Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258699 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Individual #2 refused to participate in the fire drills initiated on 8/30/24 and 12/20/24. There was no other fire drill conducted in 8/2024 and 12/2024. An unannounced fire drill shall be held at least once a month. The agency has revised the "Fire Drill Policy" to include the following addendum: If an individual refuses to participate in a fire drill, the refusal must be documented on the fire drill log. Additionally, the fire drill must be conducted at a later date within the same month, ensuring that individual participation is properly documented. It is strictly prohibited for any month to pass without a completed fire drill that includes recorded individual participation. 01/29/2025 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 12/20/24 did not include medical information pertinent to diagnosis in case of emergency. This section was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The agency has submitted the physical to the doctor for completion of the required section. As of January 24, 2025, the agency has not received a response from the individual's primary care provider (PCP). Documentation of all attempts made to obtain the necessary information will be kept in the client¿s file. 01/24/2025 Implemented
6400.207(5)(II)On 1/14/2025 at 12:44PM, Individual #2's bed was equipped with half bedrails on both sides restricting Individual's movement from the bed. Individual #2's Individual Plan, updated 11/18/2024 reads, "[Individual #2] is diagnosed with cerebral palsy on her left side and requires staff to be in arm's length when walking···Requires assistance to maintain upright seated position. Assistance with sit to stand position with either hands or grab bar." Individual #2 is not prescribed the bedrails for post-surgical or wound care, balance or support to achieve functional body position and is unable to easily remove the bedrails and there is not a plan or procedures for the bedrails to be removed by staff persons immediately upon the request or indication by Individual #2, there is not a plan that includes periodic relief of the bedrails to allow freedom of movement. An addendum to progress notes for Individual #2 from a healthcare practitioner, dated 11/21/2024 reads, "DME: Hospital Bed. The patient was examined in a face-to-face visit today to address the need for the following durable medical supply(s): Hospital Bed. Section 1; the patient requires frequent changes in body position. Section 2: positioning to alleviate pain." In addition, "PT and OT eval thru Home Health" were ordered on the progress note. There is no documentation of these prescribed evaluations for Individual #2. Individual #2's assessment, completed 6/1/2024 and Individual #2's Individual Plan, completed 11/18/2024 were not updated regarding the use of bedrails on Individual #2's bed.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.The agency had the bedrail immediately removed from the individual's bed on January 14, 2025. 01/15/2025 Implemented
SIN-00237504 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)The Annual meeting to revise Individual #1's individual plan, conducted on 08/08/23, utilized an annual Functional Assessment that was last revised on 01/13/23, more than 6 months from the completion of the assessment.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.It is now ACLA policy that the program specialist updated (if applicable), reviewed, and signed on a quarterly basis. Email documentation of correspondences will be kept in the individual¿s file. 02/09/2024 Implemented
SIN-00222539 Unannounced Monitoring 03/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 3/27/23 at 12:18PM, A 32fl oz bottle of Murphy's Oil Soap and a 15 oz can of Krylon Rust Protection Paint were unlocked and accessible on a shelf in the garage, which is accessible through the basement of the home. Additionally, a 60oz container of Gain Laundry Pods, a 1-gallon bottle of Odoban Disinfectant, a 35lb bucket of Drylok Water Proofer and 6 gallons of paint were unlocked and accessible in the basement of the home. These products' safety instructions included that Poison Control should be contacted if ingested. Individual #1's individual plan, last updated 12/21/22 reads, "[Individual #1] understands the dangers of cleaning products and other poisonous substances. However, [Individual #1] still requires monitoring when around these products. [Individual #1's] access to poisonous substances should be limited. Products should be locked up when not in use. [Individual #1] is not able to identify danger signs and warning labels. [Individual #1] may ingest personal hygiene items."Poisonous materials shall be kept locked or made inaccessible to individuals. On March 27, 2023, the chief operations officer- , removed all poisonous materials from the access of the individuals. Materials were relocated to a locked area which is inaccessible to the individuals. 04/28/2023 Implemented
6400.63(a)On 3/27/23 at 12:08PM, the hot water temperature measured 133.3 degrees Fahrenheit at the sink in the bathroom on the first-floor of the home.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. On March 27, 2023, chief operations officer decreased the water temperature to 113 degrees Fahrenheit. 04/28/2023 Implemented
6400.64(a)On 3/27/23 at 12:06PM, there was hardened dried food particles coating the bottom surface inside the oven in the kitchen of the home. On 3/27/23 at 12:07PM, there was a multitude of brownish orange dried droplets on the ceiling of the bathroom on the first floor of the home. On 3/27/23 at 12:10PM, there was a dried brownish orange substance under the entire perimeter of the clear tape, that was used to affix a paper sign, near the sink in the bathroom on the first floor of the home. On 3/27/23 at 12:10PM, there was squashed remnants of what appeared to be a dead spider, on the wall behind the door of the bathroom on the first floor of the home. On 3/27/23 at 12:10PM, there was inordinate layer of dirt and dust on the mechanical vent in the ceiling of the bathroom on the first floor of the home.Clean and sanitary conditions shall be maintained in the home. On March 27, 2023, COO- cleaned the bathroom ceiling to remove the dried, brownish droplets on the ceiling of the first floor of the home. The paper with the brownish orange tape was removed. The remnants of the spider found on the wall behind the door of the first floor bathroom was removed and the section was sanitized. The ceiling vent of the bathroom of the first floor was cleaned. The oven was also cleaned. 03/27/2023 Implemented
