:26 PM. Incident #9351769, had a due date of 3/9/2024 for the Administrative Review Section. The Administrative Review Section was entered into the Department's Enterprise Incident Management System on 3/12/2024 at 1:23:01 PM. No extensions were filed on these incidents. | 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. | CEO and Program specialist (CI) have reviewed the EIM bulletin on required deadlines for reportable incidents. CEO and Program specialist have reviewed and understand the option for extended deadlines. |
05/01/2024
| Not Implemented |
| 6400.181(f) | Individual #1's annual assessment, completed on 2/13/2024, was sent to the plan team on 1/16/2024. The assessment was sent to the plan team prior to the completion of the assessment. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | CEO has trained the Program specialist on the regulations and requirements for completing the annual assessment as well as the releases and who the assessment needs sent to. Program Specialist will complete a new assessment and send the updated assessment to the team. |
05/01/2024
| Implemented |
|
|
|
SIN-00234354
|
Unannounced Monitoring
|
11/09/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 11/9/23 the bathtub had what appeared to be mold or mildew, hair and small black participles in the track of the shower doors and around the top rim of the bathtub; the toilet had what appeared to be ashes, dried urine and dust along the base; the bathroom floor between the bathtub and toilet was covered in dust, multiple scraps of paper and a toothpaste tube cap; the throw rug in front of the sink/vanity had what appeared to be cigarette ashes and the washer and dryer were covered in dust and multiple specs of dirt and debris [Repeat violation-5/23/23, 6/29/23, 7/25/23 and 9/25/23] | Clean and sanitary conditions shall be maintained in the home. | The CEO instructed the house leads to thoroughly clean the bathroom and other areas of the home. |
11/22/2023
| Implemented |
| 6400.67(a) | On 11/923 the covering to the vent located on the kitchen wall, behind the trash can, was not attached to the vent, leaving a hole in the wall. [Repeat violation-3/17/23 and 6/29/23] | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO has contacted the maintenance man and he will be going to the home on 11/26/23 to secure the register to the floor/wall. |
11/26/2023
| Implemented |
|
|
|
SIN-00231973
|
Unannounced Monitoring
|
09/25/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(d) | At the time of inspection, a cardboard box with empty snack bags and water bottles located in Individual #1's bedroom closet. [Repeat violation-5/23/23] | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | The Trash was removed from the home. All staff have been educated on the home agencies requirements regarding trash removal. All trash is to be removed before each staffs shift is over or as needed. |
10/19/2023
| Implemented |
| 6400.114(b) | At the time of inspection, located on the top shelf of the television stand, under the television, in Individual #1's bedroom were what appeared to be the end of 2 marijuana cigarettes and ashes, as well as what appeared to be crumbs of marijuana. In addition, ashes were located on the windowsill of the back window in the spare bedroom. [Repeat violation-6/29/23 and 7/25/23] | Written smoking safety procedures shall be followed. | The individual was shown the medical marijuana that was found and the ashes. The individual was educated again on the agencies safe smoking policy and procedures. The staff in the home were spoken with about the individual smoking in the home. All staff stated that the individual is not smoking in the home. |
10/19/2023
| Implemented |
| 6400.171 | At the time of inspection, located on the bottom shelf of the television stand in Individual #1's bedroom, was a bowl with 2 red grapes and grape stems. [Repeat violation-2/21/23, 3/17/23, 5/23/23, 6/29/23 and 7/25/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The individual was educated on the need to place his empty plates in the sink once he is done eating. The staff were educated on the cleaning routine of the home and what the agencies expectations are. |
10/19/2023
| Implemented |
|
|
|
SIN-00228234
|
Unannounced Monitoring
|
07/25/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 7/25/23 multiple dirty dishes were in the kitchen sink. [Repeat Violatoin-5/23/23 and 6/29/23] | Clean and sanitary conditions shall be maintained in the home. | The CEO and House Manager have educated all DSP staff on the regulations and requirements to ensure all dirty dishes are completed before the end of each shift. The House Manager had all dirty dishes cleaned and put away in the proper cabinet. |
07/31/2023
| Implemented |
| 6400.66 | The light located outside the basement door was not operational. [Repeat Violation-3/17/3, 5/23/23 and 6/29/23] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The House Manager replaced the light bulb in the light as well as checked all other lights within the and replaced the bulbs for those lights. Additional light bulbs were purchased to be kept within the home. |
08/01/2023
| Implemented |
| 6400.67(b) | In the basement of the home, near the furnace, was a puddle of water, approximately 1 foot by 2 foot. [Repeat Violation-5/23/23 and 6/29/23] | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance was previously consulted about this issue and advised that this was not a malfunctioning piece of equipment and that this was how the home was designed to operate. Corrugated rubber matts were purchased to be placed over the area. Maintenance will be scheduled to analyze the drain and place a pipe from the furnace to the drain so there is no freestanding water ever. |
