Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00254077 Renewal 10/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66Kitchen door exit: there is no exterior light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The site manager purchased and installed solar paneled lighting at the rear exit, and basement exit of the site. 10/30/2024 Implemented
6400.80(b)Kitchen exit - The 2nd step from the bottom, cement is cracked and needs to be repaired. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The site contractor has ordered materials and will repair the cracked stairs using fresh concrete. 11/22/2024 Implemented
6400.32(r)The bedroom doors have no locking mechanism.An individual has the right to lock the individual's bedroom door.The program director ordered doorknobs with locking mechanisms, and the site contractor will install them on each bedroom door. 11/15/2024 Implemented
SIN-00232153 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(b)Physical exam FOR INDIVIDUAL 2 dated 8/18/23, was not signed by a physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The site manager initiated the scheduling of another physical examination for correction. However, individual 2 has relocated and is no longer at the residence. 04/03/2024 Implemented
6400.141(c)(3)Immunizations not recorded on physical exam for individual 1.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The site manager scheduled another physical examination for this individual for correction (appointment is scheduled for 2/16/24). 02/23/2024 Implemented
6400.141(c)(10)Physical exam dated 3/1/23, for individual 1 If the individual is free from communicable disease(s) was left blank on physical exam.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. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The site manager scheduled another physical examination for this individual for correction (appointment is scheduled for 2/16/24). 02/23/2024 Implemented
6400.141(c)(14)Information pertinent to diagnosis in case of an emergency-left blank for individual 1..The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The site manager scheduled another physical examination for this individual for correction (appointment is scheduled for 2/16/24). 02/23/2024 Implemented
6400.142(f)It was not documented that the individual 1 had achieved dental hygiene independence. There was no dental hygiene plan for individual 2 found in the record.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The new program specialists have been directed to construct a new dental hygiene plan for individual 1 following his annual dental appointment (appointment is scheduled for 3/8/24). 03/15/2024 Implemented
6400.142(g)There was no dental hygiene plan updated annually for individual 1. There was no dental hygiene plan updated annually for individual 2.A dental hygiene plan shall be rewritten at least annually. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The new program specialists have been directed to construct a new dental hygiene plan for individual 1 following his annual dental appointment (appointment is scheduled for 3/8/24). 03/15/2024 Implemented
6400.142(h)There was no dental hygiene plan for individual 1 found in record at inspection. There was no dental hygiene plan for individual 2 found in record at inspection. - The dental hygiene plan shall be kept in the individual's record.The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The new program specialists have been directed to construct a new dental hygiene plan for individual 1 following his annual dental appointment (appointment is scheduled for 3/8/24). The plan will be kept in the individual¿s programming records. 03/15/2024 Implemented
6400.152(b)The physician did not indicate on staff 1 was free of communicable diseases on the physical form. Written authorization from a licensed physician shall include a statement that the person will not pose a serious threat to the health, safety or well-being of the individuals and specific instructions and precautions to be taken for the protection of the individuals at the home. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The staff intentionally used an outdated staff physical form and failed to ask the practitioner to ¿write-in¿ that she was free of communicable diseases. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. 04/03/2024 Implemented
6400.181(a)Individual 2's annual assessment was not completed within required timeframe 7/13/22-8/5/23. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. Individual #2 relocated and is no longer with the residence. 04/03/2024 Implemented
6400.181(c)The assessment dated 6/5/23, for individual 1 does not include what the assessment was based on. The assessment for individual 2 does not include what the assessment was based on.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. Individual #2 relocated and is no longer with the residence. The program specialists will review the current annual assessment and related documents, composing a new assessment for Individual #1. 04/03/2024 Implemented
6400.181(e)(14)The ability to swim was not included in the assessment for individual 2.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. Individual #2 relocated and is no longer with the residence. 04/03/2024 Implemented