6400.64(e)On 3/27/23 at 12:17PM, there were two, 33-inch-high, trash receptacles typically used outdoors, in the basement of the home. These trash receptacles were unable to be closed due to overflowing with multiple, full white trash bags. Additional full bags of trash were stacked on top of the trash receptacles.Trash receptacles over 18 inches high shall have lids. COO, , immediately replaced the trash cans with larger trash cans which do have lids on them. 03/27/2023 Implemented
6400.64(f)A 32-gallon trash receptacle without a lid was outside on the back patio of the home.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.COO, replaced the trash can, with a large can which includes a lid. The trash can was replaced March 27, 2023. 03/27/2023 Implemented
6400.67(a)On 3/27/23, at 12:10PM, there are two holes and a crack in the lower section of light switch cover in the hallway of the home. This damage poses a laceration hazard when utilizing the light switch. There is an area approximately two and half inches by three inches of pealing and chipping paint on the wall above the vanity in the bathroom of the home. There is a crack approximately two inches long across the lower section of the outlet/light switch plate on the wall next to the vanity in the bathroom of the home. This damage poses a laceration hazard when utilizing the outlet or the light switch.Floors, walls, ceilings and other surfaces shall be in good repair. On April 1, 2023., COO- scheduled and appointment with a handy man to address BOTH light switches (hallway and bathroom). The light switch plates were replaced. The ceiling in the bathroom was painted to address the peeling paint. The work was completed on April 1, 2023, and oversight was completed by Lisa Bynoe. 04/01/2023 Implemented
6400.68(b)On 3/27/23 at 12:09PM, the hot water temperature measured 129.3 degrees Fahrenheit at the sink in the bathroom on the first-floor of hte home. Hot water temperatures in bathtubs and showers may not exceed 120°F. On March 27, 2023, chief operations officer- decreased the water temperature to 113 degrees Fahrenheit. 03/27/2023 Implemented
6400.72(a)On 3/27/23 at 12:11PM, there was not a screen in the the window above Individual #1's bed.Windows, including windows in doors, shall be securely screened when windows or doors are open. Agency COO, , ensure the contracted handyman installed a screen in the individual's bedroom. 04/01/2023 Implemented
6400.72(b)On 3/27/23 at 12:33PM, there was one and half inch gap between the bottom trim and screen door in the in the kitchen of the home. On 3/27/23 at 12:34PM, there was a one-inch by five-inch gap in the window in the basement of the home. Inside cobwebs in this area were observed to moving due to air flowing in from the outside. Screens, windows and doors shall be in good repair. On March 27, 2023, the COO- removed the cobwebs and secured the screen by re-installing the screens of both spaces mentioned above. 03/27/2023 Implemented
6400.73(a)On 3/27/23 at 12:15PM, the eleven outside steps, between the patio and the yard in the rear of the home, did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The COO- Lisa Bynoe ensured a handrail was installed on both sides of the steps. The installation took place on 4/1/23. 04/01/2023 Implemented
6400.74On 3/27/23 at 12:15PM, the eleven outside steps, between the patio and the yard in the rear of the home, did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. On April 1, 2023, non-skid surfaces were added to the mentioned steps. The COO- ensured that the non-skid surface was added to the steps, and oversaw the completion of the installation. 04/01/2023 Implemented
6400.80(a)On 3/27/23 at 12:56PM, the concrete patio, in the rear of the home, is uneven; posing a tripping and falling hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. The concrete patio of the home has been smoothed out to ensure all hazards have been removed. This tasks was completed on April 3, 2023. The work was completed by the contracted handyman and the work was overseen by COO. 04/03/2023 Implemented
6400.101On 3/27/23 at 12:19PM, there was a push-button lock, on the basement side of the door leading to the garage, posing an obstructed egress from the garage, when engaged. There is not a swing door in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The push-button lock was removed and replaced with a standard door know without a lock. This task was completed on April 1, 23. The completion of the work was overseen by COO- . 04/01/2023 Implemented
6400.171On 3/27/23 at 12:04PM, there was a unsealed Ziplock bag containing full and cut up section of red bell peppers, in the drawer of the refrigerator in the kitchen. On 3/27/23 at 12:23PM, the refrigerator in the basement of the home contained the following foods that were left unsealed: a 9 ounce container of Hillshire Farms Honey Ham, with a best use by date of 1/17/2023; a .49lb package of Buffalo Chicken deli meat, with a best use by date of 3/1/2023; a .57lb package of Deli Provolone Cheese, with a best use by date of 2/28/2023; and a 16 ounce package of soft tortillas.Food shall be protected from contamination while being stored, prepared, transported and served. COO, removed all mentioned items. according to the US Department of Agriculture, food is still safe to eat if frozen before the best buy date, therefore ACLA ensured the food was frozen. The food was removed from the freezer on March 27, 2023. In addition, the bell peppers found in the refrigerator where sealed in the ziplock bag by house supervisor Ashley Frazier. 03/27/2023 Implemented