08/15/2023
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. [Repeat Violation-3/17/23, 5/23/23 and 6/29/23] | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The CEO purchased 2 thermometer for the home one for each first aid kit. |
08/15/2023
| Implemented |
| 6400.114(b) | In the spare bedroom, located on the windowsill. were what appeared to be ashes from a cigarette. [Repeat violation-6/29/23] | Written smoking safety procedures shall be followed. | The CEO analyzed the designated smoking area and ensured that the smoke stack was in tact and present. The CEO trained the individual on the smoking procedures as well as how to store unfinished cigarettes. |
08/01/2023
| Implemented |
| 6400.171 | On 7/25/23 a pan of cooked, cold French fries was located in the oven. The oven was not turned on, nor was it hot/warm. [Repeat Violation-2/14/23, 3/17/23, 5/23/23 and 6/29/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The House Manager removed the trey of fries and disposed of them. The CEO and House Manager trained the DSP staff of proper cooking etiquette. |
08/01/2023
| Implemented |
| 6400.163(g) | Individual #1 is prescribed Medical Marijuana. On the windowsill, in the spare bedroom there was a small pile of what appeared to be marijuana. [Repeat Violation-6/29/23] | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The individual was trained on the designated area for storing his medications. The home has 2 locking bags as well as a lock box in the staff office for the individuals use. |
08/01/2023
| Implemented |
|
|
|
SIN-00226912
|
Unannounced Monitoring
|
06/29/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The kitchen of the home had dirty dishes filled the sink and covered the stove, an empty milk jug was on the kitchen counter, and empty fast food drink cups were thrown on the floor along with empty food and candy wrappers. In the bathroom, by the bedrooms, dark reddish-brown stains are splattered on the wall across from the sink vanity. Individual #1's bedroom floor was covered with dirty clothes and trash to include bottle caps, toilet paper, and chip bags. [Repeat violation: 5/23/23] | Clean and sanitary conditions shall be maintained in the home. | The House Manger and DSP staff cleaned the home thoroughly. The DSP staff on duty was issued discipline and retrained on there job duties and responsibilities, which included the cleanliness of the home. If the individual refuses to clean up after themselves then it is the DSP job to ensure the house is clean and in sanitary conditions. |
07/17/2023
| Implemented |
| 6400.65 | The mechanical vent in the full bathroom on the main floor of the home is clogged with dirt and dust, not allowing for proper airflow. The furnace vent in the bedroom hallway, across from the basement door, is clogged with dirt and dust, not allowing for proper air flow. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The House Manager and DSP staff completed a thorough cleaning of the home which included the vent coverings. All vent coverings will be part of the weekly cleaning routine. |
07/17/2023
| Implemented |
| 6400.66 | The basement door, near the washer and dryer, does not have an exterior light. [Repeat violation 3/17/23 and 5/23/23] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| This was scheduled for maintenance/installation which was completed on July 5th. The light will be monitored and checked to ensure it is operable and in working condition. |
07/05/2023
| Implemented |
| 6400.67(a) | The sliding glass door, in the dining room, leading to the back deck is broken and does not have a handle or locking mechanism. The door does not open easily in the event of an emergency. In Individual #1's bedroom, located at the foot of the bed, under the window, is a hole measuring approximately 2 inches by 4 inches by approximately 1inch deep. | Floors, walls, ceilings and other surfaces shall be in good repair. | This was scheduled for maintenance and completed on July 5th. The CEO has inspected the repairs and the door is in working condition. |
07/17/2023
| Implemented |
| 6400.67(b) | In the doorway between the kitchen and the hallway there is missing section of base board, exposing a protruding nail which could potentially cause harm to a staff or individual. In the basement, in front of the washer and dryer, near the furnace and hot water tank is a puddle measuring approximately 3 feet by 3 feet creating a potential slipping hazard. [Repeat Violation: 5/23/23] | Floors, walls, ceilings and other surfaces shall be free of hazards. | This was scheduled for maintenance and completed on July 6th. A new trim piece of cut and installed. The CEO has inspected the repairs and ensured everything is in good condition. |
07/17/2023
| Implemented |
| 6400.68(b) | At 11:43 AM the hot water tested at 122.9 degrees Fahrenheit in the bathtub of the full bathroom near the bedrooms. [Repeat Violation: 3/17/23 and 5/23/23] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The CEO adjusted the hot water temperature again. The CEO has put a request into the landlord to allow a physical device to be placed over the hot water temperature gage. |
07/17/2023
| Implemented |