6400.18(j)(1)The following incidents for individual 2 are still open and there are no documentation provided to indicate an extension was asked to ODP.The home shall provide the following information to the Department as part of the final incident report: Additional detail about the incident.The program director requested extensions from the AE, who extended the incidents as far as they could. The program director will call ODP to extend the incidences for final section submission. 02/15/2024 Implemented
6400.34(a)The home has not informed and explained the individual's rights and the process to report a rights violation annually. Last signed copy was at admission 5/1/17.Same for both individuals 1 and 2 since 2012. Individual 2's rights last completed 4/23/12.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 staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional; the organization has reasons to believe the former staff removed annual copies of the residents' rights forms, either missing or forgetting about the admissions packet. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. Individual #2 relocated and is no longer with the residence. The house manager and another staff explained his rights and completed the individuals¿ rights process documentation with individual #1 on 01/13/2024. 01/13/2024 Implemented
6400.46(b)Staff 2 does not have the credentials to be considered as a Fire Expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff responsible (former program specialist) had not renewed training nor informed the organization. Staff #2 was disciplined and subsequently is no longer with the organization. The site manager is in contact with a fire safety organization (Croker Fire Safety) to schedule training for the organization. 02/15/2024 Implemented
6400.167(a)(4)Staff 3 failed to give individual 1's his medication on 9/26/23, at 8AM at the prescribed time.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.The medication was administered but the staff responsible failed to document the medication pass. Staff responsible was disciplined for the infraction and subsequently is no longer with the organization. 01/15/2024 Implemented
6400.181(f)It could not be determined if the assessment for individual 1 was provided to the team 30 days prior to the ISP meeting. The assessment for individual 2 was not sent 30 days prior to ISP meeting assessment completed 8/5/23, ISP meeting conducted 8/11/23.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. The program specialists will review the current annual assessment and related documents, composing a new assessment for Individual #1. 04/03/2024 Implemented
6400.213(1)(i)Photo of the individual 1 provided, was not dated. Photo not dated for individual 2.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The staff responsible (former program specialist) was disciplined and is no longer with the organization. Individual #2 has relocated and is no longer with the organization. The house manager will take a new picture of individual #1, dating the photograph. 01/25/2024 Implemented
SIN-00212934 Renewal 10/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)No self-assessments of the home were providedThe agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The program specialist will be responsible for ensuring that the self-assessment of the home is completed. 12/10/2022 Implemented
6400.141(c)(7)Individual #1's Last physical conducted 10.16.2022 indicated a gyn appointment was held on 1.24.2022, but no gynecological appointment was provided.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The appointment in January 2022 was a virtual consultation for the individual's menstrual cycle management. Her annual physical and other documentation states that she is to have a gynecological exam every 5 years (also noted in her lifetime physical). The program specialist is responsible for ensuring appointments are attended as scheduled. 12/10/2022 Implemented
6400.144On 10.18.2021 individual #2 was scheduled for a follow up appointment with the doctor. This appointment should have been scheduled in April and was not conducted until 5.2.2022.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #2's follow-up appointment was scheduled and held late due to the doctor being unavailable. The program specialist is responsible for ensuring appointments are attended as scheduled. 12/20/2022 Implemented
6400.151(c)(3)The physicals provided for Staff #1, #2 and #3 did not indicate if they were free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The program director will create a new staff physical form that includes a measure for indicating if the staff person is free from communicable disease. 12/16/2022 Implemented
6400.46(a)Staff#1, #2 and #3 Had no fire safety training provided.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.Program director will resubmit in-house fire safety training documentation for Staff #1, 2, and 3. 12/03/2022 Implemented
6400.52(c)(1)Staff #1's training provided did not encompass the following areas The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The program director will enroll in trainings as they become available to ensure completion of trainings in needed areas. 01/06/2023 Implemented
6400.165(g)Individual #1's record did not have psychotropic medication reviews.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.Individual #1's psychiatric provider was able to provide documentation for virtual medication reviews after the inspection. The program director will submit those documents. 12/03/2022 Implemented