6400.214(b)On 3/27/23 at 2:30PM, the current assessments, for Individual #1 and Individual #2, were not kept in the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. COO, placed a hard copy of the most current assessments for both individual 1 and individual 2. Please note that the assessments were available digitally in the home. The hard copy assessments were placed in the home on March 27, 2023. 03/27/2023 Implemented
6400.51(b)(3)Direct Service Worker #1's orientation completed 2/3/22, did not encompass individual rights.The orientation must encompass the following areas: Individual rights.The training completed does encompass individual rights, under "New Staff Training". The training video that is used to train staff also has a designated section reviewing the individual rights. 02/03/2023 Implemented
SIN-00219423 Renewal 02/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)The physical examination, completed 9/29/22 for Individual #2 did not include physical limitations.The physical examination shall include: Physical limitations of the individual. The physical was completed to add if the individual has any physical limitations. 03/03/2023 Implemented
6400.141(c)(13)The physical examination, completed 9/29/22 for Individual #2 did not include medical information pertinent to the diagnosis and treatment in case of an emergency. [Repeated violation 3/4/22]The physical examination shall include: Allergies or contraindicated medications.The physical was completed to include if the individual has any medical information pertinent to the diagnosis and treatment in case of an emergency. 03/03/2023 Implemented
6400.141(c)(15)The physical examination, completed 9/29/22 for Individual #2, did not include special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. The physical was completed to include if the individual has any special instructions for the individual's diet. 03/03/2023 Implemented
6400.181(e)(12)The assessment completed, 1/9/2023 for Individual #1 did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. all assessments with ¿no recommendation, have been updated and will be sent to the support¿s coordinators by Friday, March 10, 2023. 03/10/2023 Implemented
6400.165(g)The psychiatric medication review, completed 1/12/23 for Individual #2 did not include the need to continue the medication. [Repeat Violation 3/4/22]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The agency has reached out to the provider, but has not received any response as of 3/3/2023. We will continue to attempt to obtain this documentation and include the attempts in the individual¿s file. 03/03/2023 Implemented
SIN-00201132 Renewal 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)The fire extinguishers on first floor and basement of the home had a 1-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Agency has replaced all cited fire extinguishers with a regulatory compliant extinguisher. The receipt of purchase was shown to the inspector. Receipt of purchase is attached to each extinguisher. 03/04/2022 Implemented
6400.141(c)(10)Individual #1's physical examination, completed 1/19/22 did not include specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. This section had written "don't know may need PPD".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. Agency has developed and implemented the "Medical Documents" system. This system includes the following: 1. Admin and supervisory staff will contact the individual's medical doctor to inform them that ACLA is a state licensed group home, and that it is state mandated that all medical forms be completed in entirety at the time of the appointment. [Physical examination completed 9/17/2022 for Individual #1includes free of communicable disease. Upon completion initially and annually, the CEO or designee educated in the requirements of Individual Physical examination will audit all individual's physical examination to ensure all required information is present and individuals' health services are arranged and provided as per medical professionals orders. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/4/22)] 03/15/2022 Implemented
6400.141(c)(11)Individual #1's physical examination, completed 1/19/22 did not include an assessment of the individual's health maintenance needs. This section was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Agency has developed and implemented the "Medical Documents" system. This system includes the following: Admin and supervisory staff will contact the individual's medical doctor to inform them that ACLA is a state licensed group home, and that it is state mandated that all medical forms be completed in entirety at the time of the appointment.[Physical examination completed 9/17/2022 for Individual #1 addresses health maintenance needs. Upon completion initially and annually, the CEO or designee educated in the requirements of Individual Physical examination will audit all individual's physical examination to ensure all required information is present and individuals' health services are arranged and provided as per medical professionals orders. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/4/22)] 03/16/2022 Implemented
6400.141(c)(13)Individual #1's physical examination completed 1/19/22 did not include allergies. This section was blank.The physical examination shall include: Allergies or contraindicated medications.Agency has developed and implemented the "Medical Documents" system. This system includes the following: 1. Admin and supervisory staff will contact the individual's medical doctor to inform them that ACLA is a state licensed group home, and that it is state mandated that all medical forms be completed in entirety at the time of the appointment. 03/16/2022 Implemented
6400.141(c)(14)Individual #1's physical examination completed 1/19/22 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. Agency has developed and implemented the "Medical Documents" system. This system includes the following: 1. Admin and supervisory staff will contact the individual's medical doctor to inform them that ACLA is a state licensed group home, and that it is state mandated that all medical forms be completed in entirety at the time of the appointment. 03/16/2022 Implemented