| 6400.71 | The emergency phone numbers were not on or by the cordless telephones in the kitchen. The emergency numbers posted on the wall, near the base of the cordless telephone, in the staff office, do not include the number for the local hospital. [Repeat Violation: 2/14/23 and 5/23/23] | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The CEO has printed labels for the home that are kept in the staff office. Each labels has the proper emergency contact numbers on them. In the event the labels are removed or phone is broken and replaced, new labels will be avaliable for installation. |
07/17/2023
| Implemented |
| 6400.73(a) | The handrail, in the stairwell leading to the basement, is not secure. The screws attaching the middle support to the wall have been pulled out of the wall. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | This was scheduled for maintenance and competed on July 6th. The CEO inspected the maintenance repairs to ensure everything was in working condition. |
07/17/2023
| Implemented |
| 6400.77(a) | A first aid kit could not be located in the home. | A home shall have a first aid kit. | The CEO purchased 2 first aid kits to be placed in all the homes. One first aid kit is placed in the staff office the other is stored in the basement to be used as a back up. the backup first aid kit will remain unopened and sealed. Once seal is broken a new back up will be purcahsed. |
07/17/2023
| Implemented |
| 6400.81(k)(1) | Individual #1's mattress had a hole measuring approximately 4 inches. | In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. | The CEO purchased a new mattress for the individual. There is also a back up mattress located at the agency office for the individuals use in emergency cases. |
07/17/2023
| Implemented |
| 6400.81(k)(3) | Individual #1's bed did not have linens. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | The House Manager went through the individuals dirty laundry and located both sets of bedding which includes sheets pillow cases and blankets which were washed immediately and placed on the individuals bed. New Laundry bins have been purchased for the individual. A weekly laundry schedule has been put in place for the individual and DSP staff to follow. |
07/17/2023
| Implemented |
| 6400.105 | During inspection, a furnace filter was observed leaning against the furnace creating a potential fire hazard.
A 5 gallon can of gasoline, with a small amount of gasoline in it, was being stored at the bottom of the basement stairs and clothing and a white, plastic, garbage bag were located against and under the hot water tank. [Repeat Violation: 2/14/23, 3/17/23 and 5/23/23] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The CEO removed the furnace filter from and placed it away from the furnace. The CEO trained the outsourced maintenance company on the regulations surrounding the storage of items around the furnace. The CEO trained the House Manager on the same requirements and overserved the next weekly house check. |
07/17/2023
| Implemented |
| 6400.110(b) | The home did not have an operable automatic smoke detector located within 15 feet of Individual #1's bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | The CEO purchased new smoke detectors from amazon and installed them. The CEO educated the individual and DSP staff on the purpose of the smoke detectors. The CEO showed the DSP staff where the extra batteries for the smoke detectors are located so they can be replaced when low. The explained to the DSP Staff that the smoke detectors will beep when the batteries are low and showed them how to change the batteries and reset the detectors as well as how to communicate the inoperable equipment to management staff. |
07/17/2023
| Implemented |
| 6400.114(b) | Cigarette ashes were located on the windowsill, above the foot of the bed, in Individual #1's bedroom. | Written smoking safety procedures shall be followed. | The CEO trained and educated the individual, DSP, and House Manager on the agencys smoking procedures which are part of the orientation and annual training. The CEO ensured the designated smoking area was equipped with seating and a smokestack. The individual was educated that all remaining cigarette butts needs to be stored outside and cannot be brought back into the home. |
07/17/2023
| Implemented |
| 6400.171 | During the inspection, the following items were not being stored at the proper temperature to prevent contamination: a pot of cooked macaroni and cheese was being stored on the stovetop, a pizza box with a slice of pizza was on the kitchen counter and an open bottle of ketchup was being stored on the kitchen counter. The following items were not sealed properly in order to prevent contamination: an open container of Kool-Aid drink mix was on the kitchen counter and did not have the lid replaced on the container, an open container of coffee grounds was being stored on the counter and the lid had not been replaced on the container, and an open box of Honey Maid Smores cereal, 12.25oz, was being stored on top of the fridge. [Repeat Violation: 2/14/23, 3/17/23 and 5/23/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The House Manager and DSP staff cleaned the home which included the left over food that was left on the counter. The DSP staff on duty during this shift was issued written discipline and retrained on their job duties. |
07/17/2023
| Implemented |
| 6400.172 | During inspection, the home did not have a sufficient amount of food. In the refrigerator, the only food present included 1 package of turkey bacon, 2 12-count cartons of eggs, butter, butter flavored spread, milk, and condiments. | At least three meals a day shall be available to the individuals.