6400.183(c)No sign in sheet was provided to indicate that behavior plan team was present for the ISP meeting for individual #1 or individual #2.The list of persons who participated in the individual plan meeting shall be kept.The program director will resubmit documentation of ISP meeting for both individuals. 12/03/2022 Implemented
SIN-00194355 Renewal 10/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The electric outlet located in the Livingroom was damaged and wires exposed. Furniture and equipment shall be nonhazardous, clean and sturdy. A new outlet cover has been ordered for the outlet. The outlet¿s expected delivery date is 11/8/21. Upon delivery the contractor will install the outlet cover. 11/15/2021 Implemented
6400.111(f)The Fire Extinguisher located in the hallway did not contain a proof of inspection annually by a fire safety expert. It could not be determined if the fire extinguishers where inspected.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 fire extinguisher inspection tag was removed and discarded of by a resident. A replacement was requested on 10/12/21, and the fire extinguisher company representative arrived less than an hour after the licensing inspection on 10/14/21. MECA admin requested the fire extinguisher tag be taped to the back of the fire extinguisher to prevent future removal. 10/14/2021 Implemented
6400.18(i)The agency did not finalize incident(s) report through the Department's information management system within 30 days of discovery, the agency failed to notify the Department in writing that an extension timely or provide the reason for the extension.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.The director has extended all incident reports, and has contacted the organization¿s investigator in regards to incidents requiring investigations. 11/30/2021 Implemented
SIN-00177708 Renewal 10/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Unsanitary conditions were observed in the basement. Items observed include cobwebs, trash, debris in windowsills and standing water.Clean and sanitary conditions shall be maintained in the home. Maintenance has cleaned out the basement. All debris and trash from having the walls finished has been cleaned and removed. The water has been removed with a dry vac. Direct care staff will conduct rounds daily to ensure the basement is clean. When necessary the staff will clean the basement, removing cobwebs and mopping up any spills/standing water. Direct care staff will document and report any malfunctioning equipment to the residential manager for repair and replacement. The house manager will immediately contact maintenance for repair. The manager will conduct weekly checks to make sure that the basement is kept clean. The program specialist will conduct monthly checks to ensure compliance. 10/16/2020 Implemented
6400.64(f)Trash and debris observed outside of individual #1 bedroom.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The trash/debris has been cleaned up from the individual's room and outside the home. The home has purchased a new trash can for individual #1 and another for outside of the home. Direct care staff will check for trash daily, cleaning any trash and debris. The manager will conduct weekly checks to make sure that trash and debris is cleaned. The program specialist will conduct rounds monthly to ensure that there is no debris inside or outside of the home. 10/30/2020 Implemented
6400.67(b)There were Exposed wires observed in individual #2 bedroom. A Missing light cover was observed in individual #2 bedroom. Floors, walls, ceilings and other surfaces shall be free of hazards.The exposed wires in individual #2's bedroom was repaired the same day as the inspection The home has had the light cover in individual #2 bedroom replaced. Direct care staff will conduct rounds daily to ensure that there are no exposed wires in the home. The manager will conduct weekly checks to make sure all bedrooms are free of hazards, reporting any issues to the program specialist. The program specialist will walk through monthly checking the home to ensure that there are no exposed wires in the home. 10/14/2020 Implemented
6400.67(b)The Vacant bedroom had a missing electrical outlet cover. Floors, walls, ceilings and other surfaces shall be free of hazards.The outlet cover has been replaced Direct care staff will conduct rounds daily to ensure that the home is free of hazards Any hazards will be documented and reported to the manager The manager will conduct rounds weekly to ensure that there are no missing outlet covers or hazards. The program manager will walk through the home monthly to ensure compliance 11/12/2020 Implemented
6400.72(b)The Vacant bedroom does not have a door. The Window in the vacant bedroom is cracked. The Window screen in individual #1 bedroom is damaged and in need of repair. Screens, windows and doors shall be in good repair. One of the resident's pulled the door off of the hinges, cracked the window and ripped the screen out of the window during a behavior. The bedroom door has been replaced, and the window screen has been repaired. Maintenance has taken the window to have the glass replaced Staff will document and report all necessary repairs to the manager. The manager will conduct weekly rounds of all doors, fixtures, and windows to ensure that they are in good repair. Any defects will immediately be reported to maintenance and repaired The program manager will conduct rounds monthly to ensure compliance 11/17/2020 Implemented
