Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00084202 Renewal 09/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The job description signed by Program Specialist #1 did not include the program specialist's responsibilities.The program specialist shall be responsible for the following: Coordinating and completing assessments. Job description has been updated to include program specialist responsibilities and was reviewed and signed by the program specialist on 9/23/2015. [As per conversation with PS on 11/5/15, PS developed a new hire checklist for required documents which include job descriptions as needed. PS will be responsible for ensuring all required paperwork is obtained and filed in personnel record. CEO or designee will review personnel files at least quarterly to ensure all required document is present and up to date (AS 11/5/15)] 10/10/2015 Implemented
6400.68(b)The hot water measured at 130.6 degrees Fahrenheit in the bathtub at 9:37 AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. Reduced water temperature to 120 degrees. Will check water temperature from bathtub periodically to protect the health and safety of the individual.[As per conversation with PS on 11/5/15, the house manager turned the hot water temperature down. PS purchased a thermometer and adjusted the water until it reached less than 120 consistently throughout the week after inspection and currently the House Manager will take the water temperature at least quarterly and document the water temperatures. CEO or designee will review documentation at least bi annually and complete random temperature checks at least quarterly. (AS 11/5/15)] 10/04/2015 Implemented
6400.73(a)The cement securing the wooden handrail located by the three bottom outside steps leading to the driveway was cracking and the handrail was loose. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Wooden handrail was secured on 925/2015 with cement.[As per conversation with the PS on 11/5/15, PS will develop a plan to ensure the homes are in good repair and in safe condition and provide training to direct service workers and house managers on the policy and procedures of physical site repairs when they are noticed. House Manager will complete bi annual safety checks of the home and document. CEO or designee will review the checklist and also complete random visits to the home to monitor for unsafe conditions. (AS 11/5/15) 10/10/2015 Implemented
6400.77(b)The first aid kit did not contain scissors and a thermometer. 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. Missing items where put into First Aid Kit on 9/22/2015. Supervisor will check on an ongoing basis to ensure compliance.[As per conversation with the PS on 11/5/15, PS will develop a plan to ensure the first aid kits have required items and provide training to direct service workers and house managers on the policy and procedures of what to do if items are noticed as missing or during bi annual physical site monitoring. House manager will document checks of the first aid kit and documentation will be reviewed at least bi annually by the CEO or designee. PS will do random checks of the first aid kit at least quarterly while on site at the homes.(AS 11/5/15)] 10/10/2015 Implemented
6400.163(b)Individual #1 who is diagnosed with a psychiatric illness had medication reviews with a licensed physician on 2/5/15 and 6/10/15.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. According to 163 (b) there shall be a written protocol as part of the ISP. This protocol is in place and is in the ISP. As per 163 (c), a psychotropic review is required every 90 days for any individual who is on psychotropic medications. Supervisor will be responsible for ensuring that these appointments and reviews are scheduled and attended within the required 90 day time frame. Proper documentation and explanation will be provided should there be an interruption in services.[As per conversation with Program Specialist on 11/5/15, the PS of each home will keep appointment and due dates for medical appointments including Psychiatric medication reviews on a calendar in the individual's record as well as a calendar on the PS computer for reminders of upcoming appointments. PS will review documentation to ensure all required elements are present and then file in the individual's record. CEO or designee will review Individual records at least quarterly for timely completion of medical appointments.(AS 11/5/15)] 10/10/2015 Implemented
SIN-00060096 Renewal 08/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106There is not written documentation that the furnace was inspected or cleaned. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnace was inspected on 8/13/14. [Annual inspections will be scheduled in advance of the 365 day timefram to ensure that compliance is met. (CHG 8/22/14)] 08/18/2014 Implemented
6400.111(f)The fire extinguishers located throughout the home do not have a date of inspection. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Extinguishers were inspected and tagged on 8/13/14. [Fire extinguishers will be scheduled to be inspected in advance of every 365 days to ensure that compliance is met. The house supervisor will check the fire extinguishers in all community homes monthly to ensure that they are tagged as inspected within the past year. (CHG 8/22/14)] 08/18/2014 Implemented
6400.141(c)(10)Individual #1's physical examination, completed 7/8/14, did not indicate if Individual #1 was free of communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Physical form was resubmitted to doctor on 8/15/14. When form is returned to KZL will send to Nancy Armstrong via email & fax. [Physical form has been obtainedd by the physician and now indicates that the individual is free of communicable disease. The program specialist will audit all physical examination forms to ensure they contain all of the required information. (CHG 8/22/14)] 08/18/2014 Implemented
6400.151(a)Staff Person #1, hired 4/15/14 does not have a physical examination. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Physical & TB completed will send to Nancy Armstrong via email and fax by 08/18/2014. [All staff persons physical examination forms will be reviewed monthly to ensure they were completed timely and contain the required regulatory information. (CHG 8/22/14)] 08/18/2014 Implemented
6400.168(e)There was no documentation of the date and location of the medication administration training for the trainer. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.Documentation for med trainer was received on 8/5/14, and was sent via email to Nancy Armstrong 08/05/2014. Will send to Nancy via fax 08/18/2014. 08/18/2014 Implemented
6400.181(e)(2)Individual #1's assessment, dated 4/28/14, did not include likes, dislikes, or interests. The assessment must include the following information: The likes, dislikes and interest of the individual. Was sent to Nancy Armstrong via email 08/04/2014. Will send via fax 08/18/2014. [Program Specialist will monitor individual records monthly to ensure that they contain the required information including the likes and disklikes of the individual. (CHG 8/22/14)] 08/18/2014 Implemented
6400.181(f)The program specialist did not provide the assessment to the SC or plan team members prior to Individual #1 annual update meeting to be held 8/25/14. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Assessment sent to ISC on 8/15/14. [Form developed to track that assessment was sent to SC and plan team members. Program Specialist will audit individual records monthly to ensure they contain the required information including documentation that assessment was sent to SC and plan team members. (CHG 8/22/14)] 08/18/2014 Implemented
6400.213(10)(iv)Individual #1's record does not include a notice that the plan team members may decline the ISP review documentation. Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation. Form was sent to Nancy Armstrong via email 08/04/2014. Will fax 08/18/2014. [Form to document the offer of declination was developed. The program specialist will audit all individual records monthly to ensure they contain the required information. (CHG 8/22/14)] 08/18/2014 Implemented