| The CEO reviewed the purchase history for this individual's home and ensured weekly food purchases have been made. The CEO spoke with the House Manager after the inspection who purchases the food for the home and was informed that, that day was grocery day and an Instacart order was being placed. The individual has a history of eating all the food within the first couple days of the grocery order. The staff have been working with the individual on not wasting food items and teaching the individual that groceries are purchased on a weekly basis. If the individual does eat a large amount of the groceries prior to the next grocery purchase then the agency will order meals for the individual until the groceries are delivered. |
07/17/2023
| Implemented |
| 6400.234 | The home does not have a dining table and chairs. | There shall be a sufficient amount of living and recreation furniture, excluding furniture in bedrooms, to seat all the individuals at the same time.
| The CEO located the previous dinning room table and chairs which the individual moved to the outside of the home for outdoor seating. The CEO purchased a new dinning room table and chairs from amazon which is scheduled to be delivered on 7/25/23. The CEO educated the individual that this furniture was for the indoor use and is not to be removed from the dinning room area. |
07/25/2023
| Implemented |
| 6400.163(d) | In the upper kitchen cupboard, located to the right of the sink, various supplements to include Glutamine, CoQ-10, Vitamin D, Tribulus Terrestris Extract, Glucosamine Chondroitin MSM, and Boron were being stored in an unlocked cabinet. In Individual #1's bedroom, on the windowsill located at the foot of the bed, was a rice sized flower of medical marijuana. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The CEO educated and trained the Program Specialist, House Manager, and DSP staff on the regulation's requirements for this individuals' medications. Although the individual does self-medicate the individuals' medications need to be kept in a locked container. The CEO purchased 2 black locking bags for the individual to use to store his medications. All management and DSP staff have been trained on how to use these locking bags as well as what their purpose is. |
07/17/2023
| Implemented |
|
|
|
SIN-00225320
|
Unannounced Monitoring
|
05/23/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | During the inspection of the home, multiple piles of soiled, wet laundry were located in the kitchen, bathroom, basement, Individual #1's bedroom and the spare bedroom of the home. The toilet had a brown sticky substance in the bowl and on the underside of the seat and what appeared to be dried urine along the base of the toilet.