6400.72(c)The Kitchen screen door lock was not operating properly at time of inspection. Outside doors shall have operable locks.The home has hired a contractor to replace the kitchen screen door. Direct care staff will check all doors daily to ensure locks are fully operational. Staff will report any issues to the manager. The manager will conduct weekly checks to ensure compliance. The program manager will check doors at least monthly to ensure compliance 11/30/2020 Implemented
6400.80(b)Trash was observed in the front and back of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The trash has been cleaned The direct care staff will conduct rounds daily to ensure that the exterior to the home is clean Any trash or debris will be immediately cleaned up by the staff The manager will conduct rounds weekly to ensure that the exterior to the home is clean Staff will be written up if this violation occurs on their shift The program specialist will conduct random checks to ensure compliance 10/16/2020 Implemented
6400.111(a)The fire extinguisher in the kitchen did not contain an adequate charge to be functional in the event of a fire.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The fire extinguisher in the kitchen has been charged. Direct care staff will check the fire extinguishers daily to ensure they are charged. The manager will check fire extinguishers weekly to ensure that they are charged Any extinguishers not fully charged will be serviced by the fire extinguisher company The manager will schedule to have the fire extinguishers serviced annually to ensure they are all charged The director will follow up to ensure that the fire extinguishers are serviced annually 10/16/2020 Implemented
6400.111(f)The fire extinguishers in the basement and second floor hallway observed at the 10/14/20 inspection, were last inspected on August 2019. 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 fire extinguishers in the home have been inspected and approved by a fire safety organization. The updated dates are on the extinguishers. Direct care staff will check the fire extinguishers daily to ensure they are tagged The manager will create a tickler system to alert annual certification of fire extinguishers The manager will schedule to have the fire extinguishers serviced annually The director will follow up to ensure that the fire extinguishers are serviced annually 10/16/2020 Implemented
6400.151(c)(3)Staff #1 physical did not indicate if they were free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Administration will update the staff physical form to include a statement that indicates the staff is "free of communicable diseases" Staff #1 has been instructed by management to obtain a new physical. The manager will periodically review all staff physicals to ensure they are in compliance. The director will audit the staff's records annually to ensure that all staff have physicals indicating that they are free from communicable diseases 11/30/2020 Implemented
SIN-00167274 Unannounced Monitoring 12/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)An all-purpose cleaner, Fabuloso, was left unlocked in the closet accessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals. The staff member locked the cabinet at the time of inspection The staff member that left the cleaning solution unlocked was written up for this violation The staff person was instructed on the importance of locking poisonous materials Direct care staff will check the supply cabinet daily to ensure that it is locked Any unlocked cleaning solutions will immediately be properly stored and locked The manager will check the supply cabinet weekly to ensure that cleaning supplies are locked The program specialist will conduct random checks to ensure compliance 12/09/2019 Implemented
6400.64(a)There were paint and wall chips on the floor along the walls of the basement, substantial cobwebs on the ceiling and moisture was built up on the floor. Hand towels used to dry hands on upper level main bathroom were soiled.Clean and sanitary conditions shall be maintained in the home. The provider had the paint chips cleaned up The provider had the walls of the basement dry locked by a contractor Direct care staff will conduct rounds to ensure that there is no chipping paint on the walls Any deficiencies will be reported to the manager for immediate repair The manager will conduct checks weekly to ensure that all walls are in good repair The program specialist will conduct random checks to ensure compliance 12/11/2019 Implemented
6400.64(f)The exterior trash can receptacles did not have lids at the time of physical site inspection.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The home has purchased a new heavy duty trash can with a lid attached Direct care staff will check for the trash can and its' lid daily Any missing trash can lids will be replaced immediately The manager will conduct weekly checks to make sure that lidded trash cans are present in the home The program specialist will randomly check to ensure that the trash cans are present and they have lids 12/09/2019 Implemented