The bathroom sink counter had a black substance smeared along the top. At 12:04PM on 5/23/2023, there were brown sticky substances and debris on the bottom shelf of the refrigerator. There was a red liquid underneath the crisper drawers at the bottom of the refrigerator. There was sticky substances and dirt spots on the floor in the kitchen. There was food splatter throughout the walls and ceiling of the microwave. [Repeat Violation: 2/14/23] | Clean and sanitary conditions shall be maintained in the home. | The House Manager immediately completed a cleaning of the home and put a schedule in place for laundry to be done. The House Manager trained the DSP and the individual on the agencies expectations of the home as well as the regulatory requirements. |
06/19/2023
| Implemented |
| 6400.64(d) | At 12:03PM on 5/23/2023, a full trash bag was on the floor of the kitchen next to the trash receptacle. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | The House Manager immediately removed the trash from the kitchen and placed it in the outside trash bin. The House Manager explained to the DSP's and the individual that when trash is removed from the trash bin it needs to be placed outside immediately. |
06/19/2023
| Implemented |
| 6400.64(f) | At 11:46AM on 5/23/2023, there was a trash receptacle, with no lid, overflowing with bagged trash and 2 long cardboard boxes, one full of trash, in the front yard of the home. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The CEO purchased temporary lids to cover the current trash bins. The House manager posted in the home the schedule for trash to be removed from the home and placed by the road. The House manager trained the DSP's and individual on the outside trash lid requirements. |
06/19/2023
| Implemented |
| 6400.66 | During the inspection, there is no light outside the back exit of the home. [Repeat Violation: 3/17/23] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The CEO purchased a temporary push button light that was installed. The CEO trained the house manager on the lighting requirements and the temporary light that was installed. The House Manager trained the individual and the DSP staff on the temporary light and to operate it. |
06/19/2023
| Not Implemented |
| 6400.67(b) | There were what appeared to be cigarette ashes located on the dresser and the windowsill of Individual #1's bedroom and on the TV stand in the living room. What appears to be a burn mark from a cigarette, was located on Individual #1's dresser in the bedroom. A burnt end of what appeared to be a hand rolled cigarette, was located on the floor along the TV stand in the living room. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The House Manager immediately cleaned the designated area along with the rest of the home. The House Manager trained the DSP's and the individual on the safe smoking procedures that they were trained on upon admission and hire.
The House Manager showed the individual and DSP's where the designated smoking area at the home was. The House Manager explained that there is not to be any smoking in the home and all smoking is to be done at the designated smoking area. |
06/19/2023
| Not Implemented |
| 6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone located in the staff office. [Repeat Violation: 2/14/23] | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The emergency telephone numbers that were printed and placed next the to computer which was next to the phone have been removed and now are taped to the back of the phone. The DSP's and individual have been trained on what these emergency numbers are for and how to communicate if the numbers are removed or go missing from the back of the phone. |
06/19/2023
| Not Implemented |
| 6400.72(a) | The sliding glass door, located in the dining room, does not have a screen. [Repeat Violation: 3/17/23] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | This was a previous maintenance issue that was reported and in the process of being fixed. The maintenance company that was contracted with needed to order parts to repair the broken door. The maintenance company was contacted to give an update on when the repair would be finished. |
06/19/2023
| Implemented |
| 6400.72(b) | The sliding glass door in dining room has a broken handle and is not set properly on the tracks. The door to the vacant bedroom is off the hinges and is leaning against the door frame causing a possible hazard. | Screens, windows and doors shall be in good repair. | This was a previous maintenance issue that was reported and in the process of being fixed. The maintenance company that was contracted with needed to order parts to repair the broken door. The maintenance company was contacted to give an update on when the repair would be finished. |
06/19/2023
| Implemented |
| 6400.74 | The eleven wooden steps leading from the kitchen to the basement of the home did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| The CEO contacted a maintenance company to complete several maintenance items in the home. Included in these maintenance items is the installation of the skid strips on the basement steps. |
06/30/2023
| Implemented |
| 6400.77(b) | The first aid kit did not contain scissors. [Repeat Violation: 3/17/23] | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The House Manager immediately went and purchased a pair of scissors for the first aid kit. The DSP staff have been trained on when using the first aid kit to ensure all items are placed properly back into the kit. |
06/19/2023
| Not Implemented |