6400.67(a)The oven and dishwasher in the kitchen were not in good repair and did not function.Floors, walls, ceilings and other surfaces shall be in good repair. The dishwasher has been removed from the home A new oven has been ordered for the home The oven's expected delivery date is 12/23/19 Upon delivery the contractor will install the new oven in the home The direct care staff will check the over daily to ensure that it is operable The manager will check the stove weekly to ensure that it is functional and operating Any issues with operations will be reported immediately to the director The director will contact the contractor with any operational issues with the stove 12/30/2019 Implemented
6400.72(b)The basement door leading to the back yard was not in good repair, it was unable to be opened at the time of physical site inspection. Screens, windows and doors shall be in good repair. A new back door has been ordered for the home Upon delivery the contractor will install the new back door Direct care staff will conduct rounds daily to ensure that doors are in good repair Any deficiencies will be documented in the repair log and reported to the manager and the contractor The manager will conduct rounds weekly to ensure that all doors are in good repair at the home Staff will be written up if this violation reoccurs on their shift The manager will contact the contractor for any doors that are in disrepair 12/20/2019 Implemented
6400.77(b)There were no scissors or antiseptic found in the first aid kit. There were only two adhesive bandages found, no assortment of bandages kept. 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 provider has ordered two new first aid kits for the home The direct care staff will check the first aid kits daily to ensure that they are properly stocked The staff will inform the manager when they use items from the first aid kit The manager will check the first aid kits weekly to ensure that all mandatory items are in the kit Any missing items will immediately be replaced in the first aid kit The program specialist will conduct random first aid kit checks to ensure that all items are present 12/20/2019 Implemented
6400.80(a)The exterior walkways and stairways around the property were covered with leaves and obstructions such as a ladder and chairs. Outside walkways shall be free from ice, snow, obstructions and other hazards. The entire exterior to the home has been cleaned The direct care staff will conduct rounds daily to ensure that the exterior to the home is clean Any debris or leaves will be immediately cleaned up by the staff The manager will conduct rounds weekly to ensure that the exterior to the home is clean Staff will be written up if this violation occurs on their shift The program specialist will conduct random checks to ensure compliance 12/09/2019 Implemented
6400.80(b)The exterior property of the home was littered with trash and out door stairwell leading to second floor had soiled clothing scattered outdoors. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.A resident had a behavior and threw the clothes on the back stairs The back stairs and the entire exterior to the home has been cleaned The direct care staff will conduct rounds daily to ensure that the exterior to the home is clean Any trash or debris will be immediately cleaned up by the staff The manager will conduct rounds weekly to ensure that the exterior to the home is clean Staff will be written up if this violation occurs on their shift The program specialist will conduct random checks to ensure compliance 12/09/2019 Implemented
6400.81(k)(2)Individual 1's bedroom did not have a solid foundation for his bed, the mattresses were not on a bedframe, they were on the floor. An order was put in for item but not on site or installed prior to individual 1's admission on 12/2/19.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Resident #1's new bedroom set was delivered on 12/6/19 after the inspection The director had previously ordered the set and was awaiting delivery The direct care staff will check resident's rooms daily to ensure that they have frames for the beds The manager will conduct random checks to ensure resident's matresses are on bed frames The program specialist will order new bed frames as needed for residents 12/06/2019 Implemented
6400.81(k)(4)Individual 1's bedroom did not have a dresser for clothes. An order was put in for item but not on site or installed prior to individual's admission on 12/2/19.In bedrooms, each individual shall have the following: A chest of drawers. Resident #1's new bedroom set was delivered on 12/6/19 after the inspection The director had previously ordered the set and was awaiting delivery The direct care staff will check resident's rooms daily to ensure that they have dressers in their bedrooms The manager will conduct random checks to ensure residents have dressers The program specialist will order new dressers as needed for residents 12/06/2019 Implemented
6400.81(k)(6)Individual 1's bedroom did not have a mirror. An order was put in for item but not on site or installed prior to individual 1's admission on 12/2/19.In bedrooms, each individual shall have the following: A mirror. The provider had already purchases a new bedroom set for resident #1 that included a mirror That receipt was available at the time of inspection The bedroom set was delivered the day of the inspection which was 12/6/19 The direct care staff will check the home daily to ensure that all residents have mirrors in their bedrooms The manager will conduct random checks to ensure that mirrors are in the bedrooms Any missing mirrors will immediately be logged in the repair log and replaced by the program specialist 12/06/2019 Implemented
6400.83(a)The oven and dishwasher in the kitchen were not in good repair and did not function. A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. The dishwasher has been removed from the home A new oven has been ordered for the home The oven's expected delivery date is 12/23/19 Upon delivery the contractor will install the new oven in the home The direct care staff will check the over daily to ensure that it is operable The manager will check the stove weekly to ensure that it is functional and operating Any issues with operations will be reported immediately to the director The director will contact the contractor with any operational issues with the stove 12/30/2019 Implemented
6400.144Individual 2: Medication was stored in the medication box that was not properly disposed of or identified. It is unknown whether proper pharmaceutical services were being provided. The following medication had no documentation via physicians order or the Medication record to explain why they were present in the med box: Accucheck lancets were expired, Glucose test strips were there with no note on Medication record if they need to be used and extra docusate tablets were found in a labeled bottle outside of blister pack. Individual 3: Some of the prescribed medication in accordance to the Medication administration record for individual 3 (no physician order was provided) were not on site at the time of review. Medication such as Pantoprazole 40mg tablet taken once daily, benztropine .5mg tablet to be taken twice daily and acetaminophen 500mg tablets to be taken as needed were not on site at the time of review or for the next scheduled dose.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The manager will audit all MARs for accuracy deleting discontinued medications from the forms The manager will audit all medications to ensure that all meds are labeled and accounted for on the MAR The manager will properly dispose of discontinued and expired medication Direct care staff will compare meds to MARs when dispensing meds Any errors found will be immediately corrected Any found discontinued or expired meds will immediately be disposed of Staff will be written up for any reoccurrence of this violation The program specialist will conduct random med checks to ensure that all meds are identified and properly disposed of The provider has contacted a medication trainer to conduct a medication training for all staff The provider is looking to have this training completed by 1/10/2020, The provider now uses the Medication Administration record from the pharmacy to ensure accuracy. 12/16/2019 Implemented
6400.163(d)Medication was stored in the refrigerator unlocked for individual 2. Basaglar kwik pen medication boxes and two sandwich plastic bags unlabeled aside from individual Donald Williams' name and the 8pm on the bag containing unknown pen and tablets. Statement from agency said that the medication in those bags were the 8pm dosage and forgotten because individual 2 would be offsite. Not all individuals in the home understand safety with toxic materials and medication was not stored in an organized manner.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 home will purchase a lock box for medication to go into the refrigerator The direct care staff will ensure that medications are in the box and locked in the refrigerator The direct care staff will check the refrigerator daily to ensure meds are locked in the refrigerator The manager will conduct random checks weekly to ensure refrigerated meds are locked safely Staff will be written up for any reoccurrence of the violation The program specialist will conduct random checks to ensure meds are safely locked in the refrigerator The director will conduct random checks to ensure compliance The provider has contacted a medication trainer to facilitate a training for all staff The provider is looking to have the training completed by 1/10/2020 12/16/2019 Implemented
6400.166(b)Medication prescribed to individual 3 to be taken as needed (PRN) were not listed in the medication administration record (MAR) provided to representative at the time of inspection. The as needed Medication on site was opened and used but no log was provided to show when medication was administered The following medication was not logged or listed on the MAR but was present in the medication box with a label: Acetaminophen 500mg tablet, Betamethasone dip lotion .5%, Levocetrizine 5mg tablet, Promethazine 2mg tablet, Fluocinonide ointment, tera-gel .5% shampoo, hydrocortisone cream 2.5%, and triamcinolone .1% ointment.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The manager has included the PRN medication on individual #3's MAR. The direct care staff will check MARs daily to ensure that PRNs are present The manager will review all MARs monthly to ensure that all PRNs are on the MARs Any missing PRNs will immediately be added to the MARs Staff will be written up for reoccurrence of this violation The Program Specialist will conduct random MAR checks monthly to ensure that PRNs are on the MARS The director has contacted a medication trainer to facilitate a med training with all staff The provider is looking to have the training completed by 1/10/2020 12/16/2019 Implemented