| 6400.81(i) | The window, in Individual's #1's bedroom, along the back wall, that looks out into the backyard, does not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | The CEO has contacted a maintenance company to install blinds on the individuals bedroom window. The House Manager inspected the remainder of the bedroom windows and ensured all other windows have proper window coverings. |
06/30/2023
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | The CEO has purchased a free standing mirror from amazon. The mirror is scheduled to be delivered on 6/25/23. Once the mirror is delivered the House Manager will ensure it is installed where the individual chooses in the bedroom. |
06/25/2023
| Implemented |
| 6400.101 | There is a turn lock on the door in the basement leading to the garage causing a possible obstructed egress. There is no man door in the garage. [Repeat Violation: 2/14/23] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The CEO has contacted a maintenance company to complete several repairs including a replacement of the door knob on the basement door leading into the garage. The House Manager has ensured the door knob is unlocked and has trained the individual and the DSP staff to no adjust the door knob until a new one is installed. The House Manager also showed the individual and DSP staff how to open the garage door in the event that the door does lock behind them then the individual or staff exit the garage through the garage door. |
06/25/2023
| Implemented |
| 6400.105 | At 12:23PM on 5/23/2023, there was an inch thick accumulation of lint in the dryer lint trap. [Repeat Violation: 2/14/23 and 3/17/23] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The House Manager immediately removed the lint from the dryer. The House Manager has shown the individual and DSP staff where the lint catcher is located in the dryer as well as how to remove the lint and dispose of it. The House manager has made spot checks to monitor the lint is being disposed of on a regular basis. |
06/19/2023
| Implemented |
| 6400.171 | At 12:06PM on 5/23/2023, two cartons of eggs with a best by date of 4/12/2023 and two cartons of eggs with a best by date of 4/28/2023 were on the second shelf of the refrigerator. [Repeat Violation: 2/14/23 and 3/17/23] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The House Manager immediately removed the expired eggs from the kitchen. The House Manager did a thorough check of the remaining food products in the home to ensure no other items were outdated. Any outdated food was disposed of. |
06/19/2023
| Not Implemented |
| 6400.186 | During interviews, the House Manager reported they stop working their shift as a Direct Support Worker at this home to face time medication administration for an Individual located at different home. [Repeat Violation: 1/5/23, 2/14/23 and 3/17/23] | The home shall implement the individual plan, including revisions. | The CEO contacted the house manager for clarification on this situation. The House Manager stated that they were not working as a DSP staff when they were contacted by the other staff for med admin assistance. The House Manager stated she was at the house doing a house visit during that time.
The CEO explained to the House Manager that whenever she is required to cover a shift she is no to proceed with her manager duties. The CEO explained that the PS or the CEO would take all incoming calls whenever the house manager is required to cover a DSP shift. |
06/19/2023
| Submitted |
| 6400.213(2) | Individual #1's records do not include Incident reports relating to the individual. | Each individual's record must include the following information: Incident reports relating to the individual. | The CEO has contacted the agencies compliance system (Therap) to see where incident reports could be filed. The Therap Rep and the CEO went over the compliance system and decided to place all incident reports in the GER ( General Event Reporting ) section. The House Manager and Program specialist were trained on how to enter GER's in therap. |
06/19/2023
| Implemented |
|
|
|
SIN-00222196
|
Unannounced Monitoring
|
04/03/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | Individual #1 left the community home, alone and unsupervised, prior to 3/30/23 at 2:48 AM. As of 4/6/23 11:50 AM, Individual #1's whereabouts are unknown. Direct Service Worker #2 was unaware that Individual #1 had left the community home. The Police Department was contacted on 3/30/23 at 7:30 AM to file a missing person's report. The individual support plan for individual #1, last updated 3/14/23 states "(Individual #1) NEEDS SUPERVISED AT ALL TIMES.". Chief Executive Officer #1 failed to ensure that supervision needs were clearly outlined in the Individual Plan. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Upon return of the individual the CEO emailed the individuals SC and requested an update to his plan supervision stating that the individual would be in line of site supervision with 30 minute checks when alone in his bedroom. All staff were made aware of the new supervision needs and will be trained on the plan once approved. |
04/10/2023
| Implemented |
| 6400.173 | During interviews, Direct Support Worker #2 disclosed that Individual #1 and Direct Support Worker #2 had taken a walk, on 3/29/23, to the local store due to not having anything to drink at the home. | The quantity of food served for each individual shall meet minimum daily requirements as recommended by the United States Department of Agriculture, unless otherwise recommended in writing by a licensed physician.