SIN-00150682 Renewal 02/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Staff person # 1's last fire safety training was completed on 6/11/14.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. Staff person #1 had fire safety training on 8/23/2018. Please see the training sign in sheet The provider will ensure that all staff have fire safety training by a certified trainer annually A copy of the training sign in sheet will be kept on file with the provider That confirmation of training will be made available to the Department upon request 03/18/2019 Implemented
6400.151(a)Staff person #1's last physical examination was completed on 2/3/16. 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. Staff person #1 will obtain a physical by 3/22/19 Staff person #1's physical will be kept on file in the home The director will create a tickler system to alert administration 30 days prior to staff physical expirations The director will alert staff 30 days before their physicals expire to ensure timeliness The director will audit the staffing records at least annually at the end of the fiscal year to ensure that all physicals are present and up to date 03/22/2019 Implemented
SIN-00135766 Unannounced Monitoring 05/30/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The outside trash receptacle did not have a lid, and .3 white trash bags outside were sitting beside it REPEATED VIOLATION NON-COMPLIANT FROM PREVIOUS INPSECTION 6/13/17Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The importance of this regulation is to make sure that rodents and insects are not attracted to or getting into the home. This problem was able to be fixed immediately. The program manager has purchased an additional trash can for the home (see the receipt). The staff will ensure that all trash is put into the trash can and covered daily. If a trash can becomes broken, cracked or a lid is missing that can will immediately be replaced out of the petty cash in the home. The house manage will check the trash cans weekly to ensure that they are in good repair and have lids on them. The program specialist will periodically check the trash cans to ensure that they are at the home and that they are in good repair to maintain compliance with this regulation. 06/30/2018 Not Implemented
6400.67(a)In the office on the 2nd floor there was water damage to 4 ceiling tiles, and 1 tile missing. In the kitchen, there was water damage to 5 ceiling tiles. REPEATED VIOLATION NON-COMPLIANT FROM PREVIOUS INPSECTION 6/13/17Floors, walls, ceilings and other surfaces shall be in good repair. The importance of this regulation is to ensure that surfaces in the home are in good repair and that they do not pose hazardous conditions. This problem was not able to be immediately fixed. The provider hired a maintenance person to fix deficiencies in the home. The maintenance person will replace the ceiling tiles. The staff will walk through the home daily to ensure that all ceiling tiles in the home are free of hazard and in good repair. Any deficiencies found will be reported to the house manager, the maintenance staff and documented in the communication log. The house manager will conduct rounds weekly to ensure that ceiling tiles are in good repair. The program specialist will check the home periodically to inspect the ceiling tiles to ensure that the tiles are in good repair and that the home maintains compliance with this regulation. 06/30/2018 Not Implemented
6400.68(b)The hot water temperature in the bathtub was 139.4 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The importance of this regulation is to ensure that the water temperature is at a temperature where it does not pose a burn hazard. This problem was able to be fixed immediately. The program specialist had the water temperature turned down on 5/30/18. The house manager will check the water temperature weekly to ensure that the temperature does not exceed 120. If the temperature does exceed 120 the staff will immediately have the water temperature turned down. The program specialist will periodically check the water temperature to ensure that it does not exceed 120 and that the home maintains compliance with this regulation. 05/30/2018 Not Implemented
6400.72(b)The kitchen screen door did not have a screen in it. Screens, windows and doors shall be in good repair. The importance of this regulation is to ensure that doors are in good repair so that insects and rodents cannot get into the house. This problem was not able to be immediately fixed. The provider will be purchasing a new screen door for the home. The program specialist will ensure that the maintenance staff installs the screen door. The staff will check the screen door to ensure that it is in good repair and free of any hazard. The house manager will conduct rounds weekly to ensure that the screen door is in good repair and operable. The program specialist will check the home periodically to ensure that doors are in good repair and that the home maintains compliance with this regulation. 07/25/2018 Not Implemented
6400.73(a)No handrailing in the basement. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The importance of this regulation is to ensure that there is no falling hazard on the stairs. This problem was not able to be immediately fixed. The provider has called a carpenter to come to the home to have a railing installed going down the basement steps. Upon installation the program specialist will check the railing to ensure that it meets the standard for compliance. 07/25/2018 Not Implemented
6400.76(a)Individual #1's window blinds were broken in the bedroom Individual #1's bedframe was broken Individual #1 2 drawer knobs missing on the dresser Individual #2's bedroom window blinds were torn Individual #2's dresser was missing 1 doorknob Individual #2's closet door was broken Furniture and equipment shall be nonhazardous, clean and sturdy. The importance of this regulation is to ensure that all furniture is clean, sturdy and nonhazardous. This problem was not able to be fixed immediately. The provider purchased a new bedframe and blind for the window. The home is waiting on the bedframe to be delivered to the home. The staff will check the home daily to ensure that bedframes and all blinds in the home are in good repair and free of hazard. The house manager will conduct rounds weekly to check to ensure that the bedframes and the blinds are in good repair free of hazard. The program specialist will conduct periodic checks of the home to ensure that all of the bedframes and blinds in the home are in good repair and that the home remains in compliance with this regulation 06/30/2018 Not Implemented
6400.81(k)(6)No mirror found in individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. The importance of this regulation is to ensure that the individuals living in the home have access to a mirror in their bedroom to assist them with maintaining their personal hygiene and appearance. The problem was able to be fixed immediately. The provider ordered a mirror for the individual's room. The staff will check the individual's room daily to ensure that the mirror is in the room and hanging on the wall. The house manager will conduct rounds to ensure that individuals living in the home have mirrors in their bedrooms. The program specialist will conduct periodic checks to ensure that the home remains compliant with this regulation. 06/30/2018 Not Implemented
6400.111(f)Fire extinguisher located on the 2nd floor in the hallway was dated January 2014. Fire extinguisher located in the basement was dated July 2016. Fire extinguisher located in the kitchen was dated 6/2016. 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 importance of this regulation is to ensure that fire extinguishers are operable in case of a fire in the home. This problem was not able to be immediately fixed. The provider contacted the Philadelphia Fire Protection Company to service the fire extinguishers. Philadelphia Fire Protection did come to the home on June 5th 2018 (see receipt) to check and tag the fire extinguishers. The house manager will check the fire extinguishers daily to ensure that they are charged and tagged. The house manager will immediately call Philadelphia Fire Protection if a fire extinguisher loses its charge and this will be reported to the program specialist. The program specialist will conduct periodic checks of the fire extinguishers to maintain compliance with this regulation. 06/05/2018 Implemented
SIN-00116772 Renewal 06/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)TWO TRASH CANS LOCATED IN FRONT OF THE HOUSE ARE NOT CLOSED AND DO NOT HAVE LIDS. Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The home has purchased new trash cans with lids The support staff will check daily to make sure that all trash cans have lids on them Any trash cans that do not have lids will be removed and discarded The manager will check trash cans weekly to make sure that they have lids on them The manager will purchase new trash cans as necessary to ensure that they all have lids 08/10/2017 Implemented
6400.67(a)THERE WAS NO HANDLE ON THE CABINET NEXT TO THE REFRIGERATOR IN THE KITCHEN. Floors, walls, ceilings and other surfaces shall be in good repair. The cabinet door in the kitchen has been repaired A hinged has been added to the cabinet door The light switch in the laundry room has been repaired and is now flush with the wall The support staff will conduct rounds daily to ensure that the house is in good repair Any issues with floors, walls, ceilings or other surfaces will be documented in the shift report and reported to the house manager immediately The house manager will contact maintenance to conduct any repairs needed in the house Upon completion of the repair the house manager will inspect the work and report the status to the director 08/10/2017 Implemented
6400.71THERE WERE NO EMERGENCY NUMBERS POSTED BY THE TELEPHONE IN THE DINING AREA. 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. Emergency numbers have been posted by the telephone in the home Support staff will check daily to ensure that emergency numbers remain posted in the home If the individual removes the emergency numbers the staff will immediately replace them The house manager will check weekly to make sure the emergency numbers are posted 08/10/2017 Implemented
6400.110(e)THE SMOKE DETECTORS ARE NOT INTERCONNECTED AND THERE ARE 3 FLOORS IN THE HOME. If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Interconnected smoke detectors have been installed in both homes by an electrician MECA has installed carbon monoxide detectors that interconnect to the smoke detectors MECA will make sure that all of its' homes has interconnected smoke detectors The manager will conduct fire drills monthly The interconnected smoke detectors will be tested at the time of the fire drills Any problems with the interconnected smoke detectors will be reported to the director immediately The director will contact the electrician immediately to resolve any issues with the smoke detectors 08/07/2017 Implemented