| The CEO checked the individual avaliable food and beverages after the individual had left the home. The individual had bottled water, milk, juice and pop avaliable to him. Staff whom made the statement said that they were taking him on a walk to calm his behavior and suggested they go to the store to get a drink. |
04/10/2023
| Implemented |
| 6400.18(f) | On 3/30/23, at 2:48 AM, Individual #1 texted Chief Executive Officer #1 reporting Individual #1 had left the community home, alone and unsupervised, and was at Individual #1's girlfriend's house. The Police Department was contacted 3/30/23 at 7:30 AM to file a missing person's report. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | The agency will be implementing a new policy which reflects that when an individual elopes and is not within required supervision that 911 will be contacted immediately. The agency CEO and program staff maintained contact with the individual and notified the authorities once they had lost contact with the individual. |
04/19/2023
| Implemented |
|
|
|
SIN-00221203
|
Unannounced Monitoring
|
03/17/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | At 11:12 AM on 3/17/2023, the hot water tested 122.3 degrees Fahrenheit at the bathtub in the main bathroom located by the bedrooms. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The agency CEO has turned the temperature down at the thermostat. Water Temperature has been checked and is currently tested at 105 degrees. |
03/31/2023
| Not Implemented |
| 6400.72(a) | On 3/17/2023 the two windows in the spare bedroom and the sliding glass door in the dining room do not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The agency CEO has ensured that all windows are secured and fully functional. The agency CEO has contacted the Land Lord of the property to assess windows and allow the agency to have screens installed. Once permission is granted the agency will contact a window covering company to install screens on all windows without them. |
04/07/2023
| Not Implemented |
| 6400.82(f) | On 3/17/2023 the bathroom located near the bedrooms did not have individual clean paper or cloth towels. | 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 agency CEO has furnished the bathroom with all towels and toiletry needed and required. The individual has been educated on the need to keep these items in the bathroom. The DSP staff working in the home have been educated on the regulations and need to monitor the restroom items to ensure all compliance is met. |
03/31/2023
| Not Implemented |
| 6400.105 | On 3/17/2023, 2 furnace filters, wrapped in plastic were stored against the furnace causing a potential fire hazard. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The CEO has removed the furnace filters and stored them on the opposite side of the basement away from the furnace. The CEO has inspected the area around the furnace and ensured no other items are within range of the furnace. |
03/25/2023
| Not Implemented |
| 6400.110(b) | On 3/17/2023 there was no operable automatic smoke detector located within 15 feet of Individual #1's bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | The individual has been removing the smoke detectors as they stated they do not like the monthly fire drills. The CEO immediately reinstated all smoke detectors and ensured all were operable. |
03/25/2023
| Not Implemented |
| 6400.111(f) | On 3/17/2023 the fire extinguishers located in the kitchen and the basement of the home were not inspected and approved by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The CEO has contacted Cintas to come and conduct and inspection on the fire extinguishers. The DSP staff have been educated on the fire extinguisher requirements and to not remove the tags from the extinguishers. Cintas will conduct and inspect all extinguishers as well as conduct the annual inspection. |
04/07/2023
| Not Implemented |
| 6400.113(a) | Individual #1, date of admission 2/1/23, was not trained in general fire safety upon admission. | 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. | The CEO has instructed the Program Specialist to have the individual date the training that was done upon admission into the program. The CEO inspected the individuals file to ensure all admission documents were signed and dated. Upon inspection it was seen that the Program Specialist did not have the individual nor himself date the admission documents. |
03/25/2023
| Not Implemented |
| 6400.141(a) | Individual #1, dated of admission 2/1/23, did not have a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This individual was released from prison without a physical. Upon admission the agency Program Specialist worked with the individual to select an insurance carrier. The individual received their insurance cards on 3/15/23. The Program Specialist contacted providers within network and the individual has a scheduled appointment with a PCP on 4/3/23 at 9:45. During this time the individual will have his physical examination. |
04/03/2023
| Not Implemented |
| 6400.171 | On 3/17/2023, located on the refrigerator door was a 16 fluid ounces bottle of Kraft Classic Catalina dressing that expired 11/19/22. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The inspector had thrown away the outdated food in the fridge at the time of inspection. The inspector had inspected all other food items to unsure nothing else was outdated. The CEO reinspected the food items later that evening to unsure everything was current. |
03/25/2023
| Not Implemented |
| 6400.34(a) | Individual #1, date of admission 2/1/23, was not informed and explained individual rights upon admission. The document was signed but was not dated therefore, compliance could not be measured. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The CEO has instructed the Program Specialist to have the individual date the training that was done upon admission into the program. The CEO inspected the individuals file to ensure all admission documents were signed and dated. Upon inspection it was seen that the Program Specialist did not have the individual nor himself date the admission documents. |
03/25/2023
| Not Implemented |
|
|
|
SIN-00217106
|
Add an Addendum
|
01/05/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | This first aid kit did not contain scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | SWAP POC to correct this violation is as follows. CEO and Program Specialist have placed scissors in the first aid kit. Program Specialist and CEO have identified a specific first aid kit on amazon that contains all required items in the regulations. This first aid kit will be purchased and placed in the homes ongoing. |
01/12/2023
| Implemented |
|
|